Alberta Health Services Archives - Alberta Views

March 10-14, 2025

Alberta Views — Fri, 14 Mar 2025 19:13:30 +0000

Monday, March 10: Legal action began against the UCP government law that prevents doctors from providing gender-affirming treatment, including puberty blockers, for those under 16, arguing it is unconstitutional to deny medical care to a specific group of Albertans and a violation of the Charter right to equality.

March 10: NDP leader Naheed Nenshi said Premier Danielle Smith should cancel her taxpayer-funded Florida speaking engagement at a fundraiser for PragerU, where she will co-host with Ben Shapiro, who supports Canada becoming the 51st state.

March 10: The Sexual Assault Centre of Edmonton has paused intakes due to significant and unexpected cuts from the UCP.

Wednesday, March 12: Forestry and Parks Minister Todd Loewen introduced legislation that, among other measures to “modernize hunting,” allows 12-year-olds to hunt without adults around.

March 12: An agreement was signed by Premier Smith and Ichiro Takahara of the state-owned Japan Organization for Metals and Energy Security at the CERAWeek energy conference in Texas. Japan is the province’s third-largest export market, with trade totalling $3-billion in 2024.

Thursday, March 13: The provincial government suspended the loan program of Alberta’s largest cattle industry lender, Picture Butte Feeder Cooperative, after an inspection, alleging financial mismanagement. PBFC, with 227 members, owes $281-million, which it says is the same amount it has loaned to its members.

March 13: A statement of defence was filed in court on behalf of Alberta Health Services and Health Minister Adriana LaGrange. It disputes the allegations in former AHS CEO Athana Mentzelopoulos’s wrongful dismissal suit by claiming she was terminated because she did not advance the UCP government’s plan to divide AHS into four organizations.

March 13: Amid a measles outbreak in Little Red River Cree Nation, LaGrange is not recommending all residents get a measles vaccination, saying it’s “a parental choice.”

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March 3-7, 2025

Alberta Views — Fri, 07 Mar 2025 23:05:31 +0000

Monday, March 3, UCP backbencher Scott Sinclair (Lesser Slave Lake) said he won’t support Budget 2025 because he’s “furious” at the amount of money for Alberta’s two major cities.

March 3, The government appointed Raymond E. Wyant, former chief judge of the Provincial Court of Manitoba, to lead an independent third-party investigation into irregularities in contracts amid an ongoing healthcare scandal. He has a $500,000 budget to report by June 30 and will be paid $31,900 a month. NDP leader Naheed Nenshi questioned the validity of the process: “He is limited to rely only on the information provided by the government itself.” Alberta’s auditor general, Doug Wylie, is also looking into contracting and procurement at the Health ministry and Alberta Health Services (AHS).

Tuesday, March 4, US President Donald Trump implemented a 25 per cent tariff on all Canadian goods and a 10 per cent tariff on Canadian energy. In 2024 Alberta’s exports to the US totalled $162.6-billion, of which $132.8-billion were energy products.

Wednesday, March 5, Alberta announced it would stop buying American alcohol and cease contracting with US companies, including a halt on purchasing VLT machines from the US—a $100-million annual expense. About 10 per cent of liquor products in Alberta are imported from the US. In 2023–2024, $292-million in US liquor was sold in Alberta. The Canadian Association of Energy Contractors said it opposes retaliatory tariffs. The 25 per cent retaliatory tariff on US sand, for example, means $250-million a year in extra costs to Alberta’s oil and gas industry.

Thursday, March 6, The Alberta RCMP launched an investigation into AHS and allegations of political interference and potential conflicts of interest within its procurement practices.

Friday, March 7, Premier Danielle Smith said her government is planning to send its supply of unused children’s pain medication to Ukraine. The government paid $70-million to MHCare Medical for the medication in 2022 during a countrywide shortage. Alberta received only about 30 per cent of the shipment and the company that provided it is now embroiled in a contracting scandal. Alberta has been sitting on 1.4 million bottles of the medication after officials determined in 2023 that it posed serious health risks to infants.

March 7, The UCP removed MLA Sinclair from caucus after he said he would vote against Budget 2025.

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Feb 24–28, 2025

Alberta Views — Fri, 28 Feb 2025 20:35:48 +0000

Monday, February 24, 2,000 education support workers from Calgary and area hit the picket lines. They joined 4,000 more workers in Edmonton, Fort McMurray, and the Sturgeon School Division who are already on strike.

Tuesday, February 25, Health Minister Adriana LaGrange fired CIO (Chief Information Officer) of AHS Penny Rae. Rae is recognized as one of Canada’s top women leaders in digital health. Previously, on January 8, LaGrange had fired the CEO of AHS, Athana Mentzelopoulos, who filed a $1.7-million wrongful dismissal lawsuit. Then, on January 31, LaGrange fired the entire AHS board.

Tuesday, February 25, Pete Guthrie, the Minister of Infrastructure, resigned from cabinet, saying he lacked confidence in the government’s procurement processes. Earlier he had called for LaGrange to step down during investigations into serious allegations made by Mentzelopoulos.

Tuesday, February 25, The legislative assembly resumed sitting for its spring session.

Thursday, February 27, the government presented Budget 2025. Highlights:

• $5.2-billion deficit on total spending of $79-billion, with more money for contingencies, tariffs and disasters

• $26-billion for capital projects such as hospitals and highways, including $2.6-billion for new schools

• personal income tax cuts costing the government $1-billion in foregone revenue and saving individual Albertans roughly $750 a year

• contributions are projected to grow the Alberta Heritage Savings Trust Fund to $250-billion by 2050

Budget 2025 also allocates $180-million over three years to build two 150-bed addiction treatment centres, one in Calgary and one in Edmonton, under the proposed Compassionate Intervention Act, which allows forced treatment.

As the Budget was being presented, 50 busloads of striking education support workers protested outside the legislature. The average school support worker in the province makes $34,500 per year, said CUPE Alberta president Rory Gill.

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Why Can’t You Get a Family Doctor?

Monica Kidd — Thu, 24 Oct 2024 09:00:19 +0000

When Elizabeth Fox moved from Athabasca to the central Alberta hamlet of Elnora in 2013, finding a family doctor close to home was a breeze. “I was pregnant,” she says, “so they’ll all take you.”

But seven or eight years later, her clinic emailed Fox to tell her she was being de-rostered—removed from her doctor’s list of patients—and would have to find a new doctor. She didn’t come in very much, and they needed the doctor for other patients.

“Don’t you just shift your patients around?” Fox recalls asking. They didn’t, and it was up to her to find someone new. With three kids and a declining number of doctors accepting new patients, that proved easier said than done. Her family joined the 650,000 other Albertans the Alberta Medical Association says lacks access to regular primary care.

Fox’s eldest has since moved out and is living on her own, but her two younger kids are still at home. Her middle child is almost through high school and has autism and social anxiety; her youngest has ADHD. Fox is a single parent and expects to apply for income assistance for her daughter once she graduates, but to do so she needs medical reports. Without a regular family doctor, she relies on walk-in clinics for these reports, but she says even some of those clinics now only see “overflow” patients—those people already registered to the clinic but who needed an appointment urgently. And it’s endlessly frustrating dealing with different clinics and their various policies and out-of-pocket charges, not to mention starting again from scratch with each new doctor she and her daughter see.

Fox thinks she might be able to find a doctor in Sylvan Lake or Olds, both about an hour away. But that’s not so simple either. “That’s a long drive, and being a single mom on a low income, it’s a struggle,” she says. “Sometimes we’ve got to move our appointments because I don’t have gas money.”

Her family joined the 650,000 other Albertans that lack access to regular primary care.

Fox has tried virtual options but doesn’t feel they offer the same quality of interaction as in-person visits, especially for her neurodiverse kids. Instead, she relies on pharmacists. (She paid one $45 recently to test her kid for strep throat.) Or the hospital. “It doesn’t matter what it is,” she says, “if it’s the littlest thing, I take them to emerg.” Wait times are long, but what else can she do?

“We,” she says, “are not getting the care we need.”

Fox is far from alone in her struggle to find regular care. In May 2024 the primary care networks of Alberta announced that visits to albertafindadoctor.ca had topped a million for the first time since the website launched in 2019. That represented an increase of 28 per cent over the previous year. Only 163 doctors were accepting new patients province-wide, down from 887 in 2020. This, at a time when the number of registered family doctors (and doctors overall) is increasing in the province. The College of Physicians and Surgeons of Alberta’s website reports 4,374 family physicians in the first quarter of 2024, which is 215 more than the same period the previous year.

How can there be a shortage, then The explanation is that when family doctors are unsatisfied with longitudinal care (seeing the same patients, often proactively, over a long period), they have plenty of other options. Following medical school, they complete a two-year residency training program that prepares them for generalist practice. While some continue in full-scope “cradle-to-grave” longitudinal care, others choose narrower practices in sports medicine or labour and delivery or cosmetic medicine. In other words, doctors are not leaving. They’re narrowing their practice.

Michelle Hart can tell you why that happens. She trained as a general practitioner in South Africa before moving to Canada in 2004. For the first seven years she worked in Daysland, a central Alberta community of 800 people southeast of Edmonton. The hospital there served a large catchment area and had an emergency department; you could have your baby there and even be admitted for awhile after you were discharged from your knee replacement in Edmonton. Sometimes people drove from the capital to Daysland for urgent care because wait times were shorter there than in the big city.

Hart was one of three to five doctors who kept the doors open 24 hours a day. Together the doctors saw patients in clinics, did shifts in emerg, delivered babies, did rounds of inpatients and even did outreach clinics in two neighbouring towns. “There were no Canadians doing these jobs. We were all immigrants, so you keep your head down and mind your own business and do the work.”

Eventually, though, being on call for days at a time and working 90-hour weeks with young kids got the better of her. “[My husband] said he was done with super-rural life,” Hart says, “and if he was never going to see me, he was going to raise the kids in the city and I could come visit him.” She resigned her Daysland practice and the family moved to Calgary.

For the next six years she worked at a couple of different clinics—both of which closed due to financial issues—before starting Hart Family Medical in the southwest neighbourhood of Signal Hill in 2017. Now her clinic is also being squeezed.

Hart’s overhead is around 40 per cent. For something like a quick blood pressure check and medication refill, the government pays her $39.49. About $16 of that goes to supplies and to pay the electricity bill and to keep good people at the front desk. “You can’t pay [your staff] peanuts,” she says. “It’s very, very difficult.”

Hart has had a few doctors join her over the years—many of whom worked with her as trainees who then wanted to stay on as colleagues—but she says it’s hard to keep them. Money is only part of it. There’s also the paperwork, which she describes as “horrible” since the COVID-19 pandemic. Before the pandemic she says she might have done two disability tax credit forms; last year she did 20. And wait times are longer, which means family doctors have more letters to write and answer trying to get their sick patients seen somewhere. She had breakfast recently with two former trainees who are now several years out of residency. One was completely burnt out and the other, after having a baby, doesn’t want to come back to family medicine. “None of that generation wants to do it,” Hart says.

This is only a slight exaggeration. Michelle Morros works as a family doctor and directs the family medicine residency program at the University of Alberta. Last year she interviewed each of the 75 graduating residents and asked them what kind of practice they intended to pursue; only four saw themselves ever pursuing the kind of “cradle-to-grave” care people generally associate with family medicine. Very soon, Morros says, her heart started to sink. Many were going to leave the province—not unexpected, since doctors don’t always stay where they trained. It was when she heard that many who were planning to stay in the province were going to do a year of extra training in “enhanced skills” that she became especially worried. Enhanced skills training can be in emergency medicine, geriatrics, palliative care—a large array of skills considered part of a general scope of practice. All necessary, says Morros, “but my job is to create that comprehensive longitudinal doc. Once you do [enhanced skills], you don’t return to comprehensive care. They actually just become mini-specialists.”

Their reasons for not pursuing the kind of generalist care they trained for… Morros says they don’t want to have to run a business. If family doctors’ compensation is going to be the lowest of all physicians, they at least want to rein in their hours and responsibilities. And they want to be able to take a vacation. Morros frames this as “moral injury.” Residents tell her that if they can’t get time away from their patients when they need to, then they’d rather not take on regular patients.

“They see some [doctors] who haven’t had a vacation in five years. They see others retiring, and their patients have nowhere to go. They don’t want that burden. It’s the burden of responsibility rather [than a desire for] a capricious flexibility,” Morros says.

Even new medical students seem to be feeling this pressure. Sana Samadi is a first-year medical student at the University of Alberta. She’s had people ask her to provide them with medical care—before she’s even a doctor. “That’s how desperate the situation is,” Samadi says. “People are just trying to find anyone they can. As learners, when we see a struggling system first-hand, why would we choose it?”

Back in Calgary, Michelle Hart doesn’t fault people for leaving or avoiding full-scope care. “All of them are lovely, smart, amazing human beings,” she says. “But they [want a] work–life balance, and I think we missed the lecture on that in school a long time ago.”

With the doctors who have joined and left her clinic in the last year or so, Hart estimates that about a thousand patients have been “orphaned,” meaning that when their doctor left there was no one to take over their care. Her own 1,500 patients might soon join them. The lease on her office runs out in October and she’s giving serious consideration to letting it all go then.

“Have you got an hour or two?” Paul Parks laughs when I ask him why it’s so hard for people to find a family doctor in Alberta right now. Parks is an emergency physician in Medicine Hat and the president of the Alberta Medical Association. While he doesn’t think it’s been malicious, he feels comprehensive family medicine has been neglected by governments for a long time, with fee schedules not keeping pace with increased demands on family doctors. Patients are living longer and have more medical conditions than in the past. They see more specialists, who all require communication.

