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Speaking out

Is the cure worse than the disease

There is enough CT and MRI equipment in the U.S. to assure access when a stroke occurs. Would we trade with a Canadian system where lack of this availability is cause of death or serious brain damage?

When Every Minute Counts

Why must you have a CT scan immediately when a stroke occurs?

The more common ischemic stroke
An injection of tPA (tissue plasminogen activator) can be lifesaving if a stroke is caused by a blood clot in the brain (ischemic). TPA Call dissolve away the clot.

But the clot-busting drug must be given within three hours after onset of the stroke; after that, it is too late to be effective.

A correct diagnosis with CT or MRI equipment is urgent--a medical emergency.

The less common hemorrhagic stroke
But, alas, if the stroke was caused by a broken blood vessel that is bleeding into the brain tissues (hemorrhagic), adding tPA could cause a fatal bleed.

All immediate CT scan of the brain Call determine which type of stroke one has had. Fortunately, there is enough CT and MRI equipment in the United States lo assure that Americans have timely access to treatment.

By Sally Pipes

From the January/February 2004 Issue

On the first Monday after the first Sunday of the National Football League season, four Arizona Cardinal players had MRI (magnetic resonance image) studies to detect whether they might need surgery. Tuesday, after the NFL's first Monday night contest, three Philadelphia Eagles were scanned.

Such use of high-tech diagnostic tests has become nothing special in the United States. With more than one MRI machine for every 200,000 residents, U.S. hospitals and private clinics are ready and willing to use their diagnostic machines on any who demand them. College and even high-school players, as well as the pros, are likely nowadays to get MRIs to determine whether ankle, knee, and other sprains are something worse--say, a torn ligament that might require surgery. Misdiagnosis, after all, can cost a player a season, or even a career. But not a life.

But misdiagnosis costing a life was precisely the concern for Trish Besner. A nurse in Ottawa, Ontario, Besner was experiencing fainting spells in the fall of 2000 and was told she needed an MRI to diagnose her condition. "The doctors keep mentioning MS (multiple sclerosis) to me," she told the Ottawa Citizen. An MRI could have ruled that in or out, as a study this September in Neurology confirmed. But the city of Ottawa had just one MRI machine for its 555,000 residents. So all she could do was wait and take the drugs that her doctor offered, along with pills to relieve anxiety and let her sleep, none of which halted her seizures. Thus, it was impossible for her to care for her toddler.

Many observers of American healthcare have come to the conclusion that the American system of healthcare is broken. Tens of millions of Americans lack health insurance, thus creating, it is alleged, a crisis of insurance. And those with insurance are seeing ever-higher co-payments for services and more control exercised over care by insurance companies, creating what some see as a crisis in quality. With healthcare costs rising at double-digit rates and the elderly complaining that the costs of their prescriptions have become unaffordable, Congress is looking at ways to control costs while federal and state governments seek to regulate private health plans more.

The critics often point to Canada--with its universal coverage and lower direct healthcare costs for doctors, hospitals, drugs, and treatments--as a model the United States might follow.

But Besner's cautionary tale should illustrate the need to look before leaping to the Canadian answer. For as Besner and other Canadians with serious health problems have discovered, the way Canada's federal and provincial governments guarantee universal access without busting their budgets is often at the expense of patients' health and well-being.

Of course, the government of Canada says otherwise. In November 2002, a government-appointed commission issued a final report, "Building on Values: The Future of Health Care in Canada." It proclaimed: "Our health system is adequately meeting our needs." Yet it then recommended that the government spend $9.7 billion over the next three years to pay for more diagnostic services such as MRI and CT (computed axial tomography) scans. This year, the government cut that bill down to $8 billion, a sum likely to keep Canadians far behind.

According to the Organization of Economic Cooperation and Development, Canada has about half the number of MRI units and CT scanners as the average for other industrial nations, ranking it in the lower third of the 30 nations for such vital diagnostic tools. It gets lumped in among the former nations of the communist block.

Canada is even farther behind in other technology. In 2001, Canada had only two functioning PET (positron emission tomography) scanners for its 31 million people, or one for every 15 million residents, versus 250 such machines in the United States, or one for every 1.1 million residents. Such scanners are particularly vital to women suffering from breast cancer. They are 80 percent accurate (even better than MRIs) in determining whether the disease will recur.

Worse for Canadians hoping to catch up, the Canadian Association of Radiologists reports that one of two diagnostic machines require immediate replacement. Cost: $2 billion.

Thus, while Canadians may confront few barriers--and no bills--when they need to see a primary-care doctor, they often pay a high price in cases of serious disease or health emergencies.

The median waiting time in Canada from referral by a general practitioner to treatment was 16.5 weeks in 2002--up 77 percent from 1993. For cancer patients, waiting times for medical oncology have increased from 2.5 weeks to 5.5 weeks and for radiation oncology from 6.3 weeks to 10 weeks. In the United States, the waiting time is a week, and it's that long only because of the need to deal with paperwork.

Some Canadians wait much longer. Jan A. Norwood certainly did. When she needed a hip replacement in 2000, she was forced to wait in line for 16 months, suffering both pain and the loss of a year and a half in income.

Apologists for Canada's system say such waits don't affect true emergency needs--though how delaying certain cancer treatment is anything but life-threatening is hard to understand. Yet even in emergency matters, Canada's system often crumbles. In a flu outbreak in 2000, 23 of Toronto's 25 emergency rooms all closed down.

In 1999, when Joshua Fleulling suffered an asthma attack, he was turned away by one Toronto emergency room and died from lack of oxygen by the time he reached one with open doors.

As far as prescription drugs are concerned, you can ask the patients who recently took advantage of a bus trip to Maine--organized by Consumer Advocare Network and Dr. Tony Lordon of St. Johns, New Brunswick--what Canadian price controls have meant to them. Provincial health ministries in effect denied them the treatments their doctors say they need for diabetes, cholesterol, and depression. They were forced to travel to Maine to get treatment. Other Canadians have waited years for new medicines readily available in the United States to combat such debilitating illnesses as rheumatoid arthritis and hepatitis C, because of the way Canada tries to control drug prices.

In short, Canada's low-cost universal service isn't an open-access system. It doesn't give patients all the choices they want or need. Instead, you must wait your turn, no matter how ill you may be.

Supporters of the system say that delays brought about by price controls and other measures are needed to keep healthcare affordable. Canadian patients in need of anything more than primary care suffer. And the healthcare system and taxpayers ultimately do, too. For the money saved from paying for better diagnostic tools and pills comes from leaving people unable to fend for themselves--or misdiagnosed. In the case of injuries, one prospective U.S. study found that MRIs for knee injuries actually saved $680 per examination and helped prevent 42 percent of surgeries. In the case of the kind of multiple sclerosis Trish Besner suffered, MRIs that catch it early enough enable treatments that can "... reduce the entire course of the disease," according to the study in Neurology.

Before making the United States more like Canada by adopting its method of price control and administration of care, reformers need to get a clear picture of what that would mean for American patients. The cure for what ails the American health system would prove far worse than the disease.

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