Health care and research in Canada, 1978. Part II JACQUES GENEST, CC, MD, LL D, D SC, FACP, FRCP[C], FRSC
The high cost of health care is well demonstrated by the expenditures of the Ministry of Social Affairs in Quebec in relation to the total expenditures of the Quebec government in the last 7 years (Fig. 1). It is of great interest to note that the annual expenditures of the Ministry of Social Affairs for health care decreased as a proportion of the total expenditures of the Quebec government from 39% in 1970-71 to 34% in 197677. The cost of health care in total dollars has certainly gone up but not in proportion to the total expenditures of the Quebec government. Fig. 2 shows the equivalent expenditures of the Ministry of Health of Ontario. The adjectives used to describe the increase in the cost of health care ("escalating", "skyrocketing") would be more appropriate to the total expenditures of all governments. The ratios of the expenditures for health services to the gross national product (GNP) of Canada or to the gross provincial products (GPP) of Quebec and Ontario are described in Table I. Expenditures for health services in Canada went from 3.7% of GNP in 1970 to 5.7% in 1976 while the GNP grew from $85.7 billion to $190 billion! In Quebec, this percentage went from 6.8 in 1970 to
7.7 in 1976 while the GPP went from $21 billion to $45 billion. Advances in technology are certainly an important factor in the increasing costs of health care, whether for the management of patients with coronary heart diseases, intensive care units, renal dialysis and transplantation programs, CAT scanning, nuclear medicine or others. One cannot see the end of this expensive "halfway technology" so well described by Thomas,18 which has had only a minimal effect on the overall mortality rate for coronary heart diseases. These increasing expenditures can only be avoided in the long term by comparatively small increases in the budgets for biomedical research aimed at the discovery of the mechanisms of atherosclerosis, cancer and high blood pressure and their prevention. Critical phase Biomedical research in Canada has gone through a very critical phase,
Reprint requests to: Dr. Jacques Genest, Scientific Director, Clinical Research Institute of Montreal, 110 Avenue des Pins, Montreal, PQ H2W 1R7 Dr. Genest's article is based on the Williams D. Scully lecture, which he delivered in Hamilton earlier this year. 614 CMA JOURNAL/SEPTEMBER 23, 1978/VOL. 119
which started in 1969-1970 when the federal government froze all the budgets of its departments. The consequences were that for 6 years the budget of the Medical Research Council of Canada remained almost stationary, with minimal increases of about 5% per year during a period of two-digit inflation, 2.5- to 3-fold increases in the cost of scientific instrumentation and an average 2-fold increase in salaries of technical personnel. Not only has the budget of the MRC of Canada shown a consistent decrease when compared to GNP (from 0.38% in 1968 to 0.26% in 1976), but as a proportion of the total expenditures for health care in Canada, the MRC budget has decreased from 1.12% in 1969 to 0.46% in 1976. A similar striking decrease is seen if one expresses the total expenditures for medical research from government and private sources in comparison to the total expenditure for health care in Canada. The percentage, which was 1.23 in 1969, went down to 1.02 in 1975.
FIG. 1-Total expenditures of Quebec government and expenditures of provincial Ministry of Social Affairs, as shown in public accounts of Quebec.
