Canada v. U.S.

• Author: WORTH, ROBERT
• Position: Interview

A health-care debate between Adam Gopnik and Malcolm Gladwell

Adam Gopnik:

I have lived under three different medical regimes: Canada, the United States, and France. I have been seriously sick under all three regimes and had many family members with similar experiences.

My wife's sister had a very, very premature baby born in Edmonton six years ago, the kind of baby who normally lives in about 20 percent of cases--and they had eight months of intensive care. I mean really intensive care. And the baby ended up living. It was a pound and a half at birth, the smallest baby that survived in western Canada in that year. The one thing they never thought about, the one thing they never considered, the one thing they never had to pay a moment's attention to was: How much will this cost? When does our insurance run out? It simply was not in the agonizing equation of worry and concern that they had to face. That seems to me, in itself, the most powerful argument you can make for socialized medicine, to put it in the bluntest possible terms.

Malcolm Gladwell:

It's interesting, because my own personal experience ... We'll start with the anecdote. When I was 16, I was working 12-hour shifts as a dishwasher. I was biking home one night in the dark and something happened and I ran off the road and I basically impaled my eye on a stick. I was unconscious for several hours, came to, biked home. When I woke up the next morning, my right eye had essentially ... The pupil had come out of the socket. A huge swelling. I went to the doctor. The doctor examined me and sent me home. The swelling didn't go down.

AG: This was in Nova Scotia?

MG: This was in Canada, in Ontario. They checked me into the hospital and observed me and the swelling didn't go down. Finally, eight days later, they took me to Toronto where I got a CAT scan. Now this is 1984, and it took them nine days to give me a CAT scan after blunt trauma to the head. The main thing in America is that's an open and shut malpractice suit. We had to drive a hundred and twenty miles to get to a CAT scan. What's interesting about this, of course, was that the doctor looked at me, and before he even gave me the CAT scan, assumed that I had suffered irreversible brain damage. He informed my mother--I was about to go to college--my mother said, "Well, [he's] about to go to college", and he said, "Well, your son isn't going to college. He has clearly suffered irreversible brain damage."

AG: So he's going to write for The New Yorker instead. [Laughter.]

MG: We're nine days after the accident! In 1984 this was state-of-the-art medicine in Canada because there were at that time something like, I think, five CAT scans in the Province of Ontario. Now, at the same moment in 1984, there were some hospitals in America ...

AG: Individual hospitals ...

MG: That had five CAT scans. CAT scans were in doctors' offices. And this is sort of a small thing but it tells you the cost. Canada has achieved a wonderful thing, which is universal health-care coverage, but it has achieved it at a price, and that is quality of care. Canadians will argue until they're blue in the face that, in fact, the sacrifices in quality care are not that great. That is, I think, a lie. There are critical sacrifices that have been made and you can argue whether those sacrifices are worthwhile or not. I happen to think that they're not. And I would rather live in a system--and perhaps this is simply a difference with me--I would rather live in a system with the economic fear, knowing that in extreme cases I'm likely to get world-class care than the reverse. I think that one of the principal functions of a health-care system is to offer all of those in the system the greatest possible chance of survival in the event of some extraordinary occurrence. And I had an extraordinary occurrence and I was given essentially Third World care. Now, I was lucky enough to survive, but that is not a risk that I would ever want to take with my own children.

AG: And you're persuaded that was, in no sense, an anomaly.

MG: In America there are clearly several tiers of care. If you're rich you get better care than if you're poor. No question about that. The benefit of that is at the high end there is ... People who are upper middle class in America demand, and there is a very efficient market mechanism for delivering to them, the absolute highest quality of care imaginable. Cost is not an object. You go over to Cornell Medical Center and walk through those halls. And I think it's really valuable to have at some point in the system an area where cost is not an object, because that's where all the innovation comes from; that's where doctors get better training; that's where those resources are available when somebody has some extraordinary event.

