A Nobel-sized predicament for us
October 07, 2003
By David Gratzer
Ah, the problems of genius: The announcement of the Nobel Prize for Medicine is usually a subdued event outside scientific circles, perhaps because the celebrated work is so often inscrutable to us. But this year's prize will be given to two men who laid the foundation for a very practical and understandable invention: the MRI scanner. The awarding of medicine's highest honour to the fathers of this diagnostic tool speaks much about the innovation of modern medicine -- and the problems with our medicare.
Paul Lauterbur and Peter Mansfield share the 2003 Nobel Prize for Medicine. Lauterbur, an American, discovered the possibility of creating a two-dimensional picture by producing variations in a magnetic field. Mansfield, a Briton, showed how it's possible to use the signals emitted by the body in response to a magnetic field to create an image. Together, they have helped revolutionize diagnostic testing.
For those who have had a bad back or a bum knee, the scan is familiar. Indeed, while the first commercial MRI was used just 20 years ago, the invention has proven precocious in establishing its importance. For spinal injuries, MS, and certain types of brain tumours, the MRI is now the gold standard for diagnostic testing. We tend to forget, of course, the pre-MRI alternatives: painful surgeries, invasive tests, and -- all too often -- diagnostic ignorance.
But the celebration of the MRI scanner throws the spotlight on our health-care system. As the Nobel winners rejoice, Canadian politicians fret. No wonder. While the MRI scanner has revolutionized medicine, Canadian health care badly lacks this basic high-tech diagnostic machinery.
Canada has just 4.2 scanners per million people. Consider the international comparisons. Japan has 23.2 scanners per million people, more than anyone else. The United States isn't far behind at 17.4, followed by Switzerland with 13.0. The median for OECD countries is 5.4. We best Hungary and Greece.
Numbers matter. A Canadian neurosurgeon practising in western New York told me that by the time he arrives in the surgery suite, his patient has had a scan and been prepped for the procedure. No doc north of the border can make such a claim. In contrast, a Canadian family doctor practising in western Canada described to me a patient who waited a year for a scan to diagnose an acoustic neuroma, a slow growing brain cancer. Our politicians tell us that compassion is the basis of our health-care system; it doesn't seem that way.
The Canadian Institute for Health Information (or CIHI) recently released a report on diagnostic equipment. While CIHI touts itself augustly as "an independent, pan-Canadian, not-for-profit organization," it is funded primarily by federal and provincial governments. Analysts at CIHI crunch numbers well, but often fall into the trap of defending Canadian medicare, rather than studying it. Most of their work appears to follow the mantra: Apologize first, ask questions later.
The press release for CIHI's study on diagnostic imaging has a spin doctor's flair, starting with the banner headline: "Report Shows Dramatic Increase in MRI, CT Scans." But the picture painted is bleak. Not only do we have few MRIs relative to other countries, but we lag behind in terms of CT scanners and angiography. Provincial governments have started to acknowledge the deficiencies, but the technology gap is great.
And this is no accident. MRI scanners are expensive to purchase and pricey to run. Government planners have a simple strategy: Restrict the supply of these services. Waiting times are the result.
And, of course, the macro-management doesn't just apply to MRIs. There is a paucity of diagnostic machines across the country, and yet an abundance of government rules to govern over them. Medicare's managers cut back on medical and nursing school enrollees in the 1990s -- knowing that our population ages. Health Canada is slow to approve new pharmaceuticals; provincial governments are slower still in funding the new drug treatments.
Thus, so much of health care management is crisis management. The waiting time for bone scans becomes perilously long in Manitoba, so the government steps in; emergency rooms overcrowd in Toronto so the Minister of Health makes a score of announcements; rural Nova Scotia becomes depleted of family doctors, so signing bonuses are offered. People often ask why are we having so many problems. In a sense, we planned it this way.
The MRI scanner represents the tremendous advance in medicine that has occurred in recent years. It also symbolizes the incredible problem with our approach to health care. We have new and exciting technology that extends life and betters living; yet, we have a health-care system built on a 1940s concept of health insurance that rations care and restricts access. Medicare's defenders continue to embrace the latter at the expense of the former. And this offers a bitter reality to the sweetness of Lauterbur and Mansfield's victory.
David Gratzer, a Toronto physician, is the editor of Better Medicine: Reforming Canadian Health Care.
©2003 National Post
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