No other nation of the western world has treated biomedical research in a more disastrous way. The least that can be said is that biomedical research in Canada has been the object of a persistent and tragic policy of neglect since 1969. What has been more irritating to the biomedical research community has been the great waste of public monies during that same period with the rebate practices and improper payments made by the Polysar Corporation, the payment of large and unaccountable fees by the Atomic Energy Commission, suspected to be for illegal or corrupt purposes and the leaking taps of many programs of our government - such as the $5 million for advertising to "improve the image of woman" or for the projects "Opportunities for youth", "New horizons" and "Canada at work, phase 2". Scientists find it unacceptable that so many grants under these programs are considered more important and receive a higher priority than biomedical research for the progress of health care and the future of Canadian society. The consequences of this tragic and short-sighted government policy since 1969 have included not only the loss of nearly 400 biomedical research workers, but even more important the lack of security for a research career. This insecurity, which has been felt deeply throughout the biomedical research community, has created a climate in medical schools, research institutes and teaching hospitals such that many young MDs and PhDs felt that there
was little future in biomedical research in Canada. With the funding situation and political pressures what they are, some governments have preferred to sprinkle ("saupoudrage") the meagre research resources on many small and isolated laboratories that do not have the critical intellectual mass or the possibilities of close interaction. The recent report of an ad hoc committee of the Quebec Health Research Council has demonstrated that such lack of vision and political expediency have resulted in great waste of money, minimal productivity and poor scientific performance.19 Four key solutions appear to be critical. They may resolve many of the secondary problems. First, experts and key representa-
tives from the medical profession must be an integral and important part of all committees of ministries of health or social affairs involved in defining policies, in planning and in implementation of decisions on all aspects related to health care. The climate of distrust and rejection of the medical profession must be changed before an irreversible situation develops at the expense of the public and of the quality of health care. Integration of medical experts into all these committees would do more than any other step to restore the interest and motivation of the medical profession, to prevent further degradation of the quality of health care and to bring a more effective control of the technological advances so important in the escalating costs of health care. Elected representatives and civil servants must realize that more than any other profession or social body, the medical profession has made the greatest progress in reforming itself and in attuning itself to the needs and the present goals of our society - even, in Quebec, to the point of accepting a ceiling on professional Conversely, politicians and highly placed civil servants must recognize their lack of expertise (in fact their ignorance) of the complex realities of health care and accept the vital collaboration of enlightened representatives of the medical profession. The numerous errors made in the last 8 years in health care have been too often the consequence of the absence of true experts from the committees that set policies, plan and
expenditures of Ontario government and expenditures of provincial
Ministry of Health, as shown in public accounts of Ontario. GMA JOURNAL/SEPTEMBER 23, 1978/VOL. 119 619
implement decisions. William J. McGill, president of Columbia University, shared that conviction when he wrote an editorial in Science Oct. 21, 1977: "The government and the bench should turn more frequently to special commissions constituted from the best and most responsible members of the scientific community in an effort to formulate wise public policy on the protection of the environment, public health and all major public safety questions." Destroy goodwill
If politicians and top civil servants keep ignoring the advice of the medical profession, they will alienate for a long time those most able to help them and the public; they will destroy the goodwill of doctors and their motivation for service. The consequences would be tragic. Premier William Davis of Ontario deserved to be congratulated when he recently set up the Taylor committee, including an equal number of civil servants and medical representatives, to study ways of containing the increasing cost of health care. Not only has this committee worked most effectively and with great mutual understanding, but it produced excellent and practical recommendations.22 The committee stressed that the "decision-making process should be less in the hands of the legislature, and more in the hands of the healthcare providers and the users of