(NOTE: The letters below are made up of three distinct but closely interrelated parts. Each one addresses different aspects of the same web of realities seniors may find themselves caught up in if they are not aware of the pitfalls in a system supposedly designed to serve them.
While each part can be read on its own, only the three parts together will provide a coherent overview of these insufficiently know aspects of government policies and programs to “serve” their senior population, especially in British Columbia, the country’s retirement haven.
These “letters” attempt to bridge this information gap, and to provide a foundation for further inquiry into conditions existing in different jurisdictions across the country.)
LETTERS FROM LOTUSLAND
An open letter to Canadian seniors everywhere
By
Paul Wagner
Paul Wagner
I
The Price of Independence
Thinking about retiring in Lotusland? You should! Carefully! Retired life in Canada’s scenic Pacific Ocean playground has a few surprises in store that you may not have counted on.
Yes, it’s all there in the “land of misty giants” as Oscar Peterson poetically dubbed Canada’s westernmost province: the majestic mountain ranges, miles of deserted beaches, the glorious rain forests with towering Douglas Fir and cedars, the pristine lakes, the mild climate that makes it possible to enjoy “The Best Place on Earth”, according to your new licence plates, practically year-round. You need a car, of course, or an RV if that’s your style and you can afford it, to get to all these places, but we take that for granted in a society that relies as much on the motor vehicle as the primary mode of transportation as ours. It’s the key to independence, to enjoyment of the outdoors, to what you always wanted to do but never had the opportunity. Now you do, you’re retired and the West Coast outdoor paradise is irresistible, you’ve always wanted to live there and now you can. But where? The Sunshine Coast looks inviting, so does the Okanagan Valley. You decide on Vancouver Island, it has the right mix of scenery, city amenities, climate and a reputation as Canada’s retirement paradise.
Victoria real estate turns out to be a bit stressful for your budget, but no matter, you settle nearby, an hour’s drive, you’ve got wheels and the time and you’re closer to nature, which is what you came for. Finding a family doctor – you’ve always had one and at your age you feel that’s a good idea, you never know – isn’t easy either. In fact they’re already overbooked and don’t take on any new patients, you learn. Waiting lists for specialists or diagnostic services can be longer than you might have time for, six months or so for an MRI, two years for a gastroenterologist. Bit of a shock, but there are clinics and you’re in pretty good shape, always looked after yourself. Sure a change from Ontario, though, where you waited three weeks for your GI appointment.
You adjust, settle in, start doing what you came for. You buy a kayak, a modest little camping trailer to keep your sore joints off the ground, and start getting out there, there are some gorgeous spots if you get off the beaten track a bit.
Your 80th birthday rolls around, you almost forgot, time went so fast, but the province remembers, it has a surprise for you, a letter, it’s waiting for you in your mailbox. The letter is from ICBC (Insurance Corporation of British Columbia), the obligatory provincial insurance agent and the people who issue your driver’s licence. It advises you that you need to take a mandatory test to assess your cognitive abilities, now that you’re 80. Everybody does, there are no exceptions, it comes with your anniversary. Your doctor will be able to administer the test, you have 30 days to complete it. If you don’t, your driver’s license will be revoked at that time. You are also advised that you can turn in your license voluntarily, also within 30 days. A bolt out of the blue, but you recover, make arrangements for the test. In the process you learn that it is not covered by your medical plan, you’ll have to pay for it. The BC Medical Association recommends a fee of $180. Some doctors charge nothing, you find out, others various increments up to the full amount.
The true price of independence at this point in time is a good GP. A conscientious physician who takes the time to adequately brief you and to make you aware of your options and rights can save you a great deal of grief later on. But if you are simply being processed and sent on your way without comment or advice you may find yourself presented with some unpleasant surprises as the process grinds on.
If you are properly prepared – information about it is also available on the Internet, incidentally – the SIMARD-MD, as the test is called, shouldn’t prove too difficult to pass, although it does have its pitfalls and traps. One of them is a memory test which requires recalling 10 common but random, unconnected and therefore meaningless words, or as many of them as you can. The score is likely to be less than perfect for anyone not used to remembering pages from a telephone book.
Anyway, you repeat what you remember, clear your mind of it, it’s over, and focus on what follows. You feel you’re gaining some ground, until the final question which knocks it right out from under your feet: you’re asked to repeat the same 10 words you’ve put out of your mind 10 minutes ago. The result is predictable for someone completely unprepared for this. It drags down your average, quite possibly below the passing score which, moreover, is calculated in somewhat unusual fashion. The dice, it seems, are loaded, but not in your favor.