Parks says the cracks were beginning to show even back in 2020, before the COVID-19 pandemic heated up. In February of that year then-health-minister Tyler Shandro made the unilateral decision to reduce or eliminate fees for complexity and additional time modifiers (extra amounts doctors can bill for a patient whose needs are not straightforward, say, heart failure with poor kidney function and a new infection). Shandro famously stated, “We don’t think that the population of Alberta is that complex.”

The announcement led to confrontations with physicians. The AMA called the clawback a disproportionate attack on family doctors, and shortly after released survey data indicating that 40 per cent of all doctors in the province were considering leaving—just as the healthcare system faced unprecedented challenges from a virus the likes of which the world had never seen. Shandro left the complexity modifiers alone and deferred further conversation for sometime in the future.

Most doctors ended up staying. But Parks says it was more a question of duty. “Physicians just sucked it up and took care of the pandemic,” he says. “I’m proud of my profession for that, because we didn’t carry on the war with government. We just took care of it.”

Four years later, though, the cracks are spreading again. Already people are not being seen at clinics. It means that while Parks still treats the usual accident victims and heart attacks, he also sees all the folks such as Elizabeth Fox who bring their kids to ERs for things that might otherwise be dealt with more cheaply in a family doctor’s office.

And survey data suggest things will only get worse. In January 2024 the AMA released results of a survey of family physicians in the province. Over a quarter responded. Of those, 61 per cent were considering leaving healthcare in Alberta altogether, while 54 per cent were at least considering leaving comprehensive care.

In Alberta only 163 doctors are accepting new patients, down from 887 in 2020.

Don Wilson is an obstetrician/gynecologist who formerly worked in Calgary but left for BC in 2020. “I sort of had this flash about how things were going to go with the healthcare system,” Wilson says, “and that’s why I decided to leave. I can’t stay and support this kind of a system that’s going to do this.”

By “this” he means the province’s unilateral changes to billing in 2020. Beyond what it might have meant for his own bank account and the stability of his practice, Wilson was concerned about what it might mean for primary care. Problems left untended upstream—preventive care missed, initial investigations not done, treatments untried—can lead to bigger problems downstream, where he works. Abnormal uterine bleeding not addressed by a family doctor, for example, can eventually land a patient in the emergency department with severe anemia waiting for the gynecologist.

Wilson was especially concerned about what it could mean for marginalized people. A member of the Heiltsuk First Nation, Wilson says he was particularly concerned about Indigenous patients, many of whom live in rural areas and have already been marginalized in the healthcare system. “The province has hemorrhaged family doctors, and Indigenous people have been disproportionately impacted.”

I spoke to Wilson in February 2024, more than a year after doctors and Alberta had agreed on a new physician agreement. He doesn’t regret leaving. His concerns with the UCP have now drifted toward the governing party’s stance on healthcare for trans people and to whether it might even defund abortion. “I didn’t have much of a political conscience until the UCP started what I would call an ideological war against the profession of medicine and public healthcare in the province,” Wilson says. “It really woke me up.”

If Wilson and the data are correct, and the province has hemorrhaged family doctors—or at least access to traditional family medicine—then what will stanch the flow?

It’s a problem the entire country is having. The Canadian Medical Association reports that more than 6.5 million of Canada’s 41 million people lack access to regular primary care, and that a third of people who do have a family doctor wait too long for an appointment. And adding training spots in residency programs isn’t a solution on its own if those positions go unfilled, as 22 did last year in Alberta, and a further 12 did this year.

All medical associations in the country are advocating for more team-based care to help ease the burden on GPs and to keep people healthier, and in 2023 health minister Adriana LaGrange announced that nurse practitioners (NPs) would soon be able to run independent clinics. Critics say that while the change may open more appointment slots in the short term, on its own it does nothing to make any clinic—whether staffed by MDs or NPs—more viable.

If family doctors’ compensation is going to be so low, they at least want to work fewer hours.

AMA president Parks is no Pollyanna, but recent progress on so-called stabilization funding gives him some hope. In December 2023 the province announced it would spend $200-million over two years to help pay doctors for work that currently goes unpaid: reviewing lab results and other documents, filling out forms. In addition there would be a new Physician Comprehensive Care Model that would give doctors an option other than fee-for-service, where much of the work has no applicable fee. That model is set to roll out this fall, though details at press time were sketchy. BC announced something similar in 2023, and Parks says it resulted in the recruitment of 600 new physicians to longitudinal primary care in that province.

Michelle Morros in Edmonton loves the work of primary care. She recognizes that her academic salary shields her from the vagaries of running a private clinic, so she can focus on the rewards of doing the work. “When I am in the room with a patient, I love it, the medicine,” she says. “I absolutely believe that if someone has a proper primary care provider, their health outcomes are so much better. I think that’s the difference I can make.”

But what of the fee-for-service doctors distracted from the medicine by trying to keep the lights on If you ask Michelle Hart, she’ll tell you family medicine is dying.

You’ll get no argument from Rob Graham. When he was a kid growing up near Trochu, his whole family of six—two parents and four brothers—went to see the same family doctor in Innisfail. When Graham married, his wife started going there, and when they had a daughter, the baby went there too.

All that changed last year when Graham, who now lives near Pine Lake, turned 41. “[My doctor] retired after the last UCP government got in,” he says,” and her clinic closed down after that.”

His first thought was for his daughter. “She’s got asthma and allergies, so there were medications we needed, and it was, like, ‘How do we get these anymore?’” Graham himself has epilepsy.

He was told they could transfer their files to a new clinic in Innisfail, which he did, assuming they’d be guaranteed a new doctor. But no. While they’re able to access a walk-in clinic 14 km away in Penhold, like Elizabeth Fox in Elnora he’s unlikely to see the same doctor twice. And it’s beginning to matter.

After a long seizure-free period, Graham had two back-to-back episodes in January 2021. He works as a millwright and pipefitter. Besides a seizure being “a pretty rough experience to go through,” Graham also can’t work or drive for three months after he has had one, so it’s important to stay on top of things to avoid having more. When he can’t get a walk-in appointment, he uses an online medical service called Maple, which offers a membership subscription for $79.99 per month (plus applicable taxes), which fortunately his work benefits cover.

“Everyone screams about free healthcare in Canada,” Graham says. “If you can’t talk to anyone, it doesn’t matter if it’s free or not. It’s kind of useless. The way things are going, I’d almost rather just pay for it.”

Still, he holds none of this against his childhood doctor—or any doctor for that matter. “If people are going through charts until 11 o’clock at night,” he says, “and you see the stress on our doctors from trying to get everybody through, I mean, it’s a thankless system.”

The health minister declined to be interviewed for this story, but her office provided a statement: “Alberta’s government is committed to making sure Albertans can access primary care when and where they need it. We want to ensure Alberta can attract the best and brightest to our province.”

It’s possible the future compensation model will start to turn things around. For now, though, Rob Graham wonders why, if he himself wouldn’t put up with poor working conditions, Alberta’s family doctors should have to. “Those guys are working flat out,” Graham says. “I think our medical system is failing.”

Monica Kidd is a journalist and family physician in Calgary who writes about health and the environment. Her previous Alberta Views story (March 2023) is “A Mountain of Medical Waste.”

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What’s Wrong With Rehab?

Euan thomson — Fri, 01 Mar 2024 09:00:08 +0000

On a frigid February night in Edmonton, I’m downtown with 4B Harm Reduction. The street outreach conducted by this non-profit society is time-tested—scour the city’s forgotten corners for people who need support. On any given shift, they might respond to drug poisonings, frostbite, heatstroke, hunger, fatigue-induced psychosis or the many barriers to accessing shelter. Mostly 4B aims to keep hope alive despite society’s structural neglect.

Tonight we’ve gathered in an underground LRT station passageway. Beside us, a long stretch of yellow fencing separates us from a lone electrical outlet, a rare treasure in public spaces. The outlet was recently deemed too popular among the city’s unhoused citizens—hence the fence.

Through slurred speech, Brandon Shaw fawns over my toque, which reads “Hoot ’n’ Blow” beside an owl logo. I offer it as a trade for his, but he declines. Someone later explains Shaw was afraid he’d picked up lice in the shelters. He was protecting me.

Brandon is the namesake of the organization (“For B”), which was launched by his mother, Angie Staines. He’s 28 years old and still alive after 12 years unhoused—but only just. In the summer of 2022, Staines and her team found Brandon blue-lipped, deep in a fentanyl poisoning. They revived him with naloxone and oxygen. But in the ensuing months he was set on fire during a drug deal gone wrong, then suffered a kidney infection, then withered through the dysentery that hospitalized over 100 of his unhoused neighbours.

Half of Alberta’s treatment beds are in explicitly faith-based facilities, with an overwhelming focus on total abstinence.

Like everyone down here, Shaw’s life could have taken any number of trajectories. Twelve years earlier he had been a multitalented and athletic kid running full speed into behavioural challenges. “I left home for the first time out of fear and shame of the pain and harm I was causing my family,” he says. “I knew something was up with me; I just didn’t know what.” He quickly gave up on youth shelters. “I didn’t last long, because of my drug use and mental health,” he says (many shelters have strict abstinence policies). “And nobody asked me what I want or what I need.” So, managing bipolar disorder and ADHD with street drugs, the runaway teenager took up residence in a tent.

Years later Shaw would wait months on a medical detox list, only to be refused support for his potentially seizure-inducing benzodiazepine withdrawal. Given that his earlier attempts at detox from benzodiazepine-laced fentanyl “felt like having a stroke,” he was desperate for a better option.

Like so many other people 4B was out to support that night, Shaw is up against systems seemingly built to fail. Successive provincial governments have ignored survivors like him while holding fast to outdated conceptions of drug use and addiction.

In 2014 Dr. Esther Tailfeathers sounded the alarm about a sudden escalation of opioid poisonings in her native Kainai Nation (Blood Tribe or Blood Reserve), bordering Lethbridge, where she practises family medicine and advocates for harm reduction. “I had no idea we wouldn’t get on top of this, we wouldn’t have a good strategy—[that by 2024] we’d still be chasing the tail of the problem,” she says. At the time, she remembers, “We thought we were an anomaly, that it wasn’t happening anywhere else to this degree.”

Kainai was at the vanguard of the cataclysmic shift in Canada’s criminalized opioid supply, from use of regulated pharmaceuticals and “old-school heroin” to potent synthetics such as fentanyl that are made without opium poppy. Recognizing the trauma of people who use drugs, their families and frontline responders, Tailfeathers’s daughter Elle-Máijá documented the period. In 2021 she released the film Kímmapiiyipitssini: The Meaning of Empathy.

Recently the doctor and her daughter “started counting the number of people in the film that have died. It was over half of them.”

Alberta has lately seen a seven-year drop in Indigenous life expectancy. In 2015 life expectancy for a First Nations man in Alberta was 67; today it’s 60. For First Nations women, it’s dropped from 73 to 66. This decline has been attributed in large part to our province’s narrow scope of drug policies, centred on abstinence. To Tailfeathers it seems like a conscious reframing of John A. Macdonald’s “clearing the plains” starvation politics. “Macdonald and all these other leaders thought they knew what was best for Indigenous people,” she says. “In 150 years there’s been no change… Making decisions about us, without us, is still colonial.”

During the NDP term in government (2015–2019), AHS incrementally piloted and adopted interventions falling under a “harm reduction” umbrella, such as naloxone distribution, supervised consumption sites and prescribed injectable hydromorphone. But these measures were too little, too late. While the tide of regulated opioids retreated—in an overcorrection to what some experts saw as loose prescribing practices—annual toxicity deaths in Alberta rose from around 100 in 2012 to 805 in 2018. In 2023 Alberta was on track to exceed 2,000 opioid-related deaths for the first time. (The data is not yet finalized.)

Elaine Hyshka, Canada Research Chair in Health Systems Innovation at the University of Alberta, still agonizes over the opportunities missed in the early days of the crisis. “The exponential increase in deaths was directly related to a change in the illegal drug supply. Before, people were primarily using prescription opioids. Those became less available, and the illegal market moved to fill that void.” With dangerous drugs flooding in, and deaths rising fast, drug policy experts called for immediate harm-reduction measures to save lives.

In the years since 2019, however, harm reduction has been turned into a political wedge, and “addiction,” an amorphous term increasingly avoided by drug-policy experts, has been reinforced as the nexus of public interventions. But we’re taking aim at the wrong target, says Hyshka. As Brandon Shaw’s story illustrates, this isn’t an addiction crisis, it’s a mass poisoning.

Successive provincial governments have ignored survivors like Brandon while holding fast to outdated conceptions of drug use and addiction.

When Jason Kenney’s United Conservative Party took power in 2019, it began cutting harm-reduction services. By 2023, grassroots overdose prevention sites had been criminalized, the number of supervised consumption booths in Alberta had been reduced by 35 per cent, and every patient in Alberta accessing a prescribed supply of hydromorphone (a synthetic opioid) was forced to accept a regimen of “witnessed oral dosing” in central facilities. To harm-reduction advocates, these restrictions became synonymous with the government’s recovery-oriented (or abstinence-oriented) focus.

Brandon Shaw experienced first-hand the staggering increase in poisonings during the transition to synthetic opioids. “I moved to BC [in 2013] when you could still buy actual heroin. …I had a somewhat normal life, working day labour, living in a ‘wet house’ [sober-living facility with loose rules]. Then fentanyl came along and everything changed.”