the health care system - the patients." It also stressed the importance of greater involvement of physicians in hospital administration, including budgeting (recommendation 11) and in the management of the health-care system as a fundamental requirement for improvement. The committee also asked that the Ministry of Health should consult fully the providers prior to making decisions about new programs. It is to the credit of Premier Davis to have shown such enlightened views and to have realized that no medicare system or any government will get anywhere unless it has the active collaboration of the medical profession. It is to be hoped that other provinces as well as the federal government will see the wisdom of such policies. I have never been able to understand how some economists, politicians and social scientists can venture with so much assurance and so
positively into the complex field of health care or biomedical research without even asking themselves whether they have the necessary expertise and knowledge. A green paper is, at present, being prepared on scientific policy in Quebec. The committee is chaired by a well-known and respected social scientist who has never had any experience of the laboratory or of what biomedical research is and the climate necessary for productivity. If, for example, I was offered the chairmanship of a research committee in the Ministry of Agriculture, this would become a problem of conscience for me and it would not take me very long to turn down such an offer since all my life has been spent in large cities and I have never lifted a bale of hay. The ready agreement of sociologists and economists to preside over such committees while being de facto so ignorant of the realities of health care or scientific research can only hurt their own reputations, since they lose all credibility among the scientific and biomedical research community. Second, the development of medical technology should be encouraged because it is an essential part of progress in the management and treatment of the sick and in our teaching hospitals. At the same time, such advanced technology should be controlled and preferably concentrated in the teaching medical centres instead of being disseminated in all regional hospitals. The teaching medical centres should be large. They should contain not less than 1000 to 1200 beds in large urban centres, if one wants to improve the teaching of medical students, facilitate clinical research by specialists (who need a sufficient number of patients for study) and enable such centres to serve truly as referral centres. How can a university hospital perform adequately its main mission of training young doctors with insufficient numbers of beds? How can clinical research facilities operate with so little clinical material? These comments are the more pertinent if one remembers that in the University of Montreal affiliated hospitals, more than 20% of beds are occupied by chronic and senile patients and therefore contribute little to the teaching of medical students, interns and residents and to clinical research. At the five affiliated teaching hospitals of the University of Montreal,
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each understandably wants to be fully equipped for renal dialysis, cardiac surgery and neurosurgery; to have special units for coronary, burn and shock patients; and to have cobalt bombs, betatrons and CAT scanners. This results in the duplication of expensive equipment and of expert personnel with a very low benefit-cost ratio. It would be far better to have two large teaching centres of 1000 to 1200 beds each and to concentrate the major technology in those centres, which would serve as referrals for large regions. I am sure that with the help of experts from the medical profession, it should not be too hard to divide the range of medical and surgical possibilities between regional hospitals and teaching medical centres. But if such a solution is imposed by bureaucrats and politicians without the intimate involvement of experts and respected members of the medical profession, it would surely meet with fierce opposition, as has already been the case. No one can argue against some priorities for the care of the aged, the handicapped and the poor, and for industrial medicine, but these priorities should not be attained at the risk of destroying other aspects of medical care and producing a dangerous disequilibrium in respect of biomedical research, teaching medical centres and hospital care. Necessary modifications Third, important modifications should be made in the teaching in our medical schools.23 Under political pressure to increase the number of admissions (a major error that took 8 years to realize and to correct) our medical schools have been in danger of becoming trade schools! There should be special emphasis on clinical skills and judgement, compassion and understanding and bioethics. This would decrease the number of unnecessary laboratory tests, x-ray examinations and prescriptions, with a consequent decrease in the cost of health care. Almost every patient coming into a hospital receives a prescription by the intern for a tranquillizer or a barbiturate. Medical students should be taught the basic principle that the optimal care of a patient must always come from the heart of a self-motivated and competent doctor.
