When Orangeville senior Donald Potter was told he was too old to receive a bone marrow transplant, he paid $150,000 to get one in the United States.
His case, recently made public by provincial Conservative leader Mike Harris, has raised the disturbing issue of health care rationing for seniors.
Potter, who has Hodgkin’s lymphoma, says he was told the cut-off age is 55; since he was 64 at the time he needed a transplant, he was told last February it was too risky to obtain the procedure. Faced with a few months to live, he went to Rochester, New York, where bone marrow transplants were done on patients into their late 70s.
Money
Potter believes the real issue is money. The government doesn’t have enough, so he couldn’t get the treatment that could save his life.
Cost-cutting resulting from the provincial government’s social contract and expenditure control plans has left physicians with the quandary of serving more people with less money. This dilemma has led them to prioritize who gets services, though physicians maintain such decisions are based on many factors other than age, including lifestyle, prognosis and effectiveness of the therapy.
Transplants
Bone marrow transplants are a particularly emotional issue for Premier Bob Rae, who in early October was driven to tears handling questions regarding rationing of this service. His brother died of lymphatic cancer in 1989 after a failed bone marrow transplant for which Premier Rae was the donor.
“I can’t knock the system that hard, I just don’t feel the government spends the money properly,” says a calm and unresentful Potter.
Many seniors are frightened when they hear the government needs to make cuts, fearing they could be the first to go when it comes to allocating rationed services.
“From the perspective of seniors it is a very scary time right now,” says David Kelly of Toronto’s Senior Link, a community social service agency. “Everything is being questioned, all our social services. Instead of looking at how to solve the problems, we’re just going to cut out things, and that’s going to be our solution. It doesn’t necessarily work.”
The issue of rationing services based on age is a dicey one. Ministry of Health spokesperson Layne Verbeek says the schedule of benefits makes no mention of age; and he’s right, because that would be unconstitutional. But when a doctor is presented with a fixed budget and a bulging sack of patients, the physician on the hospital ward has to decide who gets treated and with what. How a physician does this is theoretically based on a combination of factors, but doctors also have prejudices and misconceptions.
Rationing
Many argue such queuing is a dangerous departure from the belief that the sick deserve to be treated.
“Part of the problem is that few would admit to rationing on the basis of age alone,” says bioethicist Eric Meslin of Toronto’s Sunnybrook Health Science Centre. “Most clinicians I’ve spoken with and worked with recognize that age alone is not a relevant criterion. But most clinicians would agree age does play a role in thinking about limiting care.”
Meslin admits the idea of denying health services based upon age alone has been making the rounds among health care professionals.
Ethics
“There has been a debate in the last seven years in North America over whether age-based rationing is ethically acceptable,” says Meslin. “There is of course a spectrum of views, including the very extreme that says after a certain number of years you have obtained your benefit from society and you should step aside and allow others to make use of those resources.”
Meslin doesn’t feel good about going through any kind of health care rationing without a public debate over society’s values and what to expect from the health care system.
And he is adamant that anybody who focuses solely on attacking the high costs of high-tech medicine and an aging population is making a value judgement about how society should spend its money, not stating a fact.
“A clinician who chooses to discriminate based on age alone is not only unethical, but unconstitutional. Having said that, no clinician worth their salt would be telling the truth if they did not consider who the patient was in the fullest sense of the term, including their age. However, not giving treatment because they are 80 is a numbers game; there isn’t good enough data to support it.”
Meslin suggests a public debate on rationing services needs to take place.
Needs
“We need to ask the elderly population what they want. It may be that they don’t want the kind of things the researchers and clinicians believe they want.”
Kelly at Senior Link believes cuts to free drugs are already one example of rationing.
“There are a lot of ways we can go about changing our social services without cutting income support or access to medication. The same goes for what procedures will be performed,” says Kelly.
Potter’s case graphically shows the human cost of the heavy hand of bureaucrats in a public system trying to save money. But the high cost of U.S. health care also leaves a bad taste in Potter’s mouth.
“In the States, the cost is horrendous. At least we have that protection. But I happen to be one of the unfortunate ones that fell into the wrong slot. And there’s a lot of people like me.”