“At first, we just thought we were getting strong-ass dope… then we noticed all our friends were dying. My routine was on its head. Before, I would use four times a day. Then fentanyl came out and I was using sporadically, at weird times of day.” Shaw describes fentanyl’s lack of “legs,” its shortened effects compared to heroin or other opioids. After losing many friends to poisoning, he recognized the threat to his survival and returned to Edmonton in 2015.

As in BC, the ground in Alberta had fundamentally shifted. But a public health response equal to the crisis was nowhere in sight in this province. With few options to choose from, Shaw returned to residential treatment for his third time—for his first, as a teen, he had been involuntarily committed through the Protection of Children Abusing Drugs (PChAD) Act. He would eventually tally a total of seven attempts in the system.

Through these stays in “rehab,” Shaw learned some basic living skills. But these didn’t help him overcome his biggest barrier: securing stable housing. What he needed, according to Alberta’s drug-treatment system, was to be drug-free. “When you’re using drugs, that alone really screws you for a lot of options—there’s very little low-barrier housing. A lot of these places are 12-step-oriented.”

The 12-step method, developed in the 1930s for people dependent on alcohol, is rooted in Christian values to support people through abstinence. Countless people credit 12-step’s community support for their eventual success in maintaining abstinence. But the method has its limits and drawbacks. Critics refer to the community shaming that reveals itself, as one example, when people admit to resumption of drug use (or, to use the more stigma-laced term, when they “relapse”). Speaking of her own experience in a 12-step program, New York Times journalist Maia Szalavitz put it bluntly: “Such clearly religious practices would not be accepted as medical or psychological treatment for any other condition.”

An internal AHS document reveals that 12-step-based strategies are central in publicly funded facilities harbouring three-quarters of Alberta’s treatment beds. Around half of Alberta’s treatment beds are in explicitly faith-based facilities. Between religious undertones and an overwhelming focus on total abstinence from drugs, rehab can exclude people seeking other approaches to recovery, including ones that don’t aggravate their existing shame.

But one life-altering experience in treatment stands out for Shaw. “I’ve experienced all kinds of trauma through the last 12 years,” he says, summarizing lifetimes of harm in one breath. During an extended stint at Our House Addiction Recovery Centre in Edmonton, Shaw says, he underwent six months of trauma therapy with a professionally certified counsellor. That length of time “was the only way I was able to get vulnerable… I had to trust him more than anyone I’ve ever trusted.”

Trauma therapy, however, is expensive, intensive and outside the scope of most treatment facilities in Alberta. It takes weeks or months to conduct pre-screening and ensure that a participant is in position for routine follow-up and therapeutic work outside of regular sessions. In effect, trauma therapy requires someone to be sheltered, supported by a close network and ready to face their demons. Shaw wanted “treatment that would fit [him] individually, not just a one-shoe-fits-all, for every single person coming in.” Instead, the option offered by most rehab facilities he visited in Alberta seemed to create “a revolving door. It doesn’t work.”

After decades of advocacy by mental health professionals, Alberta not long ago was set to expand its therapeutic options. But in 2021, a day before the ribbon was to be cut on the College of Counselling Therapy of Alberta, the provincial government announced the college was “no longer a priority.” It cancelled the launch, preventing the professionalization of oversight and regulation of mental health and addiction therapy. Instead, the Kenney government doubled down on treatment facilities that are cheaper and unaccountable.

The lack of accountability at Alberta’s existing treatment services troubles Tailfeathers. “Without evaluation, we have no idea what works and what doesn’t,” she says. “[A program] might look good, but are we actually evaluating whether it’s successful or not Is there an overall decrease in mortality, an increase in people returning to the workforce, children staying in their households with their parents?” Our government is “shooting from the hip, putting all their eggs in one basket.”

Despite regularly publishing data on drug-related EMS-dispatch and drug-related mortality, the government of Alberta hasn’t shown how treatment impacts the odds of survival—if it even knows. Hyshka suggests the starting point to assess success would be to see if people who attended treatment “had any EMS activations or attended a hospital for substance use disorder for six months and one year following discharge.” In Alberta’s centralized medical system, this should be easy.

Alberta’s Ministry of Mental Health and Addiction did not reply to any of my questions. Reporting requirements to the government were, however, disclosed to me by a director and a manager at two private but publicly funded residential treatment facilities and a staff member at an AHS detox facility. (They requested anonymity to protect their provincial funding.)

The responses from the three facilities provide a rare insight into the government’s selective data management. By collecting client participation data such as number of people initiating and completing treatment, number on wait lists, and participant demographics, the government attends to the needs of the treatment industry.

Conversely, the government appears to actively ignore client outcomes, including how many people maintain abstinence or even survive in the months following their participation in a treatment program. And while the government tracks the number of people discharged early from treatment and the reasons for early discharge, this information is not publicly disclosed. As a result, the industry is protected from evaluation and scrutiny while clients continue to be ushered through the system. And the fact that one facility admitted to a “triage process” while another did not suggests the possibility of “pay-to-play”—priority access for people with the right network and a willingness to make donations.

The collecting of data on people using services and what helps them complete programs can create an impression that the programs are supporting recovery goals. But this hinges on how we define recovery and success. The lack of follow-up with patients, says Hyshka, “means the system isn’t accountable to [the public] or to patients. If you’re a politician and you’re not measuring success, you can’t be held accountable for your policy decisions.” And as Shaw points out, a “revolving door” system in which clients leave treatment only to re-enlist months later—at thousands of dollars per stay—represents a tremendous business opportunity.

It turns out that, in the distinct but overlapping worlds of addiction and drug poisoning, definitions of “recovery” and “success” are not universal.

The Alberta government claims that “acute interventions,” a veiled reference to harm-reduction services, have “come at the expense of supporting the long-term wellness and recovery of individuals, families and communities.” The implication is that helping people stay alive while using drugs comes at a cost to the individuals and their communities by delaying their transition to “recovery.” The government defines recovery as “a process of sustained action toward physical, social and spiritual healing and wellness while consistently pursuing a substance-free life.” This contrasts with harm-reduction-oriented definitions, many of which centre a person’s own goals related to drug use alongside informed consent on supports.

The goals, actions and performance metrics built into recovery-oriented (abstinence) systems of care are detailed in the 2023–26 business plan for Mental Health and Addiction. The ministry’s budget is $300-million for 2023–24, of which at least 80 per cent is allocated to addiction and mental health recovery programming and capital costs. In a rare instance, the plan specifies a secondary objective of reducing “opioid-related overdoses in the province, with a focus on Indigenous Albertans who are disproportionately affected.” The initiatives listed are limited to residential and day treatment, a helpline and an expansion of the Virtual Opioid Dependency Program (VODP)—hardly a complete recipe for managing a toxic drug supply.

The VODP was originally designed to provide access for people in rural settings to treatment and opioid agonist medications (such as methadone and Suboxone); it was recently adopted for use in prisons. However, a 2022 study funded by AHS and co-authored by Nathaniel Day, the medical director of VODP, showed considerable participant dropout. Those who could be studied, the authors admitted, “were individuals who remained in treatment and were agreeable to completing assessments, [so] they may have also had more positive outcomes.”

The best treatment for opioid use disorder is medication. “Rehab” for opioid use has little supporting evidence.

Alberta’s recovery-oriented system is operating as a flimsy raft in a storm of toxic drugs, unaffordable housing and structural neglect. Thousands of Albertans, unable to hang on, are annually lost at sea. Others, with resources, luck and a willingness to define recovery as abstinence, are eventually carried to dry land. How many Albertans are saved, and for how long, our government either doesn’t know or won’t say.

In their emphasis on mortality, advocates for harm-reduction options misinterpret the ideology underpinning Alberta government’s approach to the poisoning crisis. Long term, the government’s apparent hope is that its recovery-oriented system will give rise to drug-free communities. In the short term, however, the “pursuit of a substance-free life” is being prioritized over minimizing death and illness caused by an unregulated supply.

The way treatment programs are instructed to monitor participant mortality rates helps illustrate this ideology. An executive director at a facility (residential treatment facility #1 in the table) told me that they only learn about the deaths of recent participants through alumni, 12-step meetings, mentorship programs or when someone voluntarily reports a death to the facility. If a participant’s death is reported within two months of the person’s exit from a program, it is relayed to the Alberta government. That completes reporting.

In the run-up to the 2023 provincial election, UCP candidates frequently celebrated their system’s supposed ability to reduce deaths. But during the same period, drug toxicity deaths rose steeply, topping 195 in April 2023—Alberta’s worst month on record. The government has since pivoted to a “Recovery Capital Index” to measure the success of treatment. This approach defines recovery capital as “the combination of personal, social, community and other supports that a person can draw upon to begin and sustain their recovery from addiction,” including housing, employment and family connection among the eight factors in the framework.

An individual’s index is measured at several timepoints during treatment using the My Recovery Plan app. Created by BC-based Last Door Recovery Society, the app was licensed to the Alberta government through sole-source contracts totalling nearly $1.8-million.

David Hodgins, a professor of psychology at the University of Calgary, describes recovery capital as an “increasingly recognized construct describing dimensions of recovery beyond reduction of problematic substance use.” He points out that no research yet exists on whether the app improves outcomes, though this is typical for mental health apps. Hodgins is also careful to emphasize that recovery capital “has nothing to do with reducing drug poisoning deaths, beyond the idea that more people being successfully treated is a good thing. It may help people maintain abstinence by pointing out areas of strength and areas of need.”

The director at residential treatment facility #1, mentioned previously, was enthusiastic about Alberta’s new framework, saying, “I see the successes every day… Recovery capital is measured in simple points: when they come in, at the 30-day mark, when they exit… we see huge increases at those points and huge decreases in the barriers to recovery.”

Recovery Capital Index scores, if they improve—and assuming they can be trusted and are released transparently—may eventually help justify the Alberta government’s focus on rehab. But, says Hyshka, “if the number one goal is to reduce the death rate, funding treatment beds is not going to do that.”

She emphasizes that the gold-standard treatment for opioid use disorder is medication, while residential treatment has little supporting evidence thus far. In any case, she reminds us, “a large percentage of people who use opioids or other substances are not going to meet the criteria for substance use disorder [or for being admitted to treatment], but they’re still at risk of dying—especially if they’re accessing drugs from the illegal market.”

The Mental Health and Addiction ministry’s $300-million budget in 2023–24 is a roughly 40 per cent year-over-year increase. This is laudable spending against historical underfunding on mental health and substance use supports. But the same budget announcement designated just $14.5-million for supervised consumption sites, a 30 per cent drop that was obscured in subsequent budget releases. Underscoring this quiet manoeuvring, the UCP’s fall 2023 annual general meeting passed a resolution calling for the wholesale defunding of supervised consumption services. And the Alberta government continues to build out its plans for its notorious Compassionate Intervention Act. This legislation is expected to empower police, families and healthcare providers to obtain court orders that compel people deemed a danger to themselves or others to undergo addiction treatment.

“Tough love” might seem compassionate to some. But Hyshka says the evidence shows that people are at “much higher risk of death from poisoning” following a period of forced abstinence. She also worries that “we already have trouble encouraging people to talk openly about their [drug] use and speak out and reach for help when they need it.” Fearful of being subjected to involuntary treatment by those they trust, “people will stop reaching out for help.”

Despite plans to construct 11 “therapeutic communities,” at least four of them in First Nations communities, including Enoch Cree, Kainai, Siksika and Tsuut’ina first nations, the government is signalling further privatization in the ownership structures. Not only will the success rates of treatment remain unknown to the public and to patients, it’s unclear how public money is being spent. Tailfeathers is troubled by this lack of transparency: “It’s like building all the brick residential schools… we’ve got these things built, but nobody knows what happens inside.”

The government’s first such contracts, in Red Deer and Lethbridge, were awarded to Edgewood Health Network and Fresh Start Recovery. Edgewood is a private company backed by undisclosed investors, while Fresh Start is a non-profit. Both corporations are perennial Lead Sponsors of the Recovery Capital Conference, a public centrepiece of the UCP government’s recovery-oriented system of care.

The conference also happens to be organized by Last Door Recovery Society, the organization that licenses My Recovery Plan to the Alberta government. After a former staff member was charged with multiple sexual assaults in 2023, Last Door came under fire for alleged attempts by senior staff to prevent survivors and community members from coming forward. As individuals and treatment facilities load recovery capital scores into My Recovery Plan to shore up the government’s appearance of system monitoring, Last Door will grow its financial capital. Reducing deaths will remain a secondary concern.

To Tailfeathers, addressing deaths must be a top priority. The trauma of unending crisis and loss is “wearing down people at the frontlines,” while the government’s strategy is “way off the mark in terms of… healing people who are seeking the drugs.”

“If politicians are not measuring success, they can’t be held accountable for their policy decisions.”

It’s a sunny fall day seven months after my first meeting with Brandon Shaw, and my phone call with him is interrupted by someone dropping boxes of naloxone at his apartment. He’s been housed since spring, after detoxing at home with Staines’s support and getting access to a safe supply of hydromorphone. When he picks up the phone again he tells me, “Things are going amazing. I’m at a place in my life where I have more now than I ever have—emotional supports, people I work with in advocacy—all these people now that have come into my life… Without my mom, I can’t guarantee you I’d be here today.”

When he was unhoused, he says, he was stripped of his voice and “tired of people crossing the street to get away.” With the support of 4B Harm Reduction, Shaw has launched a public education project—The Curbside Philosophy—to restore power to his community. As a society, he says, we spend so much time talking about unhoused people—Shaw wants us to speak with them. His project makes short videos situating real people inside the politics.