I doubt that high quality medical care can be provided by young doctors who go into practice after only 1 year of internship as is at present the case for about two thirds of recent graduates. Although it can be debatable, I firmly believe that future general practitioners should have a 3-year hospital training, including 1 year of internship and a 2-year general medical residency, before being recognized as general practitioners as the Royal College of General Practitioners in Britain will require by 1981. In this way, we would solve the problem of the specialty of internal medicine which has long since become too vast for any one specialist. Best care, best doctors Fourth, the wishes of the Canadian public are cleaP in demanding the best possible health care and the best possible doctors. Therefore, our elected representatives must give increasing financial support to biomedical research which is the basis of better health care and of better doctors. It is to the credit of Senator Maurice Lamontagne that he has realized the importance of research and development for growth and progress..".'26 It is unfortunate that so far little success has been achieved in that direction. It is not enough to be satisfied that Canada outranks such countries as Turkey, Greece and Ireland in devoting 1 % of its gross national product (or $2.1 billion) in 1q77 to R & D, when Japan, Germany and the United States are spending between 2% and 2.5% of their gross national product on R & D and when a mere two companies in the United States (General Motors and IBM) surpass the whole of Canada in their budgets for R & D.27 Even Marc Lalonde, when minister of national health and welfare, admitted after the symposium on health research priorities in Canada at McGill University on May 25, 1973, that: "Health research in its broadest terms, including basic, clinical, sociomedical and organization, is underfinanced when account is taken of the fact that health care is a $7 billion industry in Canada." Recent studies suggest that a definite fixed percentage of the budget for health care should be reserved for biomedical research. Fraser, an economist from Queen's, has pro-
posed98 after a detailed study that 4.5% of all expenditures on health care go to health research in line with the recommendations of the Lamontagne report. This would place Canada in line with other developed countries of the Western world. It would also be a sign of the maturity and excellence of our country in emphasizing the value it places on intellectual achievements and contributions to the advancement of human knowledge. This would give to biomedical research workers the necessary sense of security for a research career and encourage young doctors to choose such a career, either in the basic departments of our medical schools and in clinical research centres or institutes. Budgetary planning of biomedical research funding for 5-year periods, as done in Great Britain, would be a great advance. We are fully in accord with Lalonde's "A new perspective on the health of Canadians"29 in which there is special emphasis on prevention. But it must be realized that the three major killers in modern times cancer, arteriosclerosis and hypertension - cannot be prevented unless more funds are invested in research for understanding their mechanism so that better and more specific treatment can be established. Conclusion
References 1. GENEST J:
rance-Hospitalisation. Relations 220:
90, 1969 2. PARK EA: Changing medical care in our changing national life. J Pediatr 31: 599, 1947 3. CANADIAN HOSPITAL COUNCIL: Prin-
5. 6. 7. 8.
ciples of Health Insurance Related to Hospital Participation, 1942, p 2 COSGROVE G: Public Opinion on Medicare. Canadian Institute of Public Health. Montreal Star: A-il, October 22, 1977 Health and Happiness (E). The Wall Street Journal CXCI (29): 10, February 10, 1978, editorial p 14 LAFRAMBOISE J: La d.shumanisation des soins hospitaliers. La Vie Mi.dicale au Canada Fran.ais 6: 755, 1977 Roir A: Du fiel pour Castonguay, et du miel pour Laurin (C). La Presse: July 6, 1977, p AS Roy A: Report of the President. Bulletin de la Corporation Prof essionnelle des Medecins du Qu.bec 12: d6cembre, 1972, p 180 CASTONGUAY C: The Quebec Experience: Effects on Accessibility, in National Health Insurance: Can We Learn from Canada? S. Andreopoulos (ed), Toronto, John Wiley and Sons,
1975, pp 97-125 10. PICKERING G: Medicine on the brink: Dilemma of a learned profession. Perspect Biol Med Summer 1978, Issue, p 551 11. GENEST J, BECK JC: Comments on the Report on Medicare (Vol. I) of
the Castonguay Commission, Province of Quebec. Can Med Assoc J 97: 1530, 1967 BECK JC, GENEST J: Le Volume II du Rapport de la Commission d'enqu.te Castonguay sur la Sante et le Bien-Etre. Union M.d Can 96: 1117, 1967 SHEA M: Committee to study resident distribution in Quebec. Medical Post 13 (10): 34, May 10, 1977 DIoN L: Interview with Lesage, G. La Presse, A6, April 14, 1973 GINGRAS G: Interview with Diebel, L. Montreal Gazette, May 8, 1972, p 21
