Medicine as a Community Commitment

By John Spragge

Imagine, for a moment, that an Iranian commando team has landed at Hunt's Point in the South Bronx, and set up an enclave under their military and political control. They have laid claim to all the South Bronx as the sacred soil of the Islamic Republic of Iran. The Iranian flag waves over the Grand Concourse, and baseball fans going to a Yankees game have to pay for their hot dogs (the Iranians will have outlawed the beer, of course) in Iranian currency.

Does anyone believe for a moment that American would respond to such a situation with a cost-benefit analysis? Does anyone believe the United States would concede an inch of its sovereign territory if such a cost benefit analysis showed their citizens, who live in that territory, could not repay the cost of their own defence? Who can doubt the first Iranian soldier to wade ashore would learn, instantly and painfully, that the South Bronx belongs to the United States, and the American government will defend its citizens, their homes, and their rights?

Which leaves some of us, who view the matter from the Canadian perspective, wondering why the prospect of defending their health arouses such controversy. The Iranian government does not have a beachhead in the South Bronx, or in other impoverished parts of American cities, but tuberculosis certainly does. Millions of Americans lack health insurance; millions more belong to health maintenance organisations, which may or may not agree to pay for the care they need. The US military would not think of abandoning even a handful of these people to a hostile nation without doing everything possible to defend them; but American politicians seem unable to grasp the extent to which health care affects everyone in the community, and therefore demands a community response.

Certainly, the presence of tuberculosis in the Bronx presents no less of a security threat to the wealthy streets of Manhattan than an Iranian occupation force would. This society has had plenty of painful lessons in the nature of diseases by now. We used to consider them a divine punishment; more recently, American society has treated them as a personal problem for the sufferers. As our recent experiences with germs make clear, it makes more sense to regard them as information systems, storing up the best strategies for defeating the human immune system and then devouring the humans. The more people germs infect, the more information they accumulate, and the more dangerous they get. Our experience with antibiotics should have made it clear to us that no magic bullet can take the place of effective health care, which safeguards people from infection in the first place.

Discussions about how best to provide services matter less than the spirit of those discussions. Americans do not propose to "privatise" military protection and expect individuals or communities to "contract" for protection, because they rightly see the protection of all citizens as a national responsibility. Many Canadians see health care in a similar light, and some of us find it mystifying that Americans do not. The precise manner in which the community takes care of its members who need care matters less than the basis for providing it: not as a service for those who can afford it, but as both a responsibility as a matter of self protection.

This discussion may raise the question of whether or not Canada's own health care system could use improvement. Of course, the Canadian health care needs to improve, and to continue to take full advantage of technological progress. But whether or not Canadians should improve our own health care system has nothing to do with the question of whether or not Canadians or Americans should treat the health of all of our citizens as a community responsibility. Those who frame the issue as a conflict between excellence and equity should consider two important measures of the success of a health care system: infant mortality (which Canadians suffer at a rate significantly lower than Americans) and life expectancy (Canadians live, on average, about four years longer). These measures hardly describe the collapsing system some commentators like to portray. During one of his presidential campaigns, Paul Tsongas claimed that if he had depended on the Canadian health care system, he might have died. The staff of Princess Margaret hospital in Toronto took out an indignant advertisement, pointing out the Princess Margaret Cancer Centre had developed the very treatment that had prolonged Senator Tsongas's life.

These details matter; the possibility of making improvements in Canada's health care system, which have the potential to save lives, matters a great deal. But the details matter less than the central question: why does a country which treats protecting the Albanians from the Serbs as an urgent national priority somehow lack the resources to protect the people of the South Bronx from tuberculosis and other deadly diseases?

John Spragge, a Canadian computer programmer and pilot, currently sojourns in Ann Arbor Michigan.