New directions needed in Canada’s healthcare
Health Care. Pat and Hugh Armstrong. Fernwood, 2008. Critical to Care. Pat and Hugh Armstrong and Krista Scott-Dixon. University of Toronto Press, 2008. They Deserve Better. Pat
Armstrong, Albert Banerjee, Marta Szebelehey, Hugh Armstrong, Tamara Daly, and Stirling Lafrance. Canadian Centre for Policy Alternatives, 2009.

Ignaz Semmelweis was an iconoclastic physician in 19th Century Vienna and Budapest.  In charge of a maternity ward in Vienna, he found that very high death rates from childbed fever could be decreased dramatically by having the doctors and medical students wash their hands before attending to their patients. They often went from autopsies to births.  By comparison, death rates in a different clinic in the same hospital served by midwives and those in training, who did not have contact with corpses, had a much lower mortality rate.  His campaign to promote hand washing by doctors foundered, in spite of the spectacular results he achieved when it was implemented. He died in an insane asylum. Semmelweis’ failure was due to a couple of factors.  For one thing, his finding was contrary to the official medical ideology of the time.
As well, it was seen as an attack on the dignity of respected physicians to suggest that they might be the cause of their patients’ deaths and that they needed to be told to wash their hands.  Even today, in the light of SARS, C difficile, and swine flu, hand washing continues to be a challenge in hospitals and long-term care facilities, along with cleanliness more generally. That Semmelweis compared the death rate on the midwives’ clinic to that on the medical clinic was a
recognition on his part that status was irrelevant. Lowly midwives were more successful than distinguished physicians.
A Semmelweisian thread runs through three books by Pat and Hugh Armstrong and their associates. Physicians are important, but they are not the be-all and end-all of healthcare.  In Health Care they point to the importance of home care and long-term care, where the role of the physicians is less important. Also, other players in primary care are important more generally.  As they say, “The skills of physicians alone are inadequate to the task of promoting good health. The emphasis on solo medical practices fails to take advantage of the full range of provider skills that are critical to both promoting health and treating illness or disability.”  And “Nurses, social workers, pharmacists, nursing aides, and others have much to offer in primary care.”     
In the other two books they focus on other ancillary workers – personal support workers, licensed practical nurses, kitchen staff, and maintenance staff. These people, as the title of the books suggests, are Critical to Care. 
They are skilled and yet their work is given little respect and their pay is low. They work hard, need interactive skills with their patients, and face significant health and safety hazards.  Hospitals and long-term care facilities often contract out cleaning and food services to cut costs, failing to appreciate the essential character of these functions. Private firms cut corners to maximize profits. Thus, cleaning staff are paid as little as possible and are assigned as much work as possible, leading to a deterioration of cleanliness, in some cases with consequences that Semmelweis might have predicted. 
They Deserve Better addresses conditions in long-term care. In a study based on interviews with unionized workers in Nova Scotia, Ontario and Manitoba, as well as in the Scandinavian countries, the authors found a disquieting difference in the conditions for workers and residents in long-term care. 
Staffing ratios in Scandinavia are better. Workload is lighter. Interaction with residents is greater. Care is better, more social and less simply medical or custodial. The speed-up for Canadian long- term care staff has its impact on the residents, for “the conditions of work establish the conditions of care.” 
As an example of poor care, elderly people are sometimes left in diapers until the diapers reach maximum capacity, especially in Ontario.
The study reported looked only at homes with unions. One would expect the others to be even worse. Not surprisingly, Scandinavian long-term care is more heavily public as compared to the situation in Canada.
We are told that money is tight in long-term care because of the size of the greying population, but the population in Scandinavia is older than in Canada. Yet, they provide better, more humane care in generally smaller, more home-like settings. As the authors point out, the difficulty in matching the Scandinavian level of care is not due to our aging population. Theirs is older. It is due to the ongoing mantra of tax cuts.  In Health Care the Armstrongs discuss the attack on health and social services in the 1980s and ‘90s, when there were cuts in federal funding that culminated in the 1996 adoption of a new funding formula for health, education, and social services, the Canada Health and Social Transfer.  This new, reduced funding arrangement resulted in hospital closings and the export of nurses to the United States. With fewer hospitals and a continuing shortage of nurses, can we be surprised by long waiting lists and overcrowded emergency rooms? 
But Paul Martin, who was then prime minister, announced success: he had conquered the deficit. As Pyrrhus of Epirus exclaimed following a battle won against the Romans but with huge losses, “One more such victory and I am undone!” The authors also point to the need to expand medicare to include long-term care, home care, dental care, pharmacare, midwifery, and alternative therapies. They also favour a model of primary care that is exemplified by Ontario’s community health centres and the unfulfilled promise of Quebec’s local health and
social service centres.  They correctly argue that expanding the private sector in health-
care will not cut down on wait times, as it will take resources from the public sector. The increased role for the private sector would only provide a way for the more affluent to jump the queue. 
These three books provide an important understanding of the state of health care and long-term care in Canada.
They help us to see where the problems lie and they provide the answer to those who see privatization as the solution. They also offer a vision of what might be if we have the will to make it happen.–Reviewed by Reuel Amdur in Edmonton Senior, June 2009
 

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