What Bernie Sanders Missed on His Canadian Health Care Tour
In major cities like Toronto, heart attack patients have access to state-of-the-art care. But what about in smaller municipalities like Red Deer?
A staff member of U.S. Senator Bernie Sanders huddled over David Lynch, a patient at the Peter Munk Cardiac Centre in Toronto, Ontario, this past October and asked him if he would receive a bill for the services rendered during his stay, to which Lynch responded, “No, no I am not.”
Their conversation was part of a larger tour of the Canadian health system by Mr. Sanders and his team in their efforts to show citizens back in the U.S. some of the benefits of a publicly-funded health care system.
Sanders highlighted the inefficiencies of U.S. health care in a speech at the University of Toronto, saying the biggest road blocks to cost-effective care in the U.S. have been commandeered by greedy politicians before driving his audience to consider what his home country can learn from the Canadian system.
“We in the United States have to ask a simple question,” he said. “How does it happen that, here in Canada, you provide health care to every man, woman and child, and you do it at 50% of the cost that we spend on health care in the United States?”
It’s a good question.
In the case of David Lynch, he will return home from the cardiac centre without having to a worry about an impending bill to cover the 24-hour care he may have received from cardiologists, respiratory technicians, nursing staff, and possible life support systems.
That’s a stark difference from the U.S., where depending on what city you may be unfortunate enough to have a heart attack, you could be looking at a bill for around $10,000 for just two days in the hospital.
Cost-effectiveness is, after all, at the crux of a good health care system for any country, but in Red Deer, the third largest municipality in Canada’s Alberta province where the mortality rate is 50% higher than in the Edmonton and Calgary areas, cardiac patients may be worried about more than a bill for $10,000. When suffering a heart attack, they’re often worried for their life.
What Bernie Sanders missed in his Canadian health care tour was an experience like that of Ken and Isabelle Johnston.
About a year before Sanders’ speech in Toronto, the Johnston’s were sitting down at the kitchen table for breakfast when Ken picked up the newspaper and grabbed his wife’s attention. Ken, who was then serving his first term as a city councillor in Red Deer, was shocked to read that planned advances to the care provided at the Red Deer Regional Hospital, including the addition of a cardiac catheterization laboratory, had somehow completely disappeared from the Alberta Health Services capital improvement plan.
“I immediately reacted to it,” says Ken. “Frankly, as a 62-year-old male, I sort of fit the cardiac profile for heart attack risk.”
But it wouldn’t be Ken who would suffer a heart attack. It would be his wife, Isabelle.
Cardiac catheterization labs contain equipment necessary for coronary angioplasty, a procedure commonly used to treat heart attacks with an average success rate of 95%. The coronary angioplasty and the technology required of the cardiac catheterization labs that enable the procedure aren’t new. And neither is Red Deer Regional Hospital’s fight for a cardiac catheterization lab. For over two decades, angioplasty has been validated in more than 20 high-quality studies as the standard care procedure for heart attacks.
For over a decade, physicians at Red Deer Regional Hospital have been asking their government for a cardiac catheterization lab to perform this life-saving procedure to no avail. Numerous studies have been published that prove the mortality rate for cardiac patients in central Alberta is 50% higher than for those living in the Edmonton and Calgary areas.
Petitions have been circulated and delivered. The Central Zone Medical Association endorsed and wrote a letter to the Minster of Health. Public rallies have been held. At least $10 million had been pledged to institute the lab and still, central Albertans wait for this basic cardiology program.
To aid in their efforts, Alberta Health Services (AHS) designated a committee of health care professionals, researchers, community leaders, patients and policy makers from Alberta to the Cardiovascular Health and Stroke Strategic Clinical Network (SCN). This particular SCN was tasked with reviewing the necessity of a cardiac catheterization lab at Red Deer Regional Hospital (RDRH). In its conclusion, the Cardiovascular Health and Stroke SCN provided specific recommendations and guidelines for physicians at RDRH to follow in order to receive the requested lab in what they claimed would be three to four years.
The report was completed in December 2014, but its release was delayed more than 18 months and it was uncertain which level of AHS ever reviewed this document.
“When we reached that point, we were told all of this needs to be reviewed again,” says Gustavo Nogareda, MD, Director of Cardiovascular Services at RDRH, who was among the first researchers to ever test the success of angioplasty for heart attack patients. “Our work for the last eight or nine months was focused on analyzing the problem again. So, basically, for over a decade we go through reanalyzing the same thing again and again in this bureaucratic process that never finally reaches a conclusion or a plan and wastes tax payers funds. It is sad to miss the opportunity to reduce preventable death and disability when it can be done by implementing simple strategies that also reduce operational funds.”
Despite the grave mortality rates of heart attack patients in central Alberta and more than a decade of analysis, RDRH is still without a cardiac catherization lab.
While the fight rages on, families like the Johnston’s continue to suffer.
A month after the Johnston’s read about the disappearance of the cardiology program from AHS’s capital plan, Isabella awoke with a dull ear ache. A talented artist, home renovator and an extraordinary mother, Isabella went about her day despite the pain. But by 8p.m., she was in full blown cardiac arrest and was rushed to RDRH for treatment.