Another blow may be coming to seniors on top of last August’s cuts to the Ontario Drug Benefit Plan (ODBP). Health minister Ruth Grier has been advised to terminate the policy offering free drugs for Ontario residents over 65.
Assistant deputy health minister Mary Catherine Lindberg says the 13-page report from the Ontario Drug Reform Secretariat urges the government to replace universal coverage with a system based on income.
The government argues that fiscal problems, a desire to make wealthy seniors pay, and a need to extend the program to the working poor has driven them to consider the move, while critics argue it will hurt modest-to-lower-income seniors. They say costs could be better contained by keeping universal coverage and attacking the source of escalating costs: pharmaceutical manufacturers and doctors who over-prescribe or misprescribe.
Concession
If implemented, the cuts will represent a concession by the NDP on the once-sacred principle of universality. Just last year, former health minister Francis Lankin said, “I believe strongly in universality, and we’re not looking at ending it for drug coverage of seniors.”
The proposed plan calls for single people, regardless of age, who earn over $20,000 a year, and families earning over $40,000, to pay a premium of up to $300 for drug coverage.
Those earning less than that amount will have to pay for their own drugs until they reach a limit tied to their income to become eligible for free drugs.
The government says this changes qualifying for coverage from age to income-based.
In a recent interview, health minister Ruth Grier wouldn’t be specific about what plan she would go for. But she agrees with the report’s authors that the drug plan needs reform.
“While the drug plan makes drugs available in an open-ended way to everybody over 65,” says Grier. “In many cases it doesn’t help the low-income family with parents in minimum wage jobs and has a child needing constant drugs. And when we reform the system we aren’t just looking at how we can contain costs, but also how we can make it fairer. The underlying principle of all that we are doing is equity and fairness.”
The drug benefit plan, which also covers welfare recipients, hit $1.2 billion last year out of an almost $17 billion health budget. That was an increase of 13.8 per cent from 1991, but lower than the 18.1 per cent average for the last 10 years.
David Kelly at Toronto’s multi-service agency Senior Link suggests the government go after the drug industry for wasting money promoting drugs and duplicating research projects.
According to the industry advocate Pharmaceutical Manufacturers Association of Canada’s own statistics, drug companies spent $186 million on “marketing” in 1990 while $286 million actually went to research and development.
The federal government’s own Patent Medicine Prices Review Board, in an internal study leaked to The Globe and Mail, found Canada to have some of the highest drug prices among the seven industrialized nations.
Anger
Seniors organizations and agencies almost overwhelmingly expressed anger over the report, seeing it as another attack on universality of medicare. They feel the government isn’t being creative enough solving fiscal problems.
“I strongly disapprove,” says Sara Wayman, chairperson of the Ontario board of Canadian Pensioners Concerned. “The concept of universality when it comes to services is a basic democratic principle we support strongly. People who earn $20,000 a year are still struggling to make ends meet. This would represent a real hardship.
“We also feel strongly that the high medical costs that everybody is talking about aren’t really due to universality. They are really due to the high cost of drugs, and because there has been a restraint of generic drugs by our legislature.
“They are tip toeing around the medical profession. I hope people will speak out.”
Kelly feels savings could be reaped by taxing back any benefits given to wealthy seniors, while maintaining the universality of programs.
“The group they are talking about is very tiny,” says Kelly. “And so the cost savings to the government are going to be really minimal. A whole process will have to be set up to decide who gets free drugs, and what you get is another layer of bureaucracy everyone has to go through. Studies have shown this adds to the net costs of government in the long run.”
Toronto’s innovative crime-fighting and crime-prevention experiments face elimination if and when the city is swallowed up by the monolithic megacity. And the Annex’s status as one of Toronto’s safest neighbourhoods could be destroyed by the resulting tax increases.
Since the late 1980s, thinking about crime in Toronto has focused on public safety rather than just cops in cars. Taking what can be called a holistic approach, the city has poured millions into public health programs, street lighting, safety audits and social services, and it has led the region in putting cops back on foot patrol.