AG: I'll accept that description. I think that the question then becomes, though, what the trade-offs are, because what you're describing, what you're basically saying now in plain English is, we'd rather have a system in which you have the possibility of superb care, an MRI in every doctor's office, and the understanding that means there will be many people who will simply drop off the lower end--there will be kids who get a stick in the eye and never recover from it--than have a system which attempts to equalize every stick in every eye and in doing so, fails to deal adequately with everyone. These are kind of classic questions of egalitarianism and free enterprise that go far beyond health insurance.

Again, I have to keep coming back to ... And, you know, I could offer ... I came down with a digestive disease. When you were suffering with a stick in your eye, I was suffering at the other end; and I thought that the care I got at that point ... I could put my colonoscopy against your failed MRI, and mine was beautiful.

But rather than do that, I do think that the core issue again--and it's not just a question of Canadian health care, but the larger question of health care in general--is the question about what kind of society you want. Again, I've just come four months ago from the experience of having a baby in France, which has a system that makes the Canadian system look sparse: A hugely expensive system for which we French taxpayers, for which I pay an enormous amount of money, and the system includes a guarantee of four nights in a hospital or clinic for every woman. Here in New York, with the best kind of medical insurance we could have, we had 36 hours to have the baby (my wife did, have the baby) bond with the baby, and get out. In Paris she not only was guaranteed, but it would have been very difficult for her to have less than four nights in a hospital or clinic. In fact, there was a woman who wanted to leave after three nights. An American woman. And the head of the clinic came in and said, "What's the matter? Are you very unhappy here? We're not treating you well?"

MG: Yes.

AG: And I should add, too, that in France, particularly--and I know this is true in Canada, too--it's genuinely democratic. That is, our' little boy's babysitter, who's a Sri Lankan immigrant, was pregnant at the same time my wife was and got exactly the same care: four sonograms, four nights in the hospital, the same amount of paid leave, and so on. It's expensive. There's no question about it. Although I should add that we pay in France almost to the penny the same amount of tax that we paid in New York City, because by the time you add in the state tax and the city tax and the taxes we pay to build weapons we will never see and will never be used, it comes out to be very much a wash. The crucial point is, I think, the difference in social tone between a society in which universal access to medical care is taken for granted and one in which it is something that weighs constantly on all of us, even though some of us are lucky to have good insurance, and becomes an omnipresent preoccupation to the lower middle classes and to the working poor. It's enormous.

One of the most memorable experiences I had in France was when our little boy got terribly ill with what turned out to be salmonella poisoning last Christmas in Paris, as sick as I hope I ever see him. We had to take him to the pediatrician. Our pediatrician got very emotional about it. One of the big differences between American medicine and French medicine is that French doctors are not trained to be clinical. When they see a sick child they say "Oh, my God, he's so sick! I've never seen anyone so sick! You'd better get him to a hospital right away?' So it sends the parents into a panic. We ran into the children's hospital in Paris. He got terrific care. They did a barium enema with him, and they did an MRI, and they did an x-ray. There are many people who say that the French over-test: You shouldn't be doing x-rays on four-year-old children unless they're on the verge of dying. Nonetheless, they did all these things and they did it in three and a half hours. They realized it was no physical obstruction and it had to be an infection. They gave us a prescription, and he was much better, after being profoundly ill, the next morning.

We were leaving the hospital to get a taxi and I turned to my wife and I said, "Nobody asked us anything about money!" Nobody asked us to show them our insurance. Nobody asked us to show them a credit card. It simply wasn't addressed. About six weeks later we got a bill from the hospital--because we're in a slightly funny situation because of the nature of the taxes we pay--for 600 francs, about a hundred dollars. The overriding fact was that when we arrived--and I have arrived in emergency wards in America with sick children, and you spend half an hour figuring out who is going to pay and how this sick child will be paid for--when we arrived at the emergency ward in Paris with a sick child, who would pay for this sick child's illness was simply not a question that anyone raised.

As somebody who's lived under both systems...