Oct 01, 2010
By Steven Lewis
So many voices, so little voice
There are four nurses in Canada for every physician. Public opinion polls confirm that Canadians greatly admire the profession. Nurses populate every health sector and every corner of the country. They are synonymous with health care, compassion and good works.
Medicare has always been and will always be about politics. Its core idea is distributive justice: the healthy and wealthy subsidize the care of the sick and the poor. How the system evolves is heavily influenced by its major players. Nursing’s combination of numbers, reputation and reach should translate into power and influence over how health care is financed, organized and delivered. Yet politically, the profession punches below its weight. The country is the worse for it.
Organized nursing — regulatory bodies, professional associations and unions — has historically been a stalwart supporter of medicare. If any profession can claim to be in health care for largely altruistic reasons, it is nursing. Nurses are the backbone of hospitals and long-term care facilities. Their jobs are rarely glamorous. The pay is decent but not extravagant. They deal with every kind of unpretty frailty: cognitive impairment, incontinence, the ravages of cancer, fear, loss. They are embedded in the system’s core, fully integrated into its structures. They are working and middle-class Canadians; we are they, and they are us.
Yet among providers, the health-care debate is largely framed by organized medicine. As a result, the debate is impoverished, both in substance and in ideology. Organized medicine opposed medicare at its inception and, rhetoric aside, rarely tires of chipping away at its foundations. Most recently, it has deployed the familiar tools of biased surveys, self-serving analyses and the recycling of myths to persuade us that the system is unsustainable. This predictable propaganda lands on the front pages of newspapers, and baseless arguments go largely unchallenged.
Neither the public nor nursing escapes the impact of this intellectual near-monopoly. The Canadian Medical Association and its provincial counterparts have spent the better part of the past decade pursuing policies that keep nurses in their place. The CMA’s recent report on health-system transformation praises physician assistants and cannot even bring itself to mention nurse practitioners; the Ontario family practice cartel labels NP-led clinics as grossly inefficient. NPs are a threat to the medical monopoly, and medical power has been dispatched to keep them off doctors’ sacred territory.
Organized medicine is winning all the turf battles, and neither the public nor governments have offered up much resistance. Had nurses spoken with one voice, marched on legislatures and taken their campaign to the public — armed with 40 or so high-quality RCTs and observational studies demonstrating their primary health care capacity — the outcome might well have been different. Meanwhile, as organized medicine directs the public-private debate, conjures up the spectre of a silver tsunami of boomers about to bankrupt the system and ducks any responsibility for cost or quality failures, nursing seethes in silence, only rarely venturing a timid rejoinder and never mounting a sustained battle for the public mind.
Political space is finite, and there will always be a fight for the high ground. Organized medicine knows when and how to present a united front irrespective of the real divisions within its ranks. Nursing is far less politically accomplished and far less assertive. Nurses are not saints; I have seen and criticized their own brand of fear-mongering and indefensible turf protection. But their collective support of the principles and ideals of medicare has never been in doubt. That is why it is so essential for nursing to take centre stage in the debates about the health system’s future. Doing so would benefit nursing, and it would be a great service to the rest of us.