Although my words may be harsh, they reflect my impatience at the many preventable mistakes made in 13. health care and health research, which are in great part due to the 14. elimination of all medical experts and representatives on the committees in- 1S. volved in the planning, decisionPROFESSIONNELLE DES making and implementation for the 16. CORPORATION M.DECINS DU QU.BEC: Rapport Anorganization and distribution of nuel 1976-77, Tableau IV, Montr.al, health care. Social science and bu1977, p 35 reaucratic knowledge cannot be sub- 17. TURCOTTE C: Des m.decins immigrants condamnent les quotas. Le stitutes for experience and expertise Devoir, LXJX (285): 9, December 10, in health care delivery and biomed1977 ical research. My strong feelings 18. THOMAS L: Notes of a biology-watchcome from taking an active part in er: your very good health. N Engl J trying to improve the present state Med 287: 761, 1972 of health care and health research 19. ROCHON J (chairman): Report of the "ad hoc" Committee on Evaluation of in Canada and of preventing its furResearch in the Hospital Establishther deterioration. There is sufficient ments of the Ministry of Social Affairs goodwill everywhere in Canada that to the Health Research Council of I have strong hopes that corrective Quebec. Quebec, May 1977 measures will soon be taken for the 20. LALONDE C: Pour la FMSQ: Contr6le des revenus et auto-regulations. Can welfare and the progress of our Med Assoc J uS: 1247, 1976 country. Otherwise we will fast be 21. Idem: Les omnipraticiens qu.b.cois regressing to a very low quality acceptent le plafonnement de leur restandard of health care. venu. Ibid, 670 CMA JOURNAL/SEPTEMBER 23, 1978/VOL. 119 623
22. KASTNER P: Taylor Report backgrounder: strange bedfellows suggest ways to control cost of health care. Medical Post 14 (3): 13, January 31, 1978. (The Taylor Report can be obtained from the Ontario Ministry of Health.) 23. HOULD FJ: La formation du m6decin conscient des cofits de la sant& La Vie M.dicale au Canada Fran.ais 6: 946, 1977 24. LAMONTAGNE M (chairman): A Science Policy for Canada. Report of the Senate Special Committee on Science Policy. Volume 1. A Critical Review: Past and Present. Ottawa, Queen's Printer, 1970
25. Idem: A Science Policy for Canada. Report of the Senate Special Committee on Science Policy. Volume 2. Target and Strategies for the Seventies. Ottawa, information Canada, 1972 26. Idem: A Science Policy for Canada. Report of the Senate Special Committee on Science Policy. Volume 3. A Government Organization for the Seventies. Ottawa, Information Canada, 1973 27. STEKLASA R: Build our R&D - or see unemployment rise? The Financial Post 72(5): 4, February 4, 1978 28. FRASER RD: The economics of health research. A report to the Ontario
Council of Health, Toronto, Ontario Council of Health, 1973 29. LALONDE M: A New Perspective on the Health of Canadians - A Working Document. Ottawa, Government of Canada, April, 1974
Figures used in these articles came from the following sources: public accounts, federal Department of Finance; public accounts of Ontario, Ministry of Treasury Economics and Intergovernmental Affairs; national income and expenditures account, Dominion Bureau of Statistics; Revue Statistique du Qu6bec; federal Department of National Health and Welfare; Ontario Ministry of Health and the Quebec Mmistry of Social Affairs.
Baycrest Centre for Geriatric Care. Part II: Community living at Baycrest Terrace DAVID WOODS
Rebecca Lesk is petite and neatly that is actively encouraged and fosdressed, a lively, twinkling lady. tered there. Gracious, vulnerable, yet somehow At Baycrest Terrace joining-in, sturdy. Everyone's idea of a favourite being a part of something, starts with grandma. the design of the building itself She is one of 230 residents at Baycrest Terrace, an 1 1-storey building of self-contained apartments for elderly people who can take considerable responsibility for their own lives, who need a minimum of nursing or medical help. In fact, Mrs. Lesk is seven times a great grandmother, a sprightly 85 years old; she could pass for a good 15 years younger, a fact she attributes briskly to "walking and working." A widow for 38 years, she worked until she was 70 in a dress shop in her home town of Santa Monica, California, before moving to Toronto to be near grandchildren and great-grandchildren. Nowadays she proudly wears the badge that announces her role as a volunteer tour guide at the terrace. Like many of the residents at the Baycrest Centre for Geriatric Care, of which Baycrest Terrace is one of five elements in an integrated whole (CMAJ 119: 511, 1978), Mrs. Lesk likes to be busy and active, to be a participant rather than a passive observer. She is an example of what Baycrest's medical director Dr. Cyril An apartment suite Gryfe calls the high level of function
not just another typical city apartment complex, a high-rise cuboid, stacking floor upon floor of adjoining cells. The terrace is triangular; this means there are no long and
at Baycrest Terrace
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