Not everyone from Shaw’s past has been able to transition to a life like his. “What keeps me up at night are the people I had to leave behind,” he says. His voice breaks as he describes the displacement of people who used to meet every day at the recently relocated Boyle Street Community Services, a ripple effect of the gentrification that is driving unhoused Edmontonians and their services out of the core.

Shaw knows his luck—in having Angie Staines as his mother, in surviving his interludes between the “revolving doors” of treatment, in finding a purpose with 4B Harm Reduction, in the grassroots community that supported him while he faced exclusion by the system. “I don’t want my whole recovery to be founded on… the fear of 12-step—having to tell everybody what a screwup you are. …When I screwed up, my community was behind me. People were just happy to see I wasn’t driven by fear and shame.”

Euan Thomson co-launched EACH+EVERY, which supports evidence-based, humane solutions to unregulated drug toxicity.

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The post What’s Wrong With Rehab? appeared first on Alberta Views.

Dysfunction at EMS

Jennie Russell and Charles Rusnell — Wed, 01 Mar 2023 09:00:17 +0000

The 7-year-old girl had obvious internal injuries. Her upper abdomen had been crushed at the moment of impact and she was at risk of bleeding to death. A small crowd had gathered at the car accident scene off Ellerslie Road in south Edmonton, gawking as the lone paramedic, a first responder, pulled up in an SUV.

Minutes ticked by. With no ambulance to transport the girl to hospital, the paramedic knelt beside her on the grassy median, comforting her as best he could while they waited. One minute, two minutes, stretching into 40 minutes, until finally the wail of a siren.

“I think the most important point for the public to understand is that our system is in shambles,” said an Edmonton paramedic with decades of experience. “Calling 911 is not reliable. The system’s ability to respond to your emergency is a roulette wheel.”

In our recent interviews with one dispatcher and 19 paramedics from across the province, a common theme emerged: when Albertans call 911 and request an ambulance, whether or not they receive a timely response increasingly comes down to luck.

Paramedics consistently described an Emergency Medical Services (EMS) system so dysfunctional and routinely overwhelmed it compromises their ability to provide even adequate, let alone life-saving, care. More than a dozen paramedics could readily recall incidents—in a profession where “time is tissue”—of excessive response times.

One told us he arrived at the scene of an ultimately fatal cardiac arrest 35 minutes after the call came in. Another drove past three empty ambulance stations to reach a patient, now unresponsive, and immediately started chest compressions. One is haunted by the memory of a father who had watched his seizing child convulse for 45 minutes before help arrived.

A veteran paramedic joked darkly that they don’t get a chance to develop PTSD anymore “because by the time we get to the calls that would normally cause a stress reaction, the patient is already so far gone that we’re not fighting for them. We’re just, like, ‘Oh, there’s a body’ or ‘Oh, there’s nothing we can do.’ Where it used to be we would get there in time.”

Most talked about a workplace in such shambles that it psychologically damages them. Many are counting the days until they can escape.

They spoke on a confidential basis, fearful of reprisal for voicing concerns about a system many of them no longer trust to serve the public, including their own loved ones. “If something happened in my family, I would probably phone dispatch and be, like, ‘I’m a paramedic, tell me where the truck is, now,’ ” a central Alberta paramedic said. “Because I’m going to need to know if I’m throwing my family in the car or not. Whereas, you know, 10 years ago, I would not do that.”

“The system is in shambles. Our ability to respond to your emergency is a roulette wheel.” —Edmonton paramedic

In 2004 Alberta’s health ministry assumed control of the province’s EMS system, and in 2009 it transferred its management to the newly created Alberta Health Services. Critically, AHS instituted major reforms that created a “borderless” system, in which ambulances no longer serve a specific area but can be dispatched into neighbouring jurisdictions. The main rationale was to ensure the closest ambulance responds to serious calls.

Backlash followed AHS’s centralization of most EMS services in Alberta: “The main concerns and criticisms brought forward by some EMS stakeholders and municipalities were that the evolving ‘borderless’ provincial ambulance system was leaving some communities with insufficient ambulance coverage and that some ambulances were tied up with long wait times at emergency departments in urban hospitals,” a Health Quality Council of Alberta report stated. AHS completed centralization by taking over services from Calgary, Lethbridge, Red Deer and Wood Buffalo in 2020.

Paramedics now say that, as call volumes have increased without staffing keeping pace, the borderless system has evolved into a backstop in which ambulances from rural Alberta are routinely pulled into urban areas, sometimes leaving their communities without coverage.

Sometimes the pull into urban areas is gradual, a “stairstep” into city limits: the ambulance will be dispatched to a call close to a city, then “stood down” because a closer ambulance is assigned. But before they can return to their community, they are tagged on another city call. At a certain point they are inevitably the closest available ambulance for city emergencies and are assigned call after call.

One rural paramedic likened it to the pull of a “black hole.” “You’re trying to use all of your energy to get away,” he said. Recently, when supervisors took his truck out of service so he and his partner could take their break, they instead drove as fast as they could away from the city, “far enough that there may be another truck closer than [us] when a call comes in.”

Several paramedics said it’s difficult some days to take a break, even to go to the bathroom. One rural paramedic described return trips from Calgary where he and his partner were so exhausted that it was no longer safe, and they had to pull over and sleep for 45 minutes.

But it’s not as though more ambulances is the answer. When AHS announces new ambulances, as it did last September, it omits the fact that the health authority struggles to staff the ambulances it already has. During one shift last summer, a long-time EMS dispatcher recalled that “94 trucks were down. That’s 20 per cent of [our] workforce.”

An Edmonton paramedic has been tracking ambulance staffing numbers. For the first 10 months of 2022, he says, 20–30 per cent of the city’s ambulances regularly were off the road because they were unstaffed. If these numbers reflect the daily reality, that means fewer crews are responding to ever-increasing call volumes. AHS says the number of 911 calls in Alberta has grown 30 per cent since 2018–2019.

The province blames the rising number of calls largely on the COVID-19 pandemic. But while paramedics acknowledge call volumes exploded at times during the pandemic, they maintain the system has been in crisis for years. “COVID isn’t the reason for this collapse,” an Edmonton-area paramedic said. “This collapse was coming.”

A paramedic who works solo in an SUV called a Paramedic Response Unit (PRU) said his record for responding to calls in Edmonton is 33 calls in a 12-hour shift. Another PRU paramedic based in the city’s deep south said it’s now common to be dispatched to downtown or northside calls—or even to Strathcona County, the municipality east of Edmonton.

“You’re always on a cortisol rush,” said a rural paramedic from central Alberta, “because you’re, like, go go go non-stop. And then you start to live in that high adrenaline, cortisol. Always anger, fear, flight; that’s just physiology, right And then you’re not you when you come home.”

The EMS dispatcher said call volumes have increased so dramatically over the past three years that sometimes, if she and her colleagues aren’t providing urgent advice such as how to perform CPR, they tell the caller they have to hang up to respond to unanswered 911 calls. This is known as an “urgent disconnect.”

“That’s hard to do,” she said. “That might be a call I would normally stay on the line for, and now I can’t. The next 911 might be a cardiac arrest, right I don’t know, but I need to disconnect because the phone lines are ringing off the hook. And no one else in the province is available to take a 911 [call].”

Sometimes, she said, dispatchers have to call back scared and anxious people and explain they don’t have an ambulance to send yet. “It’s discouraging. Sometimes you go home and think, ‘Did I do any good today at all I couldn’t get people the help they needed.’”

Red alerts−when no ambulances are available−have become the norm.

The dispatcher is describing a phenomenon that has entered the public lexicon—a red alert, when no ambulances are available to respond to 911 calls. All 20 frontline EMS staff we spoke to said red alerts have become the norm rather than the exception.

Red alerts should only occur during a mass casualty event, a Calgary paramedic said. “[But] here, by the time it gets two hours into a shift, we’ve already drained all our surrounding resources in the city,” he said. “So if anything were to happen, there is no one to go.

“It has gotten to the point where… it’s not hoped for, but it is stated frequently in the hallways, ‘Well, maybe somebody ‘important’ will die because of this, and maybe then something will change.’ ”

The same paramedic said they have become desensitized to red alerts. “It used to be a supervisor would come into the ambulance bay at a hospital and be, like, ‘Hey, guys, we’re in red alert.’ And you would see all the crews scrambling,” he said. Now, “we just turn to him and it’s, like, ‘Yeah No shit,’ ” he said. “But I’m going to finish my coffee and finish my paperwork because we’re always in a red alert, so what difference does my clearing immediately make?’”

The dispatcher said it is now common to have “15 [to] 18 calls pending. So we have them in our computer, but we have not dispatched any ambulances to those calls.

“And there may be calls that have been sitting there for six, seven hours,” she added.

Calls are labelled based on their level of urgency. Dispatchers code calls from A (Alpha, the least serious) to E (Echo), with subcategories denoting the degree of seriousness. A minor fall might be an Alpha while a cardiac arrest would be an Echo.

Even when paramedics respond to more-serious calls in time, patients may not quickly get the care they need.

An Edmonton PRU paramedic recently responded in his SUV to a call just west of downtown. The man’s heart was failing and his lungs were filling with fluid. “I was treating him for his heart failure on the front steps of his apartment, waiting for a transport truck to come from Sherwood Park,” the paramedic said.

“I’m five minutes away from the Alex,” he said, referring to a downtown hospital. “But here I am spending half an hour on scene, trying to stabilize this guy, trying to get the fluid out of this guy’s lungs while his heart fails, waiting for an [ambulance].” He doesn’t know if the patient survived.

Paramedics refer to PRUs as “clock-stoppers,” designed to arrive quickly to serious calls. They make AHS response times look better, but the reality for the patient is that often they’re stranded, waiting for an ambulance to transport them to hospital.

A glaring, inexplicable disparity exists between what paramedics say are consistently excessive response times and what AHS says its statistics show. The use of PRUs might explain some of the gap. Urban paramedics can attend six to 10 calls in a shift, while PRUs race to a dozen or more, skewing the response-time statistics with each stopped clock.

The AHS goal is for paramedics to respond to at least half of life-threatening city calls within eight minutes, and 90 per cent within 12 minutes. In smaller communities with populations of more than 3,000, that latter figure is 15 minutes, with lengthier benchmarks for more rural and remote areas.

Alberta Health Services declined an interview request. In a statement, spokesperson Kerry Williamson said EMS median response times “continue to be lower than or close to targets, particularly for rural and remote communities,” despite the 30 per cent increase in call volume.

In Edmonton, EMS meets its response target of eight minutes or less for at least half of the calls, he said, but that is not yet the case in Calgary.

Williamson also said the number of suburban and rural ambulances migrating into metro areas has significantly decreased. That could simply mean the ambulances are staying in the metro area, an issue flagged by rural paramedics and one of many AHS did not address.

The AHS statement touted an additional $64-million in funding to EMS in the provincial government’s 2022 budget, roughly a third of which was used to buy 19 new ambulances and add more hours of EMS coverage.

Two Calgary-area paramedics said staff have been told to park their old ambulance at a station and take out a new one. “So on paper, we can say every day the new ambulances were staffed, but they’re actively dropping the truck that I was scheduled on off the board,” one of them said.

Ambulances outside the emergency department at Edmonton’s Walter C. Mackenzie Health Sciences Centre. Photo: Alamy.

Paramedics and AHS disagree on how long it is taking to reach patients. There is no disagreement, however, that once at the hospital paramedics encounter a systemic bottleneck that chronically keeps them off the road for hours, sometimes entire shifts.

Many patients can’t be left unattended, but there are no available beds and no nurses to care for them. Paramedics park patients in a hallway and then essentially function as nurses, feeding them, helping them in the toilet, even taking them for tests.

Often there are so many paramedics waiting in hospitals that they cover for each other. “We will trade off and be, like, ‘Hey, I’ll take yours and yours, so you two can get back out. And then at your end of shift, you come back and try to take my patient,’ ” one paramedic said.

Several described clocking in and driving straight to the hospital. “I spend my whole 12 hours there,” a Calgary paramedic said. “And then I go ‘I didn’t respond to one call in a day.’ ”

There have been times when paramedics transfer care of a patient to a colleague in the morning, and “when the night crew comes back on, they are handing that patient back… people are waiting in the hallway that long, and waiting in the ER that long, for a bed.”

But sometimes when there’s a red alert and 911 calls are mounting, much like the dispatchers’ “urgent disconnect,” paramedics have to abandon their hallway patients. In fact, there is a policy that prescribes it.

A long-time Edmonton paramedic said that up until the last few years he had never even heard of this “mandatory offload” policy. “It didn’t happen for years,” he said. “All of a sudden, it was happening almost daily.” Patients, some in a terrible condition, are simply abandoned in an ER hallway, because some other Albertan, somewhere else, needs help even more urgently.

Many paramedics tempered or qualified their descriptions of how chaotic the system is and how it has affected them, because they appeared to fear being accused of hyperbole. Some simply seemed tired of talking about the “bad calls,” the incidents they may never forget. The “bad call” stories were legion, including many about patients who might have survived but didn’t.

A paramedic based in a northern Alberta town told of being called to a business for a cardiac arrest. “The vast majority of cardiac arrests don’t [survive],” he said. “If there was one to be saved, I would say it would have been this one. The stars kind of aligned for it.”

When the 911 call came in, the ambulance was nearby and the paramedics were at the patient’s side within three or four minutes. By pure luck, an off-duty nurse had immediately begun chest compressions.