Your protest that this seems unfair, that you’ve had no opportunity to prepare for the test, may get the reply that preparation for it would undermine its objectivity, render the results invalid. Well, true perhaps for other tests, but this one supposedly assesses cognitive impairment and where that exists no amount of preparation will get you through it, you’ve lost it, your mind no longer has the ability to perform certain functions. Your doctor knows this but it slipped his mind, it can happen, s/he’s not yet at the age where it’s no longer permissible to forget things.
The test can also be repeated if there is reason to question the results, but this must be done right away. Your doctor also has the option to prompt you, should s/he be so inclined or remember to do so. But once your doctor presses the computer key to submit the test results to the Office of the Superintendent of Motor Vehicles (OSMV) of the BC Ministry of Justice that deals with these matters, these opportunities will have passed until the next time, if indeed there is going to be one.
Should you feel that the test was sprung on you without adequate information or preparation, try to understand. Your doctor is a busy person, it takes time to tell you about these things, advise you of your options or the results, and time is scarce. In the interest of efficiency, doctors have learned to manage it effectively. They have mastered the art of terminating a consultation, for example. What was once achieved with a prescription and a handshake is now a simple matter of getting up and walking out when your time is up. Modern office layouts, which place the physician between the patient and the door, provide useful ergonomic expediency.
Those of us old enough to remember things we are supposedly no longer able to recall can likely think back to the introduction of publicly funded universal health care in Canada in 1968 and the fact that compensation for doctors was a major and contentious part of the preceding debates. In fact, Saskatchewan doctors had gone on a month-long protest strike before Medicare was first introduced there in 1962. The original proposal was to have doctors remunerated on a salary basis, but that was fought tooth and claw by them across the country. They demanded a fee-for-service pay schedule instead and had the political clout to get it. It’s been with us ever since, an incentive for some to see as many patients as possible during office hours, although not all physicians supported the demand then or do so now.
The SIMARD test itself is controversial at best. It has been described as biased, unfair, and designed to fail. There is also good indication that it is inappropriate for the assigned task in the reference to it by the March 2011 BC Medical Journal, which comments that “physical examinations and screening tests conducted in a medical office have limited value when it comes to determining whether patients are fit to drive”. The article goes on to recommend “behind-the-wheel tests” to assess “real world behaviours”. More about this in Part III.
You learn about your test results, well, indirectly at least, from another letter that promptly arrives in your mailbox, this one from the OSMV. It is regarding their “review of your medical fitness to drive”. This is not explained, but you are directed to make an appointment for a DriveABLE test, the “tool used to measure cognitive abilities as they relate to driving”. Test results are required within 30 days of the date of the letter. Otherwise “it will be necessary to cancel your driver’s license for public safety reasons”. The letter winds up with the acknowledgement that “this process may be challenging” but is necessary for “the safety of yourself and other road users”, and the usual encouragement to turn in your license voluntarily within 30 days.
The countdown begins with the date the letter was sent, incidentally. In the case of a postal strike, if you happen to be away or ill when the letter arrives, too bad. Should you wish to reply in writing, day one will count from the date your letter was received, not sent, and in working days only. The different standards for response times are a simple oversight, no doubt, for we are all equal before the law, justice is blind, the justice ministry understands that.
Interestingly, in all of this there is no mention whatsoever of your driving record. Mere externalities, such as your decades-long accident and traffic fines-free record, not uncommon among senior drivers, the fact that you have no physical or mental issues, according to your doctor, that would prevent you from driving safely are obviously considered irrelevant and not even mentioned. Presumably it wouldn’t do to have these inappropriate details distort the otherwise flawless logic of the process.
The call to DriveABLE, a private corporation that provides the standardized, computerized test under contract to the BC government, yields the information that the test will take about an hour and the recommendation to have someone drive you to the test appointment. There is no explanation as to why you shouldn’t drive yourself, you assume it’s so you’ll arrive nice and relaxed, it’s in keeping with the consideration and understanding shown you all along.