Carolyn Whitzman, coordinator of the Safe City Committee – founded in 1989 and a symbol of that attitude change – worries many of the services will find their funds cut or their street-level approach altered.
“I don’t know if people in Toronto realize how privileged they are,” she says. “All these programs have led us to be one of the safest cities in the world. There is nothing like the Safe City Committee in surrounding municipalities. There is nothing like it at Metro – though they do fund safety initiatives.”
The Safe City Committee was the first of its kind in North America and subsequently has been copied by other cities. Initiatives funded by the committee include pamphlets on ending sibling violence, self-defense tips for volunteer workers, a youth drop-in centre at Dufferin Mall an community safety audits.
Whitzman also worries the new meagcity will follow the advice of government consultants KPMG, who recommended replacing some police duties with volunteer labour.
“They recommended store fronts (community police booths) and reporting of accidents be run by volunteers. What if you want a police officer?”
Whitzman also doesn’t like plans to encourage police to spend more time in their cars filing reports on laptop computers. She would rather see them out on the beat.
She also fears school safety programs, like extra lighting, will be jettisoned as school boards chase savings. This also applies to the TTC and public housing. (Whitzman says some housing projects have already cut security due to provincial funding reductions.)
Another factor could jeopardize the Annex’s status as one of the safest neighbourhoods in the city. Higher taxes may chase out homeowners, and the Annex many once again become a haven for transient populations living in rooming houses, as it was in the 1960s and 1970s.
According to Joe Page, a crime analyst at 52 Division for the past quarter century, the Annex had the dubious reputation in the late 1970s of being the busiest neighbourhood in Toronto for police.
It’s a different story today. For example, in the portion of the Annex between Avenue Road and Spadina Road from Dupont south to Bloor, there was one murder in 1995 and none in 1996, and major assaults were down from nine in 1995 to five in 1996. There was one murder in the Little Italy area west of Bathurst in 1996.
If there is a good side to rising crime rates in the surrounding municipalities, it’s that councillors there can no longer ignore public safety issues. This could mean greater sympathy for Toronto’s plight from once-smug suburban councillors.
Whitzman sees hypocrisy in the attitudes of many of the satellite cities. “Scarborough has a bad reputation and other municipalities are not immune to safety issues.”
Port-au-Prince – Brand-new four-by-four jeeps in various shapes and sizes bounce over the moon-like craters of Port-au-Prince’s roads. The presence of so many expensive vehicles in a country unable to feed all its citizens is hard to take, but it is not one of the worst paradoxes of Haiti.
The appalling state of the roads – more like occassional stretches of asphalt to break up the monotony of potholes – is an apt symbol of Haiti, a reminder with every jar of the tailbone of the public squalor of the many and the private wealth of the few. The shiny new jeeps are not a sign of recent good times, but reveal who has all the money in this nation of almost seven million: the tiny Haitian elite, thieves, the United Nations and the multitude of non-governmental aid agencies.
When democratically-elected president Jean-Bertrand Artistide, deposed in a 1991 coup, returned to complete his term in office in 1994, many Haitians hoped that this country would at last begin to shake off centuries of exploitation at the hands of a selfish elite backed by American corporate masters and begin to build a democratic future.
The United Nations mission in Haiti, which includes 700 Canadian troops, is intended to support the country’s fledgling democracy. But Haiti’s future remains uncertain – as does the role the UN will play in shaping it.
Despite negotiating a peaceful and democratic transition last February 7 from Aristide – a firebrand former priest and passionate advocate of Haiti’s poor – to successor Rene Garcia Preval, Haiti hasn’t stopped its economic freefall. Economists predict the country won’t match 1991 earning levels until the next century. Political unrest resulting from opposition to the government’s privatization plans could also spell trouble ahead.
The United Nations presence, due to end June 30, has been extended another five months at the request of the Haitian government. The newly-minted UN Support Mission in Haiti, a military force of 600 UN troops supported by 700 soldiers paid through voluntary contributions, is being assembled. It will replace the current force of 1900.
Lousy loans
Meanwhile, the government of Rene Preval is negotiating with the International Monetary Fund (IMF), the World Bank and the United States to get much-needed loans to help balance the budget. Critics say the world’s banks are trying to lock the poorest country in the Western hemisphere further into crippling debt. The Haitian budget is US $750 million, 60 per cent of which the government hopes to raise from loans.
