NEW HEALTH MORALITY AND PRIVATISATION: An apple a day?
During his campaign in the recent federal election, Prime Minister Stephen Harper made an astounding reversal of his earlier position on health care.
Right up until last year, Harper had asserted his support for a two-tier health care system. In 1998, he called for scrapping the Canada Health Act. In 2002, Harper told the Toronto Star that “Moving toward alternatives, including those provided by the private sector, is a natural development of our health care system.”
The election race forced Harper to push this perspective into the closet, claiming that he is opposed to a two-tier system. However, this doesn’t negate ongoing federal efforts to dismantle our Medicare system.
We’ve come a long way since the struggles of the 1930s Depression that led to calls for universal health care. Pioneered in Saskatchewan, it was not until 1966 that the national health care system was established. Since that time, Canada has been recognized internationally as a centre for innovative thinking about health care. However, this thinking has been invariably co-opted to underpin federal and provincial efforts to cut health care costs. The current perspective of the Conservative government is a logical extension of this history.
A central axis in debates among health care theorists in this country has been about the relative importance of cure versus prevention, distilled in the old adage “an apple a day keeps the doctor away.” Though the value of preventing human suffering and injury in the first place may seem commonsense, only a small percentage of total health expenditure (5% of the $142 billion spent in 2005) goes toward prevention and public health programs.
Even the nature of prevention has been subject to debate, since it raises the question of how health is affected by social factors. If the dimensions of health are not limited to physical disease, to what extent should the health care system be responsible for addressing social causes of ill-health?
MEDICAL INDUSTRIAL COMPLEX
Canada’s health care system is founded on a biomedical model that narrowly focuses on the physical causes and processes of disease. In this model, disease is prevented by using medications and vaccines, or reducing exposure to known risk factors. Health policies based on this model involve health and safety regulations or health education campaigns to persuade people to avoid risk factors or encourage them to seek regular health screening.
The biomedical model is strongly linked to clinical practice. Access to clinics and hospitals, medical technologies and pharmaceuticals are seen as the key to quality health care. As a result, by far the largest component of health care expenditures has historically been in physicians, new buildings, medical machinery, and drugs.
Despite new theories and policies accounting for the non-medical aspects of health, the biomedical model continues to be the dominant influence in our health care system. A powerful lobby including the Canadian Medical Association and the pharmaceutical industry continues to assert the primacy of this model in health care. Research based on this model receives the greatest share of funding.
Non-governmental organizations, most notably a variety of cancer prevention and treatment associations, have successfully lobbied governments and health care providers to introduce screening tests and preventive interventions – at times even before their effectiveness was established.
These biomedical interventions are widely marketed as effective methods for not only reducing risk, but also reducing the economic burden of disease. Thus this model remains the highly profitable bedrock of the so-called “medical industrial complex.”
BLAMING THE VICTIMS
At the other end of the spectrum, disease prevention has been seen as secondary to or even irrelevant to levels of health in society. In the 1970s, a health promotion ideology emerged advocating public education programs to encourage “healthy lifestyle choices.”
Health promotion policies were criticized for disregarding the broader social and environmental context of human behaviour and for overemphasizing personal responsibility for illness. Concerns were raised about a “victimblaming” mentality that absolves society from its responsibility to the sick and needy. These policies have also arguably led to the establishment of health as the New Morality and thus paradoxically have contributed to the overmedicalization of society.
Failures in the first phase of health promotion led to a focus on social — determinants of health, and a stress on the importance of creating healthy living and working environments. The language of holism, community development, participation, and empowerment was added to the health promotion vocabulary. In 1987, national strategies to combat AIDS, heart disease, impaired driving and drug abuse were established.
But both variants of the health promotion agenda failed to reduce health inequalities because the messages and programs remained less effective among those most at risk: poor, immigrant, and aboriginal people. Health promotion discourse was vague, and allowed conservative policy-makers to undermine not only Medicare but even the health promotion agenda itself. For instance, in the 1990s the relatively low cost Active Living and ParticipACTION awareness programs justified shifting resources away from public fitness and sport programs.
The concept of empowerment was particularly paradoxical: Is it really possible for a bureaucrat to “empower” individuals or communities while continuing to set the agenda? The concept of empowerment was used to return responsibility for health to provincial and municipal governments, and eventually to individuals. This meant privatisation and downsizing of public health care.
A NECESSARY EVIL?
The most recent paradigm shift in Canadian health care took place in the early 1990s with the introduction of the “population health” perspective. Population health advocates identify prosperity as the most important determinant of health. However, structural inequalities are not seen to be the problem. Rather, the theory is that socio-economic gradients in health affect everyone and therefore the solutions should target everyone – “a rising tide lifting all boats.”
The population health model is highly complicated, involving numerous factors and feedback loops. The health care system is viewed as a necessary evil, and spending on it is just like spending on the military: “a regrettable use of resources.” Since a more wealthy society is a more healthy society, supposedly the most effective policy is to shift resources away from health care and toward economic development.
The new health morality thus involves an imperative to accept federal cuts to social spending and work hard in the service of corporate profits. The population health model turns out to be drawn from a neo-liberal market ideology.
HEALTH INEQUALITIES
The several turns in health care ideology over the past four decades have led to essentially the same policy outcomes. The major health policy proposals that followed the creation of Medicare in Canada have invariably assigned a prominent position to prevention, while calling for a reduced role for the health care system.
The slogan that prevention is better than cure was interpreted to mean that prevention is better than the illnessobsessed health care (or “sickness-care”) system. As a result, the arguments for prevention have been construed as arguments against Medicare. Adoption of both the health promotion and population health models in policy coincided with cuts to Medicare.
Clearly, universal access to health care has not eliminated inequalities in health. Indeed, there is evidence that health inequalities have actually increased following the introduction of marketoriented policies resulting in reduced public spending on health. This happened despite a 45% expansion in the dollar value of the Canadian economy over the past two decades. In fact, indiscriminate cuts to health care spending have disproportionately affected the poor because of their higher health needs and their inability to pay for private health care.
The new health promotion and population health ideologies coincided with the rise of neo-conservative politics and neo-liberal economics in North America, along with a weakening of the labour union and women’s movements. Health care cuts have impacted the working conditions of the lowest paid health care workers, who are mostly women, and have shifted more responsibility for health care onto unpaid “informal” health providers, also mainly women.
The end result of the new policies has been a weakened, chronically underfunded and under-staffed Medicare system with eroded public support. This has opened the door to calls for privatization and deregulation. The medical profession has facilitated this trend by persistently refusing to take into consideration any health factors that cannot be addressed within hospital walls, and by advocating high tech care even when it is immensely expensive and minimally beneficial.
Clearly, erosion of the social welfare system and attacks on living standards can have disastrous effects on the health of the poorest and most vulnerable people in our society. Despite major advances in health technology and correspondingly huge profits for the medical- industrial complex, we are now seeing a resurgence of largely preventable diseases in Canada – including a number of diseases such as tuberculosis that were once thought to be eliminated.
This grim reality only reinforces the importance of defending the universal health care system. Now is the time to renew the old slogan, “Health care is a right!”