But he and his partner were both primary care paramedics and couldn’t administer epinephrine, a drug used to kick-start the heart. The community’s two advanced-care paramedics were on a low-priority transfer in another town. (Transfers are common in rural communities; ambulances take patients to larger facilities that have specialists, diagnostic tools such as MRIs/CT scanners, etc.) “We waited for well over half an hour for advanced life support to show up,” he said. The patient died while they waited.

Two weeks later, the young paramedic had his first panic attack.

Several paramedics told of driving across a city, or into the city from a rural community—up to an hour and a half—to reach an emergency call such as a cardiac arrest.

These sorts of system failures are known by EMS management. There is a voluntary reporting protocol, a Reporting and Learning System (RLS) online form that paramedics are encouraged to file when a system failure occurs.

Most paramedics said the RLS is useless because management gives no indication their reports are acted on. A Calgary-area paramedic said he has filed hundreds of RLS forms. “It doesn’t seem to change,” he said. “Occasionally you get a phone call from your supervisor saying things like, ‘Well, that’s just how the system is,’ when the whole point of those reports is to try to change the system.”

Several told us they were directed to stop filing RLS forms. In nearly every interview, paramedics said EMS managers don’t listen to frontline staff.

Compounding their frustration is that some systemic fixes are obvious: don’t use scarce ambulance resources to transport patients to appointments or tests unless absolutely necessary; expand access to mental health supports and family doctors to relieve the emergency room bottleneck; educate the public about when it’s appropriate to call an ambulance.

A rural paramedic working outside Edmonton told us, “Albertans need to stop calling 911 for unnecessary calls…. There needs to be an educational piece.” Another estimated that maybe one-fifth of his calls don’t actually require EMS. But many paramedics told us people often aren’t in a great position to judge whether they or a loved one truly need an ambulance, so, when in doubt, they should call.

Others pointed out that Albertans don’t always have an option. One Edmonton paramedic said lack of access to after-hours care puts stress on EMS: “Another factor is no access to urgent care centres…. You know, you cut your hand in the middle of the night—medicentres, they don’t even take walk-ins anymore, it’s mostly just by appointments. So you have to go to a hospital for those minor things, right?”

Paramedics say call volumes have increased without staffing keeping pace.

Many added that a big part of the solution is not only for AHS to hire more paramedics but also to create a culture that will retain staff. Ambulances are regularly unstaffed because paramedics call in sick, are off on stress leave or have abruptly quit the profession. Most of the paramedics we interviewed talked about a culture that wasn’t based on mutual respect or trust with management and was at times confrontational. Some called it toxic and said workers who speak up are disciplined.

In a departure from the rote AHS talking points, the government of Premier Danielle Smith in late 2022 acknowledged Albertans are waiting too long for ambulances. In a November news release, it announced new AHS administrator Dr. John Cowell will work to improve EMS service, including by reducing the time paramedics spend at hospitals and allowing them to decide whether a patient needs to be transferred by ambulance to the emergency room.

Those changes, if implemented, may come too late for some paramedics. Strikingly, many of the paramedics we interviewed said they’re already searching for another job—“Everybody’s looking for a way to get out,” one rural paramedic said of his colleagues. Others doubt they’ll make it more than a few years in their current positions.

The overwhelming picture that emerged is of people who entered the profession out of a desire to help others, only to be ground down by a system so dysfunctional, so demoralizing, that many struggle every day to muster the will to continue.

A paramedic with more than two decades’ experience described how he sits on the edge of the bed before the beginning of another stretch of shifts, debating whether to call in sick. “You just kind of take a minute, and always the thought is, ‘It’s quarter after four in the morning and this has got to be my life again for the next 96 hours. Have I got the gas in the tank to do four days of this or not?’ ”

Still, at least for now, many are dedicated to the profession. They continue to file the RLS reports in the hope of changing the system, and they continue to work the long hours and the forced overtime.

“I’m a fixer, I guess,” a rural paramedic told us, explaining why he’s been providing information about substandard service for the union’s social media. “The public is unaware,” he said, his voice quavering with emotion. “They don’t know how bad it is until it’s too late, until they call for help and no one comes.”

Jennie Russell and Charles Rusnell are Edmonton-based investigative reporters who for the past decade have specialized in political accountability journalism.

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Should Medical Laboratories Be Public?

Steve Globerman and Ross Sutherland — Wed, 01 Mar 2023 08:00:50 +0000

Steve Globerman says no

Senior fellow and Addington Chair in Measurement at the Fraser Institute

Private, for-profit companies operate labs across Canada for outpatient diagnostic testing. Public health labs and labs in hospitals and urgent care centres are government-run. Notwithstanding that private labs have been operating here for decades, they remain controversial. Opposition resurfaced again recently with Edmonton-based DynaLIFE’s takeover of community lab services from the provincial government. Critics claim the transition prioritizes profits over patient care.

The argument for privatizing diagnostic lab services is broadly the same as for private-sector provision of services such as road repairs, electricity and telecommunications. Namely, private owners have what economists call “high-power” incentives to be efficient. These, in turn, are linked to expected profits. In a competitive market with informed consumers, the only way suppliers can increase their profits is by being more efficient: by lowering costs and/or improving quality of output. In state-owned-and-operated enterprises, incentives to improve efficiency are weaker and more indirect. Namely, consumers and other stakeholders must lobby politicians and bureaucrats to effect change or must vote new politicians into office. Hence it’s unsurprising that research supports the proposition that private firms are more efficient than comparable state-owned firms.

Diagnostic labs in Canada aren’t directly compensated by final consumers. Rather, provinces negotiate contracts with private companies through a request for proposal (RFP) competition. Labs technically have only one primary paying customer, i.e., government. In the case of outpatient diagnostic testing, traditional competition within the marketplace is thus effectively replaced by competition for the marketplace.

In principle, competition for the market should produce outcomes similar to competition within it. Namely, the market should be served by the most efficient firm that offers the lowest quality-adjusted prices while providing acceptable returns to shareholders. Some critics argue profits represent forgone resources that could have been spent on patient care. But profits are incentives to innovate, which is the main avenue for long-run efficiency improvements. Conversely, the incentives in a government bureaucracy discourage innovation, since rewards to decision-makers in a bureaucracy are only weakly, if at all, tied to innovation, especially if it harms the financial interests of entrenched interest groups such as public sector unions.

An indirect benefit of RFP competition is the information provided to government about the costs of diagnostic lab testing. Companies’ responses to fee-for-service RFPs issued by the government provide insight to health ministries regarding reasonable budgets for diagnostic testing done by public labs.

The net benefits of privatizing diagnostic lab services depend on how well the government runs its bidding process. Still, evidence suggests that competition can be robust even when only two firms are competing in or for a market.

Ross Sutherland says yes

Author of False Positive: Private Profit in Canada’s Medical Laboratories

Our healthcare system would have more money for care, better integration, patient access and working conditions, and more democratic and transparent decision-making if it used only public, non-profit medical lab services.

For-profit companies such as Alberta’s DynaLIFE make most of their money from the public. Yet we don’t know how this taxpayer money is spent. What are the senior staff salaries and the profits paid to DynaLIFE’s parent corporations, LifeLabs and the US multinational LabCorp We don’t know how the company’s compensation is calculated, its scope of services or other contract details. This business confidentiality reduces accountability and limits public policy discussions.

Government studies and academic research have long found that for-profit labs cost more. In 1995 Ralph Klein cut payments to private labs by 40 per cent. This—and the companies’ resistance to integration—led to the formation of the non-profit Calgary Laboratory Services, a recognized world leader. Similarly, in 2017, Medicine Hat’s for-profit lab was found to cost more, and the work was transferred to the public sector.

Why are private providers more expensive Piecework rates, at the core of most private-sector contracts, increase marginal costs. It costs more for private companies to raise capital than for government to issue bonds. Profit taking and negotiating, renegotiating and litigating government contracts increase costs. Overuse is a consistent symptom of for-profit lab delivery. And more possibilities for corruption raise the cost of private providers. Meanwhile, the theoretical safeguard of contracting-out—competition—has disappeared. One or two companies dominate every publicly paid for-profit medical lab market in Canada. DynaLIFE’s Alberta monopoly is one of the tightest.

A broader concern with having two publicly financed lab systems (one public, one for-profit) is less efficiency and higher costs. Each requires its own government bureaucracy, payment system and managers. Different workflow patterns in hospitals and the community result in underutilized capacity. Managing data, processing samples and overseeing quality are harder.

Even in a scenario when a private lab pays workers less, reduces patient access, has less quality control and mainly processes only simple tests, thus keeping costs similar to the public sector’s, the structure required for a separate for-profit system would take significant money from patient care.

System fragmentation also ships work from smaller hospitals to centralized private labs. This can mean the difference between a small hospital providing the range of tests needed for a local ER and inpatient care, or cutting back services.

If all provincially funded medical laboratories were integrated into a public, non-profit system, costs would fall, efficiency would increase, patient access and working conditions would improve and we’d be making healthcare decisions only in the public interest.

Steve Globerman responds to Ross Sutherland

Ross Sutherland makes several arguments for having all medical laboratories in Canada be public, which effectively means owned and operated by provincial governments who already fund most diagnostic laboratory testing under provincial healthcare plans.

One argument is that while the services provided by privately owned labs are paid for with taxpayer money, the costs of private labs are not itemized and publicly disclosed, in deference to confidentiality considerations. Hence, taxpayers don’t know exactly how their money is being spent to obtain diagnostic services, e.g., on salaries, to owners in the form of profits and so forth. Sutherland sees this lack of transparency as creating risks of opportunism and even fraud by private labs.

This argument is puzzling, because politicians and bureaucrats act as agents for taxpayers when it comes to the provision of all sorts of publicly funded services. If politicians and bureaucrats can’t be trusted to contract effectively with private diagnostic lab companies and manage contracts to ensure that companies fulfill their commitments, why should they be entrusted with the responsibility to manage entire provincial health systems, among other programs?

It’s also economically illogical, because a precise itemization of costs at a specific lab would involve arbitrary allocations in the context of companies that do business in multiple provinces. Such companies have common costs, such as senior manager salaries, accounting, insurance and legal expenditures, and bulk input purchases that are shared by facilities across Canada. Any allocation of common costs to specific facilities would be arbitrary. Likewise, imputing profitability to individual labs, or sets of labs, is meaningless, since individual labs in a nationwide network aren’t run as individual profit centres. What should matter to taxpayers are the terms and conditions of the private bids for providing lab services, not the cost structure underlying the offer prices of the bidders.

What should matter to taxpayers are the terms and conditions of private bids, not the cost structure.

A more meaningful argument by Sutherland is that the limited number of companies that participate in the bidding process for contracts, usually two at most, makes for a non-competitive process, with resulting high costs and/or compromised service quality. He also asserts that the cost structure of private labs is higher than that of public labs, in part because governments can borrow money more cheaply than private companies can. To support this he cites two instances when provinces transferred work to public labs from private labs because expected cost savings weren’t being realized.

While a bidding process is likely to be more competitive when there are, say, four or five bidders rather than two, economic theory and empirical evidence don’t preclude a competitive outcome when as few as two companies compete to serve a market. Moreover, provincial governments have substantial market power as monopoly buyers of diagnostic lab services. In a bargaining environment where a single buyer is contracting for services from a small number of suppliers, a competitive outcome is certainly possible. Moreover, for-profit diagnostic labs have continued to operate over a long time in several regions of Canada. A reasonable inference to draw from this is that private labs generally deliver value for taxpayer money.

Sutherland worries about duplication of overhead costs such as management salaries in a system where a government finances and supervises public and private labs. In fact, one of the benefits of contracting out lab services is that it reduces the administrative burden on provincial bureaucrats, who would otherwise do more day-to-day administration and monitoring if all labs were public entities. The performance of private labs also provides insight to politicians and bureaucrats who administer health systems about whether public labs are operating efficiently. Indeed, benchmarking an organization’s performance against those doing similar activities is common in the private sector to assess whether the organization is performing as well as might be expected.

The assertion that all decisions would be made in the “public interest” if all diagnostic labs were public entities is belied by the long waits Canadians endure to see their family doctors (if they even have one) and specialists. Clearly politicians and healthcare bureaucrats are failing to respond to Canadians’ demand for timely access to medically necessary services. The suppression of private markets for basic healthcare services is contributing to wait times that many patients and physicians view as not being in the public interest. The lesson to learn from Canada’s broader experience is that expanding the role of the public sector bureaucracy in the operation of diagnostic labs would likely do more harm than good.

Ross Sutherland responds to Steve Globerman

Professor Globerman’s assertion that competition will drive cost savings, efficiencies and innovation in laboratory services is derived from abstract classical economic theory. In fact, this privatization defence has no relationship to the real-world history of for-profit medical laboratory companies or their impacts in Canada.

In the mid-1970s hundreds of small private labs were delivering publicly funded patient care. At this time of maximum competition, the five provincial governments using for-profit labs all had growing concerns about quality, conflicts of interest and escalating costs. Over the ensuing two decades many attempts were made to control utilization, limit fraud and conflicts of interest, make fees more reflective of actual costs and improve quality. All were stifled by for-profit company opposition.

By the 1990s uncontrolled private lab costs forced governments to unilaterally cut payments: by 11 per cent in Ontario (1993), 20 per cent in Manitoba (1995), 45 per cent in Alberta (1995) and 20 per cent in BC (2004). To limit private-sector-caused damage, Saskatchewan shifted most lab services to the public sector in 1995. The other provinces (NB, NL, NS, PEI, QC) have always primarily relied on non-profit providers.