Despite years of training on how to use a cardiac catheterization lab to treat heart attack patients, the competent cardiology staff at RDRH knew their treatment services were limited. They immediately gave Isabella a clot-busting agent called a thrombolytic to stabilize her. But the clot-buster is only a temporary fix with a failure rate of 40 to 50% and potential negative effects like the increased risk of stroke.
Once RDRH cardiologists administer the clot-buster and their patient is stabilized, they must work with their teams to prepare patients to be transferred via an ambulance or helicopter to the nearest available hospital with a cardiac catheterization lab in Edmonton or Calgary.
In central Alberta, where the winters frequently bring heavy snowstorms and ice, transporting a patient in cardiac arrest is far from ideal. To transfer a patient from RDRH to the Foothills Medical Centre in Calgary, for example, takes around four hours or more, and when it comes to heart attack patients, time is muscle. The longer a patient has to wait for proper heart attack treatment, the worse the damage to their heart gets.
In Isabella’s case, she was transported by helicopter to Calgary with inopportune odds for survival.
“Your day starts a certain way and by midnight, you’re watching your wife depart off a helipad with a less than 50% chance of survival,” said Ken. “It’s very, very surreal.”
But Isabella made it to Calgary where she was given a cardiac angioplasty to save her life; however, too much time had passed before receiving proper treatment and Isabella’s heart was below 40% capacity upon returning to the ICU at RDRH for recovery. She would spend 100 days fighting for her life before she passed.
“Isabella was able to come to terms with the fact that her heart would never return to normal,” says Ken. “She spent 100 days in the ICU preparing us for her departure, but her heart attack shouldn’t define her. It was her demise, but not her life.”
Since then, Ken, who was recently re-elected as a city councilor, has been quietly working to gather constituents in the fight for the cardiac catheterization lab. Through conversations with members of parliament, labor unions, and physicians, Ken is working to try to get all parties together in one room to solve the issue once and for all.
“The municipal government act charges municipalities with certain duties to the citizens which we represent,” says Ken. “A core duty is a good quality of life. No one can tell me in a room full of professional adults, that we can’t arrive at a deal. No one can say that’s not possible.”
Even with public rallies, petitions, and letters from the Central Zone Medical Association, Dr. Nogareda cautioned that while the community is very involved, their ultimate trust in the equitability of the system can make it challenging to mobilize people in demanding actionable change.
“I came from Argentina where around 50% of people would typically say ‘no’ to participating in a clinical trial,” he said. “But here, in Canada, people trust the system so much that, in my experience, 90% of people say ‘yes’ to clinical trials.”
And for many Albertans, especially those living in large urban areas, they’ve had every reason to trust the system. Part of the mission of Alberta Health Services’ strategic plan is “to provide a Patient Focused Health System that is accessible and sustainable for all Albertans.”
Take Kaniz Shafiq, a lawyer from the UK whose husband has been an internist at RDRH since they moved to Red Deer in 2006, for example. Kaniz had been aware that RDRH provided limited services and didn’t mind traveling to Calgary or Edmonton for dermatology needs; however, it was when her husband suffered a heart attack while on call at RDRH that she realized the gravity of the situation.
“I rushed to the hospital before gathering my three children to follow my husband to Edmonton,” she said.
As the ambulance drew nearer to the hospital, Dr. Shafiq lost consciousness for eight minutes when he suffered a second heart attack followed by a cardiac arrest requiring resuscitation.
“They revived him and we’re truly blessed that he’s good, but I don’t even like to think about the damage it’s done to his heart,” said Kaniz. “It was preventable! He had his second heart attack because we don’t have a cardiac catheterization lab. The second attack was preventable.”
Like Ken, Kaniz joined the rank and file of central Albertans fighting for the cardiac catheterization lab. She went to legislators who refused to talk to her, telling her they didn’t have time. She wrote to members of parliament and was ignored.
“I will go down on my knees and plead and beg if that’s what it will take, but I don’t think it would work,” says Kaniz. “AHS has a duty of care to Red Deer, Edmonton and Calgary, and right now, their duty of care is limited to Edmonton and Calgary. This is a breach of their duty and they’ve been made well aware of this through publications and reports that stated if we don’t have this facility in central Alberta, we will lose lives. And we literally are.”
It’s especially frustrating in an affluent community like Red Deer, where Dr. Nogareda likened it to “the Texas of Canada” due to the city’s history as an oil boom town. And just like Texans, the citizens of Red Deer are extremely proud of their community.
The people of Red Deer are diligent and have spent generations building their city up to what it is today with robust community centers, bike paths donated by the oil industry, and neighborhoods that have garages that can hold two cars, a motorcycle, and probably an RV too. In truth, they are some of the most hard-working and industrious folk who are the type to refuse to come into the hospital until they have crushing chest pain.
But with the demand for cleaner energy and renewal resources, the oil business is less lucrative and despite a growing population, Red Deer is experiencing a shift. Shortly after Dr. Nogareda moved to Red Deer, he witnessed Alberta’s health care structure change from one where geographical areas had their own form of local decision-making to a more centralized system. The resulting changes don’t allow smaller communities like central Alberta with a population of half a million people to influence their health care system in the same way as cities like Edmonton and Calgary with roughly 1.3 million people.
