Demedicalize this! though i love the bold spirit and all-for-one, one-for-all populism of Michael Moore's hurrah for universal, government-funded medical care, Sicko surprisingly reflects the backwardness of the U.S. system the guerrilla filmmaker exposes.
Whether government-funded or profit-driven, the domination of sickcare thinking over health care thinking is the paramount issue and Moore can't go there. Sure, the universal and government-funded medicine praised in Moore's flick is superior. Canada and Europe produce better health outcomes (greater longevity and higher rates of infant survival, for example) for about two-thirds the relative cost of the U.S. private system, which sucks up a punishing 14 per cent of U.S. GNP.
But government-run health care by itself has few prescriptions for prevention.
The people featured in Moore's doc are suffering from the failure of the U.S. system to deliver what's called third-stage prevention services. These are interventions that help sick people manage their diseases and avoid unnecessary complications.
Doctors and nurses provide third-stage prevention when they follow coronary heart disease patients to make sure they take the right meds to prevent another heart attack, or check diabetics to help them avoid heart surgery or kidney dialysis.
It doesn't take a brain surgeon to figure out that such ongoing relationships between patient and medical team are easier to foster when patients aren't worried that a doctor's visit will cost an arm and a leg.
But many of the people in Moore's movie, including Moore himself, could benefit from an earlier and more advanced form of intervention called secondary prevention. That's when conscientious docs get patients in a high-risk group to take charge of their own health.
That may mean counselling patients in exercise and diet strategies or therapy for smokers as they quit. If the advice comes in time, a statistically likely disease can be prevented.
The salaried British doc in Moore's film gets a cash bonus whenever he convinces patients to change risky habits. That's money well spent.
By putting docs on salary instead of per-visit piecework, by setting them up in clinics where health care teams include skilled counsellors, by rewarding time spent counselling over time spent issuing prescriptions, the Brits are moving their medical system toward secondary prevention. It's a rethink that's particularly urgent in a world facing an acute-care emergency 1 billion people confronted by obeseity and another billion by starvation.
There's been little more than flirtation with such reforms in Canada, where only a fraction of secondary prevention benefits are harvested from publicly funded medicine.
But earlier and better than secondary prevention is primary prevention, which may well treat people who are feeling fine. It could involve education about simple changes to reduce the falls that put many seniors on a downward, painful and expensive spiral. Teaching elders to keep up their strength with weights and remove throw rugs dramatically reduces falls, says Michael Rachlis, Canada's leading advocate for patient-centred care.
But the notion goes far beyond the important but timid moves of the province's Ministry of Health Promotion, which this week launched a new nutrition telephone service connecting the public to dieticians. It's a sorry substitute for banning junk food ads aimed at kids, as they do in Quebec.
This two-year-old ministry, the second of its kind in the country, works with an annual budget of $373 mil compared to the Ministry of Health's $28.5 billion.
A take-charge prevention campaign would develop gardening and snack programs in childcare centres and classrooms and press for daily fitness programs in schools and workplaces. Downsize this, Moore might say.
Health and well-being belong together as much as brushing and flossing, strength and flexibility, running and playing, local and sustainable, comfort and joy, healthy, happy and wise.
Since Moore likes Canada so much, he should check out the Ottawa Charter for Health Promotion, adopted almost 20 years ago, in 1988. It put social support, self-esteem, personal and community empowerment on the to-do list of primary prevention activities that can reduce the need for medical care by increasing access to social and personal caring the kind of caring that gave such a boost to the people Moore took to Cuba for treatment.
Unfortunately, such strategies are what business writer Clayton Christensen, author of The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail, calls disruptive innovations.
These are brilliant breakthroughs that are suppressed because they threaten a power shift from doctors to nurses, farmers, cooks, gardening teachers and patients, for example. The resistance to that shift explains why publicly financed medical care doesn't automatically transition to publicly financed health care.
And why Sicko, with all its empathy and humanism, feels so yesterday by the standards of most of the world, where the medical monopoly over health is unaffordable.