Industry pressure to offset the payment cuts led to protected market share, less access for community patients to public hospitals, fewer community collection centres and new technology subsidies. All of these policies drove monopolization while undercutting patient access and entrenching system fragmentation. The changes also didn’t solve the problem of high costs.

Ontario’s 2015 Expert Panel Review recommended cutting a further $50-million from for-profit lab payments because of hospitals’ lower costs, the “significant profit margins” in for-profit labs and a “generous” payment structure. The 2013 BC Laboratory Reform Committee report echoed similar sentiments. Since the 1970s, in dozens of communities, the public sector improved access and optimized the use of expensive equipment. These programs included Hamilton’s Health Sciences Laboratory Program, the Hospitals In-Common Laboratories and Calgary Laboratory Services. All of these innovations were undermined by private-sector political campaigns.

Increasingly, governments are using requests for proposals to award long-term contracts for laboratory services. But proper government oversight, which Globerman notes as a requirement for the use of RFPs, has been tough to achieve. The inquiry into the 2013 multi-billion-dollar 25-year RFP for Edmonton’s community laboratory services found conflict of interest, a lack of transparency, poor record-keeping and undue influence from second-hand information. In addition, corporate confidentiality led to “doubts about the validity of the selection of the preferred proponent.” Concerns have also been raised about the RFP awarded to DynaLIFE.

Real-world experience in Canada shows that paying private, for-profit labs to provide services weakens care.

Diagnostic services are rapidly changing, with regular announcements of new tests and procedures and a fast-evolving healthcare system. In this context, the move to long-term contracts rather than promoting innovation is likely to create complex and expensive renegotiations with a sole-source provider and significant “barriers to entry” for other companies at the end of the contract.

Studies that indicate for-profit companies save costs are most often done by consultants hired by pro-privatization governments. Although the study results are released, the calculations and assumptions behind them rarely are. Studies that haven’t undergone public scrutiny can hardly be considered good evaluations of the information. Even when privatization savings are likely, they usually come at the expense of patients and healthcare workers.

Secrecy is also demoralizing to laboratory professionals, who should have significant input into major policy decisions yet are often cut out of the process. Similarly, backroom decision-making undermines public confidence in government.

Higher costs and the inherent inefficiencies of for-profit lab services take money away from other critically important initiatives, such as expanding the range of tests, increasing access points, developing new technologies, training staff and improving compensation to retain staff.

System fragmentation is particularly harmful to patients in small communities, whose samples are shipped to centralized private labs. This can increase turnaround times and lead to longer periods between specimen collection and processing, both of which affect quality.

Practical, real-world experience in Canada shows that paying private, for-profit lab corporations to provide essential medical services increases system fragmentation, undermines public healthcare, impedes innovation, costs often a lot more and undercuts democracy. Our healthcare system is stronger when all publicly paid lab services are non-profit and focused solely on the public interest.

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Should All Long-Term Care Be Public?

Rebecca Graff-McRae & Peter Shawn Taylor — Mon, 01 Nov 2021 20:23:02 +0000

Rebecca Graff-McRae says yes

Research manager at the Parkland Institute

If we are lucky we will grow old. If we are lucky, someone will care for us when we do. We all deserve and need the highest quality of care at different stages of our lives. So why should corporations exploit our need for care in order to profit Profit is generated by an erosion of care standards; there is an inherent conflict between profit and care.

The overwhelming expert consensus indicates that for-profit long-term facilities provide less care and a lower standard of care compared to non-profit or public providers. The province’s recent Facility Based Continuing Care Review report found that private, for-profit facilities in Alberta underdelivered on the hours of care they were funded to provide; public facilities overdelivered. This affirms a similar audit done in 2020 by the office of the BC Seniors Advocate. Moreover, public facilities in Alberta and BC provided more total hours of care than private facilities. These care hours are directly correlated with health outcomes and quality of life for residents.

A 2020 Parkland Institute survey of Alberta long-term care workers revealed a clear disparity between profit-based and public facilities with regard to staffing. When asked whether their facility had adequate staffing to provide quality care, 34 per cent of workers in for-profit facilities reported they never have adequate staff-to-resident ratios to meet resident needs, compared to just 7 per cent for public facilities. Private not-for profit facilities fell in the middle, at 16 per cent.

Why are staffing levels lower in for-profit facilities Because labour costs are the easiest way for providers to cut expenses and generate profits. In Alberta in 2020, large for-profit long-term-care chains such as Revera and Extendicare paid their staff from 70 cents to two dollars per hour less than the AHS standard. These and other for-profit chains went on to claim the Canada Emergency Wage Subsidy during the pandemic—only to shift the majority of the funds to shareholders as “profit.”

Meanwhile, for-profit care providers lobbied the Alberta government for legislation such as bills 58 and 70, which will erode regulations and limit legal liability for negligent facilities. Alberta continuing-care residents and their families have also been asked to consider paying “top-ups”—out-of-pocket fees—for better meals, additional bathing and hygiene services, and more one-to-one care. This effectively creates a multi-tier system, in which only the most affluent seniors would be able to access the care all our elders deserve.

Ontario’s Long-Term Care Commission report acknowledged that limiting the profit motive in the delivery of care is key to rectifying the systemic flaws that had such tragic consequences during the pandemic. The highest priority for long-term care providers must be to achieve the highest quality of care. This can’t happen when underdelivering care hours, carving off profits to shareholders, underpaying staff and cutting corners. It requires sustained public investment and public delivery.

Peter Shawn Taylor says no

Senior features editor at C2C Journal

Many arguments can be made contrary to the proposition that the entire long-term care sector should be publicly owned and operated. The most convincing is that such a thing is simply infeasible.

The private sector has long provided housing and care for Canada’s seniors and currently operates a majority of long-term care homes nationwide. According to the Canadian Institute for Health Information, 53 per cent of Alberta’s 176 long-term care homes are run by either private for-profit or private non-profit (largely faith-based) operators. The remainder is publicly delivered through Alberta Health Services or its subsidiaries. If we consider beds instead of homes, the percentage comprised by the private sector rises to over two-thirds: 37 per cent for-profit and 33 per cent non-profit.

To shift to an entirely government-run system would mean buying out or compensating all this embedded capacity. Given that the biggest issue facing long-term care into the future is a looming massive increase in demand due to a rapidly aging population, it seems inconceivable that a government would choose to spend its scarce resources converting more than half its existing long-term care capacity to public ownership rather than adding much-needed new beds to the system.

But even if the financing were manageable and there were no impending Grey Wave, why would anyone want to pursue such a confiscatory policy If you listen to certain politicians, media and unions, it’s because there’s something illegitimate about allowing the private sector to care for seniors—the lamentable death toll in Canada’s nursing homes during COVID-19 apparently proving this. Yet this is a case of dogma trumping facts. As a recent review by MNP accountants of Alberta’s continuing care sector observed, the key variables in explaining outbreaks are building characteristics and community transmission; similar results hold for Ontario. While much can be done to make our nursing homes safer, a government takeover isn’t going to solve anything.

Further, the folks whose opinions really matter don’t show animosity towards the private sector. Rather, they seem to appreciate the choice it offers. The independent Health Quality Council of Alberta regularly surveys residents and their families at nursing homes. According to a 2018 survey: “Overall there was no strong evidence to suggest any difference in experience across ownership type.” A more recent study asked about staffing in the pandemic. The results suggest a private-sector advantage: “AHS sites had less-positive responses compared to private [for-profit] sites and not-for-profit sites.”

Ridding the long-term care sector of private providers just to scratch an ideological itch would be ruinously expensive, especially in these fraught times. It would also make future improvements and expansion more difficult. Plus, residents and their families don’t even care about the issue. So why bother?

Rebecca Graff-McRae responds to Peter Shawn Taylor

Peter Shawn Taylor’s argument against a wholly public long-term care system is anchored in two contentions: feasibility and cost. Both are misdirections, based on assumptions and sweeping statements rather than evidence.

To transform long-term care into a wholly publicly owned and operated system is neither “infeasible” nor “inconceivable.” It has simply been, up until now, politically unappealing. Feasibility is often a cover for political will. The question is not about buying out all existing for-profit facilities, but whether the public should enable and subsidize the private sector while underinvesting in public facilities.

All budget decisions are based on policy choices, and all policy choices are political. There has always been enough fiscal capacity in Alberta—and indeed in Canada—to make policy choices that support the public good. That our current provincial government shies away from these choices is not an indication of feasibility or utility but rather a marker of priorities. There was money to invest in a pipeline that was dead in the water even before the cheque was signed. There was money to contract out surgical procedures rather than add capacity to public operating rooms. There is money to pay a private corporation $160-million annually to perform routine laboratory testing, but not to build a much-needed public lab that would become a long-term provincial asset. Similarly, Alberta has in the past (under the original Affordable Supportive Living Initiative program) offered substantial capital funding to private seniors care providers rather than invest in publicly owned infrastructure. As a province, we pay the same amount of operating funds to for-profit providers as we do to public providers—for fewer care hours delivered, fewer staff and a subsidy to shareholders. If the same funding doesn’t produce equal care, it can’t be considered good value for money.

The COVID-19 correlation with ownership model is nuanced and complex—particularly the 2020 study by Stall et al. referenced by Taylor. The lead author himself indicates that other factors, not captured in the research, also contributed to the for-profit disadvantage. Older design and multiple residents to a room were not the only correlated factors to larger COVID outbreaks and higher fatalities; the correlation to ownership model remained even when the design factor was controlled for. And neither that study nor an Ontario government analysis of its findings included data on staffing, even though acute staffing shortages during the pandemic are widely seen by experts as a big factor in outbreaks and poor care. Seniors care researcher Margaret McGregor evaluated multiple studies emerging from the pandemic, and concludes that the “evidence clearly shows that ownership matters when it comes to staffing, and staffing matters when it comes to managing outbreaks of COVID-19 in LTC facilities.”

Chain status was also a significant factor in the severity of COVID-19 outbreaks, and this is reflected in the four largest Canadian chains being named in numerous class-action lawsuits. Revera, Extendicare and Sienna were also named in a significant suit in 2018 that alleged the chains put profit before care and neglected the basic well-being of their residents.

Research undertaken by Tara Carman for CBC in February 2021 produced similar findings to Stall et al.: the majority of COVID-19 outbreaks and fatalities in BC occurred in private facilities, despite an approximately equal division of ownership among for-profit, not-for-profit and public providers in that province.

As for “dogma trumping facts,” the definitive expert consensus is that the profit motive impinges on the quality of care delivered (Ronald et al. 2016). When seniors care advocates call for universal public funding and delivery, they do so based on overwhelming evidence from decades of study. Why, then, does it suit governments, corporate chains and lobby groups for LTC to not be publicly delivered Because of a rigid belief that “the market” always eventually produces the best product. And when it doesn’t, it’s caveat emptor for seniors, and bonuses for shareholders and executives.

Taylor references the Health Quality Council’s Long-term Care Family Experience Survey, but this subjective data is presented in a way that obscures more than it illuminates. While the difference in perceived quality between public, for-profit and not-for-profit facilities was not statistically significant within the terms of the study, public (AHS) facilities collectively scored higher on every measure than either the for-profit or the not-for-profit sectors. Moreover, the survey makes very clear that seniors and their families care deeply about receiving quality care: the most frequently expressed concerns were fewer care hours, short staffing and having to pay out-of-pocket for additional care. These factors are more strongly correlated with private facilities in the meta-literature.

We have the ability and the capacity to deliver the highest-quality care for our seniors. Should we continue to funnel that money to private organizations for inferior care Inconceivable.

Peter Shawn Taylor responds to Rebecca Graff-McRae

According to my interlocutor, Canada’s long-term care crisis is not the result of COVID-19 or generations of neglect by government. Instead it is due to the continued and horrifying presence of profit in the sector. “Profit is generated by an erosion of care,” she claims. “There is an inherent conflict between profit and care.” We’ll get to her curious definition of profit-making in a moment. But first, it’s necessary to point out the much larger conundrum in her argument.

In order to remove profit from long-term care, Graff-McRae argues it’s necessary to place all nursing homes in the province in government hands. But doing so requires that she abandon a substantial portion of the sector that is already free from profits. Private, non-profit operators currently account for about a third of all beds in Alberta; this includes many operations serving specific cultural and faith-based segments of the elderly population, such as Calgary’s Wing Kei Care Centres. These don’t earn a cent in nasty profits, and they offer services not provided by any government-owned operations.

So why would anyone convinced that profit is antithetical to good care demand the elimination of the entire not-for-profit portion of the private sector and all the diversity it provides The only obvious answer is that this isn’t about eliminating profits from the sector but about creating a brand-new government monopoly. And while this may represent a boon for public sector unions, it does a grave disservice to seniors and taxpayers alike.

Beyond the loss of choice that would result from public-sector domination, such a policy would inevitably raise costs without any improvement in care quality. The price per bed for constructing new nursing homes skyrocketed after the Notley government abandoned an effective program that cost-shared capital expenses with the private sector in favour of government control. The 2019 Alberta Health Services performance review said it was impossible to tell how much public sector nursing homes actually cost to run and recommended the province consider selling them. “Private delivery may be more efficient and appropriate,” it concluded. Quality matters. But so do costs.