But there is a condition. Haiti must embark on a structural adjustment programme: widespread firings of the public service, privatization of most of the public sector, loosening of controls over foreign capital, adherance to the ethos of global trading blocks espoused by the North American Free Trade Agreement (NAFTA). Some call this neo-liberalism, others neo-conservatism. Either way, it forces this impoverished country to limit how it can address rebuilding a crumbling infrastructure.
The government’s hands are tied, though, as the conditions were part of the deal to return Aristide to power.
A Canadian public relations company, Gervais-Gagnon-Covington Associates, has been paid US $800,000 by the American government to sell the idea of privatization of Haiti’s handful of idle and near-bankrupt state enterprises.
In order to plunge deep into this Haitian quagmire, I pitch up at the legendary Hotel Oloffson – made famous by novelist Graham Greene in The Comedians – and begin interviewing in the languid atmosphere by the pool.
“Aristide has put Haitians in a giant trap with the IMF plan,” says Jane Regan, who runs an independent news service based in Port-au-Prince. “The US $1 billion in loans will double the national debt.
“Haiti used to be self-sufficient in rice – last year they bought US $56 billion in US rice. The roads are worse now than a year ago. Right now the UN mission is of questionable worth and Canadians are getting taken advantage of. They have been sent to clean up after the Americans. These are the same neo-liberal economic policies that hurt Canadian workers – just imagine what Haitians are feeling!”
Regan thinks that, so far, the only people to make any money out of this arrangement are businesses and the more than 800 NGOs operating in Haiti. And on that note, the feisty Regan disrobes and plunges into the Hotel’s pool.
According to Kim Ives, a reporter with the Haitian newspaper Haiti Progres, there are a few cracks in the solidarity between Preval and Aristide: “Aristide is hitting out against privatizations. In a two-hour TV interview, he drew a line between himself and Preval.”
One of the few visible signs of change in Haiti is the dusty Octobre 15 road leading from the airport past former president Aristide’s palatial home on its way to the wealthy suburb of Petionville. It is bordered on one side by Camp Maple Leaf, and on the other by dilapidated shanty towns and desperate street vendors.
Cynics point out the road conveniently serves the interests of the elite once again. It offers a direct and more or less pothole-free route from the secluded mansions of Petionville to the airport – a crucial escape route in a politically volatile developing country. In fact, a development of monster homes that would make a Canadian suburbanite blush is going up near the airport to capitalise on this.
Canadian troops
Caught between the Haitian government and its people is the United Nations, including Canada’s troops. Canadian troops form the first line of defence – along with Preval’s personal secuity guards – to defend the National Palace. They accompany the president wherever he goes, 24 hours a day.
Some fear growing resentment among Haitians for government policies will pitch the population against the soldiers.
At Camp Maple Leaf, the home base of Canada’s military contingent in Haiti, the troops are scrambling to adjust to a new mission sanctioned by the United Nations. As of June 30, they must take a back seat to the troubled Haitian police force as it tries to prove that the intensive training provided by police from around the world has paid off.
In the first week of July, the Canadian soldiers of the Royal 22nd Regiment – the famous Vandoos – receive confusing news about a change in their firing orders or Rules of Engagement. ROEs dictate the tone and behaviour of peacekeepers on a UN mission and, as the experience of Somalia demonstrates, they can be the difference between success and disaster.
As the new mandate starts, the Canadians are first told they will be only able to use deadly force to defend themselves and not Haitians. If a member of the government is assassinated, they must stand by. If a Haitian is clubbed to death before their eyes, they must stand back. It is a qualitative change from their ROEs prior to June 30.
Ottawa military spokesman Captain Conrad Bellehumour says the change is indicative of an evolving mandate. But a military spokesman in Haiti says the old ROEs are now back in force, and Canadians can intervene to save a Haitian’s life.
“Maybe somebody’s been listening to Jean-Luc Picard too much,” quips retired Brigadier-General Jim Hanson, in a reference to TV show Star Trek’s prime directive of non-interference in a culture.