But with a potential $10 million donation from the Red Deer Regional Health Foundation, a non-profit that contributes millions of dollars a year in medical equipment to modernize RDRH, and a clear, indisputable need for the lab, what is stopping the Cardiovascular Health and Stroke SCN from voting in favor of this basic cardiology program?
According to Kaniz Shafiq, central Albertans simply aren’t politically strong enough.
“We have the competence in our critical care and cardiology teams here in Red Deer,” she says. “It isn’t about medical incompetence, this is about political incompetence.”
And she’s right.
Of over 30 members in the Cardiovascular Health and Stroke SCN, more than 90% are from the Edmonton or Calgary communities, leaving only a few voices to represent Alberta.
But, in following the money, one discovers that over the last 15 years, Edmonton and Calgary municipalities received more than 15 times more funds per capita in health infrastructure than the residents of central Alberta. Among saving lives, preventing further heart damage, and reducing rehospitalization rates, a cardiac catherization lab at RDRH would save AHS over $3.4 million in annual operating costs.
“If the cardiac procedure is relocated here, the system will significantly save funds by shortening the length of a patient’s stay, reducing rehospitalization, disability and transfer costs,” says Dr. Nogareda. “Keep in mind that, as it stands right now, the cost for performing angioplasty is being spent after people are transported to Edmonton and Calgary and, unfortunately, procedures are often delivered late when significant heart damage has occurred. Therefore, we are spending more resources and delivering suboptimal outcomes due to a geographical barrier to reach the catheterization lab in time.”
In fact, reducing the annual operative costs of cardiac patients to Edmonton and Calgary would pay for the cardiac catheterization lab in just five years. So why wouldn’t the financial savings influence the SCN? Here in the U.S., the decision to invest in and implement something as lucrative as a cardiac catherization lab would surely be an easy decision for hospital administration.
Dr. Nogareda says it’s market force versus equity.
“In the U.S., health care is driven by market forces, so it’s really who has money to pay,” he says. “In Canada, it’s more equitable, but it’s also more political in the sense that regions with higher populations have the most poll for the distribution of resources.”
And, as Dr. Nogareda puts it, political will, or lack thereof, has many motivating factors.
These larger city centres seem to use their votes not only to monopolize life-saving technological medical advances like cardiac catherization labs, but also to ensure that their fee for service isn’t diminished by a reduced number of heart attack patients being transferred in from the rest of Alberta.
In view of the overwhelming scientific evidence favoring angioplasty and its benefits, the ability of this SCN to decide against saving lives and provincial funds is incredibly frustrating when considering it is made up in part by cardiologists just like Dr. Nogareda.
“The physicians in RDRH have the same caliber of training as in Edmonton and Calgary,” says Dr. Nogareda. “A similar quality of care could be delivered here if we were given the same resources.”
This continually frustrating scenario complicates the healing process for someone like Ken Johnston and confounds the reasons why someone like Dr. Nogareda entered medicine at all.
To continually encounter road blocks in any profession is frustrating, but when the road block is saving another human being’s life, the mental trauma it can take on a physician should not be understated. Physician depression and suicide rates in the U.S. are extremely concerning, and it isn’t just because these medical professionals are required to have the above average emotional intelligence needed to maintain a sense of normalcy concerning matters of life and death. It’s in part because of their frustrations with a medical system that continually blocks them from practicing standard medicine in the way they know their communities need it most.
“Many times, I cannot sleep at night,” says Dr. Nogareda. “Every time I face a heart attack patient, it refreshes my memories and frustrations for everything we’ve done. Collecting data, writing papers, talking to people, meetings after meetings, and you face this situation again and again. This is deeply frustrating. To the point of anger.”
But no matter how irrational it is that for sheer profit, people would prevent a population whose leading cause of death is heart attack from obtaining life-saving technologies, or deliberately inflate the cost of a Hepatitis-C drug because of its rare healing effects, it is a reality that we must choose to accept and learn from in order to change.
“As far as I know, perpetual discussion has been going on for a decade,” says Kaniz Shafiq. “I want decisive and immediate action.”
Evidently it is possible that, in Canada, where you don’t start recovery from a heart attack with a bill for $10,000, that politics still get in the way of providing integrative, cost-effective, equitable care for all.
Should Americans listen to Vice President Mike Pence who joked with the people of Alaska that he needn’t remind them “about the failings of national socialized healthcare?”
Or Sanders, when he encouraged us to “look all over the world and…ask the hard questions. Is it working better there? What can we do to make our system better?”
As Dr. Nogareda points out, we can look at many other countries with national health systems that seem to work so well, but often those countries have a smaller population and thus, a smaller demand for services and resources.
“It’s easier with a rich country with a relatively small population,” he said in reference to the much-lauded health care system in Denmark. “But apply that same concept in India or China and it’s a different story when you need to cover billions of people. Even a country that’s considered first-world still has inequalities based on politics and other factors that deter equitable care in the U.S. and Canada.”