As for the claim that making a profit is somehow inimical to providing high-quality care to seniors, this calumny ignores the fact operators cannot simply fill their pockets with cash meant for residents. Money allocated for specific functions in Alberta’s patient/care-based funding model must be spent as designated or returned to government. And all long-term care homes are regulated to the exact same standards. As for frequent cries from unions and activists that outcomes for residents are worse at for-profit homes, the 2021 report on Alberta’s continuing care sector by consultant MNP reviewed the evidence and concluded: “…this is not the case.”

Ontario’s Marrocco Commission also looked into that province’s long-term care sector’s response to COVID-19 and similarly declared the ownership debate irrelevant. “The characterization of homes based on their tax status is not helpful,” its report states. What matters is whether individual operators, however the nursing home might be owned, do a good job serving their clients. The report calls this being “mission-driven.” Then again, keeping your customers satisfied has always been the hallmark of a successful business.

After considering the myriad causes and impacts of COVID-19 on their respective long-term care sectors and making numerous recommendations for change, most of which focus on government regulation, both the Marrocco Commission in Ontario and Alberta’s MNP report were emphatic that the private sector should play a major role in providing care for seniors now and in the future. “Diversity of ownership types” is seen as a particular strength for Alberta in the MNP report. The Marrocco Commission said the private sector is crucial to funding much-needed expansion and improvement. Neither called for a hostile government takeover of the entire sector.

Setting aside ideological flights of fancy for more practical considerations, there are many clear and substantial benefits arising from the private sector’s continued participation in long-term care. It provides vital choice to meet the needs of Alberta’s diverse senior population. It also offers competition to a monolithic and expensive public sector plus access to capital necessary to grow the system to meet future needs. Finally, and perhaps most importantly, the private sector is the unquestioned leader in innovation. Consider, for example, the recently opened and much-lauded Bethany Riverview facility for seniors with dementia at the Bethany Care Society’s state-of-the-art “campus of care” complex in Calgary. However much one might admire big government, it’s rarely for being innovative or daring.

Much needs to change in how Canada cares for and houses its elderly. But one thing that shouldn’t is the vital and continuing role played by the private sector.

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Holy Healthcare

Ryan Hoskins — Sat, 01 Apr 2017 20:36:26 +0000

“Just tell them we don’t have it here.” That’s what the nurse told me in Killam Hospital, an hour east of Camrose. I’d asked what would happen if a woman came into our ER asking for the morning-after pill. The nurse wasn’t being self-righteous, but simply explaining the policy.

As a physician that locumed for weekend shifts in rural Alberta hospitals, I’d not previously worked in a public facility run by a religious institution. Unbeknownst to most people—including myself until I signed up—Alberta isn’t administered by only one health “superboard” (as Alberta Health Services is sometimes called). In fact, 23 hospitals and health facilities compose a separate board within AHS, led by the Catholic Bishops of Alberta, called Covenant Health.

In Killam the absence of emergency contraception owes to the ethical mandate prescribed by the hospital’s Catholic administration. According to Covenant Health’s corporate policy and procedures manual, “it is never permissible for Catholic healthcare providers to terminate an established pregnancy” or administer medications that have termination as their purpose. The only exception is for sexual assault—where the “assailant’s act is a violation of justice, and any semen within the woman’s body is considered a continuation of the unjust aggression.”

The morning-after pill works for up to 72 hours after unprotected sex, but the sooner it’s used, the greater its effectiveness. When there’s no pharmacy open on the weekend, and when the nearest other hospital is 40 km away, a teenager or any woman without a vehicle could be in trouble if their local hospital won’t help them.

The scenario was theoretical for me in Killam. I saw cowboys thrown from horses, an alcoholic farmer with a bleeding gut, the usual cuts and bruises—but no distressed women as I tended the ER. What was certain, though, was that the hospital, funded with public dollars, was passing judgment over private behaviour in no uncertain terms.

Covenant is now raising concerns that extend far beyond birth control. Following a Supreme Court ruling in 2015 and the federal government’s passage of Bill C-14 last year, Canada has approved physician-assisted dying. Just as it stated about emergency contraception and abortion, Covenant Health will not permit physician-assisted dying in its facilities. Their stand has many patients and physicians questioning how public hospitals can continue to be administered by Catholic agencies and operate under different medical ethics.

The Catholic Bishops of Alberta lead Covenant Health, a separate board within AHS comprising 23 hospitals and health facilities.

Covenant Health has the largest budget and covers the largest geographic area of any public Catholic health agency in Canada. Where the trend in other provinces has been to gradually absorb such agencies into the secular system, Covenant has lately been growing. Should Covenant Health continue to be protected and allowed to grow in Alberta, or is the role of the Catholic Church in administering public healthcare an anachronistic legacy that must be changed

Hospitals in Alberta—indeed in most of Canada—began through the labour of Catholic missionaries. The first in Alberta was established in 1863 by the Sisters of Charity (Grey Nuns) in St. Albert. Dozens of others were soon created to provide care for indigenous people and the hundreds of thousands of immigrants staking out a new life on the prairies. Managed as charitable organizations, these hospitals were the only option for people without the means to pay for private doctors. They led the battle against tuberculosis and the 1919 influenza outbreak, and established the first schools of nursing.

Their role changed after the Second World War as Canada and its provinces brought in government-funded healthcare. Universal coverage of hospital and doctor services coincided with a dwindling number of Catholic missionaries—soon there simply weren’t enough to run religious hospitals. Many Catholic hospitals handed over their administration to municipal and provincial authorities; others closed their doors. Between 1969 and 1975, 20 Catholic-administered hospitals in Alberta made this transition.

In 2008 the Stelmach government embarked on an unprecedented experiment in Canadian health management, amalgamating all provincial health services under a single, arm’s length corporate body. Alberta Health Services (AHS) was meant to harmonize services and exploit economies of scale.

At the time, only a few Catholic hospitals remained in Alberta; the last one in Calgary had gone over to the government in 1969. But rather than absorb the surviving faith-administered hospitals into AHS, the province decided to bring these institutions together under their own separate administration. Covenant Health would be anchored by the high-patient-volume Misericordia and Grey Nuns hospitals in Edmonton, but would include small hospitals, long-term care facilities and hospices across the province, from Banff Mineral Springs Hospital to Killam Hospital.

Today Covenant Health accounts for 10 per cent of ER visits in the province, 20 per cent of deliveries and 12 per cent of acute care beds. Its 2015 budget was $895-million, or roughly 5 per cent of the provincial health budget. Covenant remains largely dependent on public funding—88 per cent of its revenue in 2015 came from the government. Its budget has grown over the past few years as Covenant builds long-term care facilities.

CEO Patrick Dumelie says Covenant works under “dual accountability.” Its board has a commitment to AHS, which sets annual targets for quality and cost. But Covenant must also adhere to policies set by the Catholic Bishops of Alberta. These men, the leaders of the seven dioceses spanning Alberta and the Northwest Territories, approve appointments to an intermediary board entitled Catholic Health of Alberta, which appoints Covenant’s 11-person board. The Most Reverend Richard Smith, Archbishop of Edmonton, also holds one of the Covenant Health board positions. (Smith was appointed archbishop by Pope Benedict XVI in 2007.)

The bishops, says Dumelie, ensure that Covenant fulfills its “thousands-of-years-old calling to serve others… through protecting the sanctity of life from conception to natural death.” This includes guiding the policies adopted by Covenant on, among other things, birth control, pregnancy termination and end-of-life care. But the continuation of Catholic administration of hospitals in Alberta is entirely at the discretion of the government in power.

Alberta isn’t the only province to permit faith-based groups to manage health facilities. Across the country, 124 hospitals, hospices and long-term care facilities are affiliated with the Catholic Church. They’ve gone from covering 35 per cent of national healthcare needs in 1968 to just over 5 per cent today. A handful of other faith-based providers exist, with affiliations to the United Church, Seventh Day Adventists and the Jewish faith.

Ironically the only province with no Catholic health providers is the one with by far the largest Catholic population—Quebec. Church control of hospitals in Quebec was ceded in the 1960s Quiet Revolution, when a conscious effort was made to throw off what was seen as oppressive clerical meddling over many aspects of social policy. Elsewhere in Canada the process of secularizing health administration has been gradual and conciliatory. Catholic management hasn’t been forced to cede control, but little effort has been made to preserve it. When provinces restructure services or build new facilities, they tend to close religious facilities at a pragmatic pace that honours Catholics’ historic contributions but affirms the importance of secular administration.

As with emergency contraception and abortion, Covenant Health will not permit physician-assisted dying in its facilities.

Such was the pattern in Ontario between 1996 and 2000 under the Ontario Hospital Restructuring Commission, when 43 hospitals were shut down or amalgamated. It was briefly the pattern in Alberta prior to 2008, when several religiously administered hospitals were closed. It is the pattern in BC, where Comox’s St. Joseph’s Hospital will be replaced with a facility without Catholic administration.

But this isn’t the case for Covenant Health, which is expanding. Covenant Care, created in 2014, brought into the organization’s purview a number of new long-term care facilities with a combined budget of $56-million. Covenant is also distinguished by its geographic reach. In other provinces, the few remaining Catholic hospitals tend to be free-standing structures under regional health jurisdiction. Covenant spans a province, including urban hospitals and rural hospitals that are often residents’ only nearby practical option.

In February 2015 the Supreme Court handed down the Carter decision, recognizing a Charter right for medical personnel to assist in dying when patients are mentally competent and suffering a severe and incurable condition. On June 16, 2016, after lengthy debate, the federal government passed Bill C-14, giving legislative permission for what became known as medical assistance in dying.

Although the change had support from 85 per cent of Canadians and 88 per cent of Albertans, according to a 2015 Ipsos survey on behalf of Dying With Dignity Canada, the ruling and the law faced opposition. The question of whether individual doctors should be compelled to perform the procedure—or at a minimum refer patients for it—was challenged by the Christian Medical and Dental Society.

But the question of whether public institutions—hospitals, hospices, long-term care facilities—should be able to deny assistance has raised the most concern.

Covenant Health stated in May of 2016 that it has an “ethical and moral opposition to medical assistance in dying” and that the organization’s “unequivocal position to not provide or explicitly refer” must be recognized. Functionally, this means that any assessment of capacity, any answering of technical questions, and the act of assistance in dying itself would require a transfer away from a Covenant facility.

The Alberta government thus far has accommodated this objection through the creation of AHS’s Medical Assistance in Dying Resource Team. Team members are patient “navigators” brought in for all requests for medical assistance in dying—whether from patients or from facilities that object to the procedure.

CEO Dumelie believes this team ensures a seamless experience for patients. “We organize transfers for all sorts of reasons every day,” he says. “There’s no reason why we can’t do this well.” By February of this year, 85 Albertans had received medical assistance in dying. Ten of these people had been transferred from Covenant facilities, Dumelie says, “without concern.”

Others aren’t convinced the transfer plan is adequate—or that it ever could be. Dr. David Reggler is a family physician in Comox who conducts physician-assisted dying and has participated in five procedures. He recently resigned from the ethics committee of his Catholic hospital because it decided that all patients who opt for medical assistance in dying must be transferred to a community 45 minutes away.

“The process of medical assistance in dying involves first confirming that a patient has capacity, then waiting a minimum of 10 days, and then confirming on the desired day of the procedure that the patient has capacity and continues to seek the procedure,” he says. “Realistically, these patients are frequently in an extremely fragile situation. To move them at any point during this process can be a tremendous burden. It can undermine the entire intention of dying with dignity.”

Dr. Reggler says that if Canada follows the model of physician-assisted dying adopted in the Netherlands, where 85 per cent of procedures are conducted by the patient’s own family doctor, more such deaths will occur in rural areas. “It’s not an overly complicated process [and] can easily be brought into the training of a GP. It can be done at any facility where patients can stay overnight—an acute care centre, a hospice, a residential care centre.”

He predicts a problem if Covenant Health’s nine rural Alberta hospitals continue to refuse medical assistance in dying, because they’re often a patient’s only choice. But even Edmonton presents a challenge. There, Covenant is responsible for 71 of the available palliative and hospice beds—or 90 per cent of the regionally available spots.

The case of Ian Shearer, an 84-year-old Calgary man living in Vancouver with palliative heart and kidney disease and severe chronic pain, brought attention to how transfers can do harm. Shearer was denied a request for medical assistance in dying from St. Paul’s Hospital, a Catholic facility near where he lived and where he’d been admitted for care. On the day he chose to die, his ambulance was delayed three hours and his medications were withheld to allow him to confirm consent. The ordeal, last August, was described by his daughter as “unnecessary… excruciating suffering.”

To understand Covenant Health is to consider much more than its perspective on medical assistance in dying. Advocates suggest Catholic healthcare has a special “ethos” of compassionate care, emphasizing those who are neglected, that is worth preserving. Outside of the morning-after pill, only a few practical inconveniences are created by Covenant when it comes to women’s health. Early-term abortions are not regularly provided in any Edmonton hospital. And although elective tubal ligation isn’t typically provided at Covenant, it will be if a woman seeks it and is having a C-section delivery anyway—thus avoiding a second surgery.

“It’s just like working at any other hospital,” says a colleague of mine who works in the Misericordia ER. “The only difference was I had to fill out a different form for getting hospital privileges.”

But if the benign effect is an argument for maintaining Catholic-administered healthcare, it’s an even more powerful argument for ending the extra administration. If the care is essentially no different, Covenant Health merely represents an added layer of senior management in a system already top-heavy with administration. With Alberta spending the second-highest amount per capita among the provinces on healthcare, streamlining bureaucracy can’t be overlooked.

Dr. David Swann, leader of the Alberta Liberals, calls the senior management of Covenant Health “redundant.” Rather, he suggests, “more primary healthcare out in the community is what’s needed. Not higher salaries for unnecessary leadership in Covenant Health.”

