Mark Miller, C.Ss.R., Ph.D.
In Canada it is not enough
to count our health care blessings
At the end of October the Canadian Bioethics Society held its I I th annual convention in Edmonton. Invited to the meeting were the executive board members of the International Association of Bioethics. These committed bioethicists came to Edmonton to share some of their experiences and expertise with those of us who work in the Canadian health care system.
The presentation that struck me most deeply was by a woman philosopher, Hasna Begum from Bangladesh, who spoke about the influence of poverty on health care. This courageous woman is trying to bring a basic health care ethic into the practice of medicine in her country. She is finding much resistance among the privileged medical elite (most of whom are male); but her talk focused on how difficult it is to talk about medical ethics when the overwhelming reality for most of the people of Bangladesh is pitiless poverty. Her presentation provided one of the clearest examples of the relationship between poor economic conditions and a struggling health ethic for the people.
To begin with, in order to stay in power the governing party must use most of the country’s budget on the “defence” sector, despite large numbers of troops that literally have nothing to do. Hence health and education, proper communication systems, etc., all receive what remains after the military’s insatiable appetite has been, if not stilled, then at least held at bay.
Begum also pointed out that unstable governments, quite common in developing nations, are particularly vulnerable to pressure from the military. Corruption at all levels increases the inequities.
Furthermore, Begum observed that much of the aid money that governments of developing nations receive from the First World simply fills the pockets of the local wealthy. Where there is money, there are always people willing to ensure they get their share (or more), while the poor often benefit scarcely at all. Foreign aid can hardly be called “aid” if it does not reach those in need. (This is one reason, in my own thinking, for such services as the Canadian Catholic Organization for Development and Peace which has a long history of putting the donations of Catholics into the hands of local people where projects will serve local needs.)
Because the general populace is uneducated, the accountability of the medical profession also leaves something to be desired. Using examples from the Dhaka daily newspaper, the Independent, Begum provided evidence of the incompetence (or, perhaps worse, the uncaring attitude) of some doctors. For example, a 16-yearold boy underwent surgery for the removal of a diseased kidney. The doctor removed the wrong kidney and the boy died several months later, his family completely impoverished after paying for his hospital care. The medical establishment tends to protect rather than discipline such doctors.
The number of medical professionals is also inadequate for the population. For 120,000,000 people, there are 28,459 doctors -and only 319 registered nurses! Many medical professionals, she also pointed out, seek good salaries by treating only the better-off and they have no scruples about ignoring the poor and indigent.
Drug companies from First World countries, often in collusion with local medical personnel, test and use unproven drugs (and, at times, dump risky drugs) because the ethical demands for the protection of research subjects are unenforced in such poverty stricken nations. Begum said that to her knowledge there is not a single ethics committee in all of Bangladesh, her own efforts to challenge the failures of the medical system notwithstanding.
Are there lessons for us in Canada? I believe there are many. To begin with, Begum’s straightforward analysis made me appreciate. two things about our Canadian health care system. First, it is there for us, regardless of the problems we face. And, consistently, at least 85 per cent of Canadians who have experienced the system’s care firsthand have reported being “fully satisfied” with the care they received.
Second, as Tim Flaherty, from Health Canada, pointed out in his response to Begum’s paper, we are a society that is consciously and consistently working to make our system more ethical, more responsible and more cost-effective. We have many glitches (some rather large), but we are working on repairing what we can, as we can. And this repair work on the system is not only possible, but is part of the system.
Furthermore, Begum’s talk made me look at -poverty in Canada. Unquestionably, the poor have poorer health, in part because they are not educated to work the system, in part because they often live further from the particularly good care (as on our reserves), and in part because aspects of poverty, like diet and stress, take a toll on health.
From an ethical point of view, I was reminded that our good Canadian medical system must constantly work to ensure that the poor and all the marginalized are treated fairly (in the Catholic perspective, we would call this the “‘option for the poor”) and are not overlooked in the planning and providing of proper health care.
But I was even more troubled by the realization that a “national ethic of health care” (looking only at Canada) is terribly myopic when one hears that even the basic provisions for protecting health are beyond the reach of the poor in places like Bangladesh.
It is not good enough, I believe, for us in Canada to be grateful for what we have in health care. We need to begin thinking about a global social justice where what we take for granted, perhaps in accord with a more frugal and simpler lifestyle, can become the norm for all peoples.
It is.fortuitous that the winner of this year’s Nobel Peace Prize was Doctors Without Borders. These brave medical personnel often go where poverty and war have made a shambles of people’s lives. They give of themselves to help people live and heal and survive. They become a model for all of us about seeing the needs of our brothers and sisters beyond our own borders. And they remind us that the conditions of poverty (,and notice how often war is fought in poor countries) make health care a much bigger issue than hospitals and doctors and our own care.