Preval’s police
A large banner hangs over a Port-au-Prince street: “Police + Population = Securite + Paix”. The UN has placed its greatest emphasis on reforming Haiti’s policing and justice system. The Police Nationale d’Haiti (PNH) was formed, and the RCMP and the American Federal Bureau of Investigation (FBI) were asked to provide training. The idea is to break from the past – when the military used policing as an opportunity to terrorize the population – and establish a police force to serve and protect.
But the efforts of the Haitians and their international police advisers have had a mixed success. According to Canadian soldiers, the Haitian police need to be coaxed into conducting routine patrols and have not given up patrolling in large numbers in the back of a pick up truck with rifles at the ready. To be fair, seven police officers have been killed since January, in what many believe is an organized campaign of terror orchestrated by sympathizers of the old dictatorship and drug gangs.
According to Sergeant Serge Martin of the Vandoos, “The PNH use 15 police officers to patrol and don’t talk to anybody.”
“You don’t depend on police to protect you,” claims Regan. “The Haitian government has no control over them. You don’t know if there is going to be a coup tomorrow.”
Jean-Yves Urfie, editor of the pro-democracy Libete newspaper in Port-au-Prince, believes the campaign to kill police goes back to the United States. “I am convinced the coup d’etat was financed by the Republican administration. I believe the Republicans want to destroy things here to show (President) Clinton wasted his time bringing Aristide back.
“The government was forced to incorporate former members of the military into the police force. And it would be terrible if the population develops the impression all cops are bad.”
“They are 10 years away from a viable police force,” concludes Hanson.
A stop at the fourth precinct police station shows just how far things still need to go. At the counter is a lone police officer, sharply turned out in his beige shirt and yellow-striped navy pants, courtesy of the Royal Canadian Mounted Police. But this proves to be a veneer of change. Canadian soldiers ask if everything is alright. They then ask to see tonight’s prisoners. The officer sheepishly leads the troops down a narrow corridor to 9 ‘ by 12 ‘ foot cell stuffed with nine prisoners. It is very hot and the stench from an open drain overflowing with sewage is nauseating.
Outside the Penitencier National in downtown Port-au-Prince, a yellow concrete structure with peeling pain, Haitians lined up to feed the inmates, talk about their frustrations with a justice system that has collapsed. Many complain that only the rich, who can hire lawyers, can enjoy the fruits of democracy. While state-directed beatings and killings have been dramatically reduced, most prisoners rot on remand until they are charged with a crime. Heiner Rosentdahl, the UN representative in Haiti in charge of prison reform, tries to be upbeat. “There have been no changes in conditions in Haiti’s prisons. Treatment of the prisoners is better, though there have been some abuses. We have developed a nation-wide register book of prisoners to help keep track of who is in prison.”
Another mixed blessing, according to Rosendahl, is the new requirement that all prisoners be fed two meal a day. The food is so poor, prisoners have been getting sick.
He is frustrated with the pace of penal reform. “The Haitian prison system hasn’t had a budget since October 1995, because of battles within the parliament,” he says. “The Haitian government didn’t ask for a plan to change this situation despite the minister of justice visiting the prison for the first time.”
According to Rosendahl, it is not the routine killing of thieves by mobs that worries the elite. Nor is it the assassination of police officers, or the untold thousands dying of disease and hunger. The only thing that is beginning to rock their world is a new phenomenon for Haiti: kidnapping and extortion.
Voodoo economics
For such a seriously depressed economy, there is an astonishingly large number of lottery booths – or Borlettes – on Haitian streets. They are so plentiful, they join gas stations as the main landmarks of the streets.
The industrial park which is now home to the remaining American troops stationed in Port-au-Prince, is a good monument to Haiti’s economic problems. Dilapidated and only barely functioning, this facility once supported, directly and indirectly, a large portion of the city’s population. As crummy as the sweatshop jobs were, they provided valuable income for the capital’s poor.