Covenant CEO Dumelie dismisses these criticisms. “People like to focus on the smallest of pieces but it depends on the overall context. We perform well in terms of accreditation and are good value for money.”

But it’s difficult to square how Dumelie’s 2015 salary of $560,000 can be justified when AHS CEO Dr. Verna Yiu earned about $575,000 in the same year to oversee a budget nearly 20 times bigger. Nor is it clear how critical each of the 12 members of Covenant’s senior leadership team are when their job descriptions match similar positions in AHS.

As for the claim of compassionate care disproportionately directed towards society’s most vulnerable, there are certainly signs of this. Alberta has a rapidly aging population and disappearing patient-centred care. Covenant Health fills many of the gaps, from its geriatric mental health program in northern Alberta to its new long-term beds and palliative care.

Meanwhile many of Canada’s most progressive healthcare programs have emerged from Catholic facilities. St. Michael’s Hospital in Toronto and St. Paul’s Hospital in Vancouver are known internationally for the work they do on injection drug use, HIV and the urban poor.

Bud James, mayor of Killam, is a 50-something small-business owner born and raised in his prairie hometown. He’s adamant that Covenant Health has a unique ethos that leads to high-quality care, crediting Covenant with, for example, a recent extraordinary effort to keep an elderly couple together in assisted living. And James says his attachment to Covenant is premised on general, not religious, terms. He believes that in contrast to AHS, Covenant considers “holistic care” and “understands the unique needs of a rural health facility.”

But Steven Lewis, a Saskatchewan health policy expert, has a more dispassionate view of the alleged superiority of Catholic-administered care. “We hear this all the time—that there’s a different vibe at Catholic facilities,” he says. “Yet no one to my knowledge has ever demonstrated that with research. But let’s say it’s true—good, then we should all learn from it. It is good for elderly couples to stay together regardless.

“But the argument that [such care] can’t possibly take place in a secular system is ridiculous. We have examples all over the world of great care provided in non-religious facilities. The argument that it’s necessary in even a small way to impose a particular religious view of healthcare in order to make this happen has no defence.”

Alberta is not a particularly Catholic province—Statistics Canada reports that 23 per cent of Albertans are adherents to the faith, the second-lowest rate in the country and well below the national average of 44 per cent. But religious pockets—a number of French-Catholic communities, and Edmonton’s sizeable Ukrainian Catholic community—create important local constituencies.

The appointment of former Premier Stelmach—himself a Ukrainian Catholic—in 2016 as chairman of the board of Covenant, which was created during his tenure, undoubtedly brings a level of political heft.

There may be other benefits for Covenant Health aside from maintaining the privileged role of the Catholic Church. Given Covenant’s separate budget from AHS, any cutbacks to its facilities will be more transparent—and likely more scrutinized. This gives local administrators an incentive to maintain the special attention they receive in being outside AHS.

The clearest reason for Covenant’s continued role, however, is the absence of any challenge to it. The potential backlash is presumably too fierce for the government to make an issue of the arrangement.

But the time has come, says Lewis. “If we were to redesign the healthcare system today, we wouldn’t allow Catholic administration to continue… When Canada consisted of two religious groups, Catholic and Protestant, it was a simpler world. We now have a much cleaner separation of church and state… It’s the political norm that state institutions be even-handed about religions.

“Frankly it’s reprehensible that government doesn’t go to the wall on this. They say [to patients], ‘Well you can go somewhere else.’ Well, sorry, then you’re accepting the imposition of a religious view on people who have no choice.… It takes principle to raise [this issue] and stand up, and governments are basically cowards.”

So far, the province has settled for a workaround when it comes to medical assistance in dying. It’s time to change course. Alberta should have a transparent and comprehensive review of why in 2017 nearly $1-billion in healthcare funding is under the administration of the Catholic Church. And an answer of “because it’s always been that way” isn’t good enough.

Ryan Hoskins is a GP and emergency room physician based in BC who regularly locums in rural Alberta.

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The post Holy Healthcare appeared first on Alberta Views.

The Unheard Patient

Jane Harris — Sun, 01 Nov 2015 16:07:22 +0000

My wake-up call came on June 22, 2013, when Victim Services volunteers dropped me off at a local emergency room after a violent assault in which I was whipped and choked, my neck cracked and my head split open. Nurses left me bleeding in the waiting room without medical attention for over four hours before moving me out of sight. By the time the ER doctor stitched up my head, I’d been bleeding for seven and a half hours. As he stitched, he lectured me on domestic violence. Nobody bothered to do a CT scan. Nobody checked the neck injury. Nobody examined the open wounds on my back, arms, legs and neck. Nobody checked my blood pressure. Nobody even offered me a glass of water, let alone the IV that I likely needed.

“They probably thought you were a marginalized person,” explained a friend who works in healthcare when I asked her about it. She thought her explanation made sense—that socially marginalized people shouldn’t expect the same kind of care as “regular” people.

The experience in emergency was just the beginning of my medical nightmare. Within days I was seeing white lightning bolts flashing through my eyes from inside my head. I started forgetting things, couldn’t walk very far, slurred and scratched for words and could not retain complex thoughts.

Doctors, nurses, even receptionists—people who would have thought me competent before—now gave me sad, pitying looks. I was too ashamed to tell them I had no food in my house unless my kids dropped off a bag of groceries, or that I didn’t have money to get to a specialist in Calgary.

More than once I considered putting on my coat, walking to Lethbridge’s famous railway bridge and jumping off. I didn’t. Later, I would find out that four people did jump off that bridge to their deaths in 2011. I wondered how many were marginalized Albertans unable to get the help they needed.

After the attack I couldn’t shake the feeling I was locked in a box, screaming for help, but no one heard me. Because my attacker was also my husband, and because my injuries affected my thinking and speech, healthcare practitioners kept treating me as someone not credible enough to tell my own story. Nobody was listening.

People in the system seemed to make assumptions about me. It started in Emergency, where the nurse did not ask what had happened. She assumed my husband was a run of the mill domestic bully and that my head was cut open in a fist fight. These notions determined where I was placed in the ER triage. Nor did it end there. Assumptions also affected the treatment prescribed when I showed up at the doctor’s office a few days later and he saw for the first time the bruises over more than 40 per cent of my body, the head and neck injury, and my symptoms of post-traumatic stress.

Sure, my family doctor wrote down where the bruises were and checked to see if I could walk straight. He booked a CT scan and x-rays. He seemed sympathetic, too—except when he began talking about my “fatal attraction” to being beaten. He would go on talking about my “fatal attraction” until we parted ways early in 2015. When I showed post-traumatic stress symptoms—zoning out and reliving the trauma again and again—he said I shouldn’t “let myself” get so wired up. I should move on with my life. He wondered aloud if my breathless speech was a symptom of mental illness. When I said I was afraid of winding up homeless, he agreed I would probably always be poor. The bone-cracking pain I felt at the injury sites he dismissed as migraines. I pointed out a chart on his computer that showed I was an inch and a half shorter six months after the attack. He said, “That’s interesting. Have you started slumping?” Did he think I was exaggerating, or imagining my injuries Did he think I was angling for sympathy or a disability pension?

Nobody bothered to do a CT scan, check my neck, examine the open wounds on my back, arms and legs, check my blood pressure. Nobody even offered me a glass of water.

My family doctor’s smiling staff told me to “stand here,” “go there” and “sit here.” They seemed to think I was going to wander off and get lost. Though I arrived at the office on time, I was often left sitting in the waiting room for an hour or two before seeing the doctor. Did they assume I no longer had anything important to do?

Some of my symptoms were getting worse after a year, and I asked to see a psychiatrist. When I finally got an appointment, the bemused doctor read the referral letter to me out loud. The reasons given for my being referred included that I had once been politically active and that I had filed a successful complaint to the Alberta College of Physicians and Surgeons. The letter also said I talked fast, suffered from migraine headaches and had “legal troubles.” The letter did not say I was the victim of a violent crime. It did not say I had requested the appointment. It did not mention tests confirming damage to my visual memory or my symptoms of post-traumatic stress. The psychiatrist was kind, but he was swayed enough by the referral letter to ask me why I “needed” to see my injuries differently than my doctor did. I went home feeling contaminated and shamed.

Did I deserve this treatment I wasn’t sure. But I knew I didn’t like it. I tried to grab back respect by hiding how desperate and sick I was. I’d throw on a business dress, slap on lip gloss and do my best to cover up the fact that I’d been beaten, or that I sometimes slurred my speech, woke up terrified, was tired all the time and couldn’t remember where I put things. I tried not to look crazy. I got so good at it that I scored “mildly depressed” on the inventory I took at Foothills Hospital. When I got home, I resumed hiding away in my room. Because I had no income, my thinking often involved whether to continue into homelessness or to end things by jumping off the railway bridge.

Later on, when I was well enough to look into the difficulties I had experienced with the healthcare system, I found that my reactions to increasing marginalization were fairly typical. Research by the Alberta Disabilities Forum shows that disabled Albertans with mental health issues start to believe they deserve poor treatment. To avoid further marginalization, they keep mental health problems a secret.

The problem is clearly not all in their heads. Deanna Williamson, chair of human ecology at the University of Alberta, led an investigation of low-income Canadians’ experiences with health-related services. Her team’s study, published in the journal Health Policy in 2006, found that low-income Edmontonians and Torontonians tended to avoid healthcare workers who were abrupt, rude, indifferent and judgmental. Study participants said they quit asking for help when staff in clinics and helping agencies didn’t listen, forced them to tell their story multiple times in front of strangers or mistreated them in other ways. They also felt that workers expected them to beg for publicly funded services.

Even if they qualified for help, many study participants couldn’t access health-related services because they weren’t near a bus stop or they couldn’t afford to travel to the appointment. Some services were only open a few hours a week and had long lineups. In other words, some Albertans can’t afford to buy a bus ticket or put gas in the car, let alone rent a hotel room in order to keep an early morning appointment with an out-of-town specialist. Others, especially the working poor, can’t always get to a community mental health clinic when it’s open.

Some healthcare workers may be too stressed and overworked to care. Kelly Maguire of Lethbridge worked in home care for 20 years before giving up her juggling act between clients’ needs and the funding maze. “I saw a great number of people who were marginalized and isolated, whether it was from a brain injury, dementia or cancer,” she told me. Maguire says she “found it frustrating that there is a system in place that ensures a driving licence can be suspended after a seizure, for example, but that the same level of sharing information is not applied to ensuring families know what resources and supports are available for the short term and long term.”

Even middle-class patients with good jobs can become marginalized. Maguire remembers a professional woman, who seemed okay after a car accident. Never suspecting she had a brain injury, she carried on with her plan to fly to the UK to deliver a paper at a conference. Alone in a hotel room in London, she couldn’t remember whether to put her bra or her blouse on first. She came to the terrifying realization that something was wrong with her brain. “Her intellect was always intact,” Maguire says, “but some very specific parts of her brain were injured, [a fact that was] not identified until months later. She thought she was going crazy. Many medical professionals told her family she was just seeking attention.”

The system is designed by people with food in their fridges, money in the bank, sick pay and disability benefits. It works best for people who are the same.

I had a similar experience about six weeks after I was injured. I walked into the Canada/Alberta Service Centre in Lethbridge for the third time in three weeks. It was a morning in early August 2013. I knew I needed to make some money. The first two times I had tried to talk to someone there, the staff were too busy to help and the circular layout of the room confused me, so I left. On the third try, I managed to make it to the front of the lineup. I sat down in front of a woman behind a desk. She asked me what I needed. I said, “I don’t know.” Then I burst into tears and went home. Nobody stopped me.

I spent that summer picking apples and pears off the ground and gathering bottles to take to the depot to get money to buy bread. Fortunately my daughter also brought me groceries every couple of weeks. It was another eight months before anyone told me I qualified for the Alberta Adult Health Benefit. That meant I didn’t need to stretch my thyroid medicine an extra week each month, but it did not fix everything.

By the spring of 2014, I had nearly given up on getting better. That was when I came closest to walking off the railway bridge. I wish I could say that a saviour from Alberta Health swooped in and rescued me. I wish I could say the system finally worked. I wish I could say I am “all better.” But I can’t.

I am still unable to turn my neck all the way to the left. I still can’t ride in an elevator by myself. I still walk sideways sometimes and scratch for words when I am nervous. I still have days when I am convinced I have no future. Sometimes I still feel marginalized.

But I have a new family doctor. I have three supportive children. I am recovered enough to work as a journalist again, and perhaps that is why I am still here. I am making a career of asking questions people don’t want asked. I will go on asking those hard questions. I am not ready to stop challenging assumptions.

Most Albertans assume our complex web of health services serves everyone, but my experience has proven to me it does not. My conclusion: It is a class issue. The system is designed by people with food in their fridges, money in the bank, sick pay and disability benefits. It works best for people who are the same. People who are perceived as being on the margins are given different and insufficient access and service. I know that Albertans with injuries similar to mine sleep on mats in homeless shelters every night, and die sooner because their manageable illnesses are not treated. I know that some commit suicide when shame and assumptions keep help away.

Money alone won’t help these Albertans get well. We need to ask the right questions: “Can you afford this prescription “Can you tell me everything that happened to you tonight?” “Do you need a ride into the city to see this specialist, or bus fare to get to the mental health clinic?” It would be a start.

Lethbridge-based Jane Harris is the author of Finding Home in the Promised Land (Shillingford Publishing, 2015), a memoir.

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