What does Brian Day say (or not) about privatized medical education?

In August, the Canadian Medical Association passed a resolution during its annual meeting in Montreal calling for “public-private partnerships to facilitate the expansion of medical school capacity.” According to Brian Day, an orthopaedic surgeon and immediate past president of the Canadian Medical Association, Canada has a single-payer problem in medical education and in payment for physician services, which he said means “splitting up a pie that’s not big enough” resulting in a “rationing of resources.” During a talk to the University of British Columbia Clinical Faculty Association in October, he emphasized that Canadian health care is underfunded, and he predicted that, consequent to the Chaoulli decision, all provinces will follow Quebec`s lead to allow private funding of medically necessary services.

According to Dr. Day, private funding is needed: “That’s the way we’re going to get better health care for more people and how we’re going to get better funding for medical education.” He gave examples of private funding for medical infrastructure in Vancouver: the Jack Bell Research Centre, the Pattison Pavilion of the Vancouver General Hospital, and the Gordon and Leslie Diamond Health Care Centre. “This is all private money going into ‘public health care,’” he said, but if he meant to illustrate how the profit motive can enhance health care, his examples failed him. All three of these buildings, which are part of the Vancouver General Hospital clinical, education, and research campus, were named for prominent BC philanthropists.

I join Dr. Day in applauding the generosity of these donors, and I hope that wealthy people will continue to enhance medical research and education in Canada through charitable giving. But donation is not the same as investing in health care funding and delivery in order to generate profit. Surely the distinction does not escape Day, so his confusion is puzzling. Furthermore, he mentioned none of the problems that commercial health care can bring, which Dr. Marcia Angell presents in a recent Canadian Medical Association Journal essay. You can read more about peer-reviewed research on the downside of privatization on the CDM Web site.

As the meeting drew to a close, Day pointed out that Canada has too few physicians. Given a physician density of 2.1/1000 compared with a mean of 3.1/1000 among OECD countries, few would argue that Canada should not train more doctors. Day then brought up the proposal of a new medical school situated in BC’s Fraser Valley and affiliated with Simon Fraser University. This is the best thing that could happen to the UBC clinical faculty, he said, because UBC has a monopoly. He suggested that clinical faculty, some of whom are unhappy about UBC’s unwillingness to bargain with them collectively, would be better off if another institution provided competition. When an audience member asked about the role of a public-private partnership in the venture, he said the medical school would likely be in Surrey, BC and added, “I know more than I can tell you.”

According to two members of the SFU Faculty of Health Sciences, the medical school they and their peers envision would promote primary care and community medicine. Brian Day is not known as a champion of these issues. He founded a private surgical clinic, and during his remarks, he said that once Canada eliminates wait lists, medical tourism can develop as a “big industry” to provide procedures for well-off foreigners. This would be a source of funding for domestic health care, but he didn`t go so far as to say it could also create profit for investors and clinic proprietors, such as himself. Before the meeting ended, Day and some supporters obtained a hasty vote, with as many abstentions and nays as yeas, in support of the concept of a second medical school in BC.

Do we need more medical graduates? Yes, and UBC has just expanded its entering medical class to 256 students. It’s unlikely that the province will support another medical school right away, given the establishment of campuses in Prince George, Victoria, and Kelowna. Private money may be necessary to open a second faculty of medicine, but private-school graduates would come away with high debt, and if Day’s vision of commercialized payment and delivery prevails, perhaps an indoctrination.

Randall F. White, MD

More on Howard`s complaint and its significance

by Randall F. White

Melvin J. Howard wanted to build "the largest privately owned health center in Canada.” According to documents filed with Foreign Affairs and International Trade Canada, he incorporated Regent Hills Health Centre in January 2003 in the province of BC. The original plan involved purchase of 9.5 acres in Vancouver, and he had begun securing financing and undertaken negotiations with the Canadian firms DGBK Architects and Ledcor Construction, Ltd. The scheme involved a Delaware company which would raise funds by selling bonds through Ziegler Capital Markets, a U.S. investment bank specializing in health care financing, "exclusively to American citizens, funds and companies." The loan would have passed through TD Bank in Vancouver, but the money would have flowed from and to the United States.

The Regent Hills Health Centre intended to offer outpatient surgery, laser dentistry, diagnostic imaging, physical and occupational therapy, ambulatory and medical education programs. The 215,000 square-foot building would have housed 14 operating rooms and 110 beds. Nowhere in the documents is a mention of how many physicians and nurses would be needed, how they would be recruited, or any acknowledgment of the peculiarities of health care financing in British Columbia such as the Medical Services Plan.

Howard wanted to open Regent Hills in February 2007, but given the dates on the documents, his plans in Vancouver have been derailed for some time. In the NAFTA complaint, Howard alleges obstruction of permitting by "municipalities or city officials," and loss of deposits on contracts to purchase 5 separate land parcels. Documents suggest he may have shifted his plans to Surrey after Vancouver denied him permission. Furthermore, he mentions "community activist (sic) opposing the private surgical center."

All this indicates that Mr. Howard doesn't give up easily. He is angry, aggrieved, and perhaps grandiose. But according to Todd Grierson-Weiler, Canadian attorney who specializes in NAFTA arbitration, Howard’s submission is amateurish and has little chance of advancing. As for his threat to invoke the General Agreement on Trade in Services, according to Ellen Shaffer of the Center for Policy Analysis on Trade and Health, only the U.S. government could initiate this action against Canada. Unlike NAFTA, the World Trade Organization, which administers GATS, does not permit investor-initiated actions against member states.

So perhaps this is a tempest in a teapot, but dismissing the “NAFTA bogeyman,” as Grierson-Weiler does, fails to acknowledge the crucial lesson. U.S. corporations are not going to give folksy Canadian entrepreneurs a free run. If a market in health care develops in Canada, multinationals like Minneapolis-based United Health International will be at the ready, and for them, NAFTA will be an essential tool.