I'd seen this many times before: a generic travel poster promising jewel-toned, turquoise seas washing over dazzling coral-white sands. A pair of flawless sun-bronzed legs were framed by a cobalt-blue sky and lush, tropical foliage.
But the advertising slogan that dominated it was jarring.
"SUN SEA AND A NEW KNEE."
I was at Destination Health, a medical travel trade show recently held in Ottawa, Canada, standing in front of a sales booth for a clinic in the Cayman Islands. Aside from knee replacements, medical services on offer also included neural-spinal surgery, chemotherapy, and an extensive menu of other non-emergency procedures.
The booth was one of many representing clinics and medical travel services from places like Mexico, Costa Rica, Argentina, and Germany. While each clinic specializes in different areas of medicine, almost all promise the same thing to prospective customers: no waitlists.
Canadians take justifiable pride in their publicly-funded healthcare system, which promises free healthcare to all. It is fundamental to their cultural identity, founded on a deeply-held belief that access to primary care should be based on need—not on the ability to pay.
But instead of protecting the poor from the ignominy of preventable medical problems, B.C.-based orthopedic surgeon Brian Day, the former Canadian Medical Association president and one of the leading proponents for allowing pay-for-service healthcare options in this country, says that the much-revered Canadian system is not actually equitable at all. That's partly because wait times for some treatments are so long that it makes them effectively inaccessible. Unless, that is, you can pay to skip the line.
The story of a Quebec woman who waited nine years for an appointment went viral
According to a 2015 report by the non-profit think tank Fraser Institute, waiting for medical treatment is becoming a "defining characteristic" of Canadian health care. The story of a Quebec woman who waited nine years for a medical appointment recently went viral, partly because so many people can relate. The Canadian Institute for Health Information notes that in 2015, only 64 percent of Alberta patients had gotten cataract surgery within the targeted "benchmark" of 112 days. In B.C., 47 percent had received a knee replacement surgery within the target, 182 days.
182 days is a long time to wait—that's almost six months—and in B.C., it's worth emphasizing, most patients were waiting even longer than that for a knee replacement.
Medical tourism shows such as the one I attended could be symptomatic of a poorly performing system. Most of the target customers can afford the sometimes-hefty price tags involved in paying out-of-pocket to avoid waitlists, or are willing to go into debt to do so. Although foreign clinics might provide a timely service—one that comes replete with sun, sand, and surf—they might not offer the same degree of safety and oversight as what's available in Canada. Take the proliferation of clinics offering bogus, and often dangerous, "stem cell treatments": The New York Times recently featured the story of a patient who developed an aggressive mass after seeking stem cell therapies abroad.
Day called me on a recent Friday evening, after spending the day in the B.C. Supreme Court, where he has launched a court challenge against the provincial government.
His challenge on behalf of five plaintiffs (the sixth has since died) is based on the idea that people should be allowed to privately pay for medically necessary services, if these services aren't available in a timely fashion within the publicly funded system.
Day argues that taking away the patient's ability to choose a private alternative—and thus forcing them to suffer and even die unnecessarily while they wait for treatment—is a violation of their constitutional rights. If he's successful, critics argue, it could signal the end of Canada's universal health care access by creating a two-tiered system.
The lowest access and the worst outcomes in healthcare in Canada are in the lowest socio-economic groups
But in practice, two tiers already exist. Even if patients can't pay within Canada for medical treatment, they can travel to another country to do so.
"The lowest access and the worst outcomes in healthcare in Canada are in the lowest socio-economic groups," Day argued.
Valorie Crooks, an expert on medical tourism at Simon Fraser University, said that this oversimplifies a complex issue.
"His suggestion that wealthy Canadians have, on average, better health outcomes because they can afford to travel elsewhere for care is ridiculous, as it ignores the social determinants of health that we all know about," said Crooks when I phoned her.
She said that people with low socioeconomic status have poorer health outcomes because they have poor housing options, greater exposure to environmental toxins and hazards, less education, fewer connections with people of power or influence, fewer financial resources, and poorer nutrition when compared to those with those who are relatively well-off.
"One [doctor] told me to stop asking why and learn to live with it"
Some Canadians go abroad for services because they are looking for procedures, such as stem-cell therapies, that are not approved in Canada. Others, such as Michael Jubenville, an optician who lives in Windsor, Ontario, say they can no longer bear the suffering that comes with long wait times. He explained to me that he has the financial means to go abroad for treatment, but he first put his faith in the local healthcare system when he started experiencing debilitating neck pain, about 19 years ago.
Jubenville told me he tried unsuccessfully to get a diagnosis for 15 years, sometimes waiting years for consultations. He explained that he was often told the pain was all in his head.
"One [doctor] told me to stop asking why and learn to live with it," said Jubenville.
Finally, out of desperation, he visited the offices of Kelly Meloche, head of International Healthcare Providers in Windsor, who specializes in helping Canadians find diagnostic consultations and treatments abroad.
At stake is the very foundation of Canada's public health-care system
"He walked into my office, in great pain," said Meloche. "He told me 'my headache is bigger than this room'." She said she asked Jubenville what options had been offered to him so far. "He said, 'They are telling me to go to aqua aerobics.' "
Following an unsuccessful treatment in Florida, Meloche referred him to a specialist in the Henry Ford Medical Center in Michigan. "They diagnosed me with cervical dystonia literally within three minutes of arriving in the doctor's office," explained Jubenville.
Jubenville's experience presents a compelling case for having a hybrid model that compliments the public healthcare system with privately-funded alternatives. But at stake, as laid out by the B.C. government as it fights tooth-and-nail to keep the system as-is, is the "very foundation of Canada's public health-care system." Government lawyers told the court that if the plaintiffs succeed in their challenge, it would actually make the problems experienced by Jubenville and others worse.
This could happen, they say, by attracting doctors and other medical staff away from the public system, and drawing them to potentially more lucrative jobs in private clinics.
Following his diagnosis, Jubenville was able to get Botox treatment in the US for his condition, which causes muscles in the neck to contract painfully. "It was the first time I was myself in 15 years. It was wild. It just totally stopped," he said. But as he became increasingly resistant to the Botox dosages, his dystonia flared up again. He's currently unable to work, but is fortunate enough to be supported in part by the family business.
In Canada, Jubenville received a deep brain stimulation device (sometimes called a 'brain pacemaker'), which has helped manage his symptoms. In the US, an operation to implant the device would have cost in excess of $100,000, he told me. In Canada, the entire thing—surgery, device and all—was free.
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