The Haitian economy under Francois Duvalier and his son, Jean-Claude, before the chaos of the late 1980s and 1990s, was based on assembling manufactured goods for the US market. Haiti was the world’s largest producer of baseballs, and ranked as “top three in the assembly of such diverse products as stuffed toys, dolls and apparel, especially brassieres. All told, the impact of international subcontracting was considerable,” according to author Paul Farmer in his book, The Uses of Haiti.
Today, Pierre Joseph, a Haitian-American from New York City, has a new job: he screens the ID cards of Haitian workers as they enter the park. He says there were once over 50 factories operating here; now there are 30.
Evidence of Haiti’s economic collapse is everywhere. On the walls outside the National Palace is scrawled Aba Preval Granhanje – Preval is a liar. Across the wide boulevard in a square are around 75 homeless children. They joke with the Canadian soldiers, especially boyish 2nd Lt. Marc Verret, who looks like a baby in soldiers clothes. The kids beg him for water and money.
In the market area, the piles of garbage, rotting meat and excrement make a muddy devil’s stew. Homeless children sleep on top of the abandoned crates. One small child is curled up in an American flag, asleep.
Desecrating dead
The dead also suffer the indignities of economic ruin. Outside the gates of the Hopital Generale, a man lies dead on a broken trolley in the yard. Others still alive, with limbs missing, are sprawled out on the ground. Chickens and goats roam the grounds. In the back is the main morgue for Port-au-Prince. The odour just 25 feet from the entrance to the morgue is normal for this city strewn with rotting garbage and stewed by a hot sun.
Inside, an overpowering odour like rotten chicken meat is the product of 450 human cadavers. Like rag dolls laid out in a ghoulish toy store, row upon row of children dead from starvation and disease – Haiti’s infant mortality rate is 127 per 1,000 babies born – are stacked almost to the ceiling. There are also adults. Old women, young men badly mutilated for stealing, are strewn out on the dirty concrete floor and on shelves.
There is no refrigeration, and according to military doctor Major Tim Cook, “something really nasty is going to come out of there if they don’t do something.”
Proving peacekeeping
More is at stake in Haiti than the re-building of a politically and economically devastated nation. For Canada’s armed forces, shaken and little stirred by the Somalia scandal, it is an opportunity to make amends. This time around, the peacekeepers are keeping the needs of the local population foremost in their gun sights. When the Vandoos head out on another one of their 24-hour patrols, the atmosphere is friendly and filled with gentle ribbing with the locals. They have the advantage of being able to speak French, a language understood to varying degrees by most of the population.
The approach of the individual soldiers varies widely. On a routine patrol, Alpha Company engaged in good-natured kidding around, with splashing the locals the worst offence. But a day out with Charlie Company, led by Sergeant Serge Martin, proved another story. The two privates assigned to accompany a group of journalists were a couple of operators. The day included a visit to a perfume shop, a trip through the wharf area looking for prostitutes and constant propositioning of the local women.
One Canadian corporal with the Vandoos, Eric Charbonneau, has been trying to make a small difference to the lives of the 400 people living in the community of Cazeau, a shanty town near the international airport. He has started literacy and hygiene lessons and raised money to help the residents build concrete houses to replace the mud dwellings they currently inhabit.
“I was walking along the fence and started to build a relationship with the kids,” he explains. “Some guy approached me and needed some help. It took three weeks to build a relationship. They are too used to white people giving away things for doing nothing. They were surprised when they had to work for it.”
At the gates to Camp Maple Leaf is a spray-painted sign. In Creole, French and English beside a Canadian flag, it says “No More Jobs.” While it could look at home back in Canada, it illustrates how important the presence of soldiers, the United Nations and charities are right now to the economy.
Some observers see the UN presence as part of a slide back into dependency on foreign money, restricting Haiti’s ability to assert itself. But others believe the turn to the international community is Haiti’s last hope of breaking with a past littered with dictatorships and poverty.
According to Captain Roberto Blizzard – an erudite and wise observer of the situation – the base has been stampeded with desperate Haitians looking for work. Blizzard has tried to find work for as many Haitians as he can, even helping them to form a laundry co-operative he hopes will survive long past the Canadians’ stay.
“There is a danger of the Haitian people turning into full-time beggars,” he says with sadness.
David South Consulting 
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