Another piece of paper you are asked to sign as you arrive for your test is similarly reassuring. Two signatures are required, one for your consent to the process which includes the statement that “the nature and anticipated effect of what is proposed including the significant risks and alternatives available have been explained to me”. You feel increasingly calm and confident that everyone involved is indeed acting in your own best interest. The second signature indicates your consent for release of the information about to be obtained to the parties indicated on the form which, not surprisingly, includes the OSMV. The letter doesn’t tell you what will happen if you don’t sign. It doesn’t need to, by now you’ve got the message.
You are now adequately prepared for the test and guided to an airless, windowless cubicle that looks very much like a storage room with one corner cleared for the specially designed computer where you will spend the next hour or so.
The test package consist of 10 parts, each composed of numerous, often a dozen or more individual tasks to be performed. They can be divided more or less evenly into those that are objective and straight-forward, and those that are ambivalent, misleading, confusing, even deceptive, whether by intent or coincidence. Whether either of the two groups represents a fair assessment or meets the stated diagnostic objectives is open to some question. The response mechanics of the computerized test, a combination of touch screen and control button, criticized by some as being unfair to older people who may not be computer literate, are actually quite straight forward and unlikely to pose a serious impediment to the execution of the tasks. These, incidentally, are claimed to represent real-world driving situations, but that is unlikely to find much credence among those who have been exposed to them.
According to the Alberta-based corporation who developed it, the DriveABLE program has been carefully, thoroughly and of course successfully evaluated using test groups of different ages. However, their website provides no information as to whether the evaluation process included independent assessments or peer reviews, nor any comparison of the results of the different age samples and their respective success or failure rates.
For most of its 10 parts, but not all, the program provides practice runs. With adequate attention and concentration (but without cognitive impairment) it is not exceedingly difficult to respond correctly. But do not let this lull you into a false sense of security. In the actual application critical parameters change and especially response times shorten dramatically. Others, such as visual and other distractions, are introduced. For reasons of space one example will have to suffice.
The final section of the program consists of a series of simulated hazardous traffic situations based on fairly common and realistic occurrences. It displays animated images as you would supposedly see them through the windshield of your own moving car. The challenge is to react correctly to the situation shown. What you see on the screen, however, are images of generally poor quality, washed out, difficult to identify correctly, and distorted perspectives which make it difficult to assess pertinent factors such as distance. A voice over describes elements of the scene, such as the speed you are travelling at. It also reads four possible responses, which are additionally spelled out on the screen before you. You are to select the correct response by tapping it. As you concentrate on the distracting voice and text before you the image you need to analyze, the component most essential to your response, disappears, or appeared for only a brief flash. Unlike the practice runs, these episodes cannot be repeated.
Give yourself an additional test, a final question. Better yet, pose it to the designers of the DriveABLE test: How many real-life traffic hazards have they encountered that required not only concentration on what was happening and an immediate response to it, but also on a description of the event and a response to a multiple choice reply projected on their windshield before being able to decide on an appropriate action? How might this have affected their reactions and the outcome?
At the end of the DriveABLE test you’ll be asked to sign yet another form. It advises you that you may also need a road test, that you will be advised of the results of the DriveABLE test by letter, and that it could take several weeks before you receive that letter. A bit further on a line in bold face and larger type set between two double asterisks commands your attention. It says: “We strongly recommend you do not drive until you have heard about your results.” Could this be because your license can be cancelled within mere minutes of test completion (the program self-evaluates and instantly transmits the results to the OSMV), but it takes 4 - 6 weeks to notify you whether you passed or failed? Or is it motivated by concerns about public safety, and yours, of course? After all, you could possibly have an accident on your way home, or to-morrow, now that you’re 80. Uh, let’s just think about this for a moment. That’s not a possibility for anyone under 80? Really? As you think about this, any lingering doubts as to the real purpose of this process are being dispelled one by one.
Brian Kieran, a columnist for Victoria’s Monday Magazine described the test as “designed to fail seniors” and “focused solely on getting as many seniors off the road as possible and doing so in a manner that is costly and intimidating”. Not many seniors who have gone through the process are likely to disagree. The passing rates, as far as they are known, range between 15% and 30%, depending on the source, and seem to corroborate this columnist’s observations.
A letter to OSMV seeking information about passing rates as well as accident statistics of seniors compared to those of other age groups and the consideration given to individual driving and traffic fine records went unanswered. Presumably these are mere distractions from an otherwise objective and impartial process and therefore of little relevance.
A letter to OSMV seeking information about passing rates as well as accident statistics of seniors compared to those of other age groups and the consideration given to individual driving and traffic fine records went unanswered. Presumably these are mere distractions from an otherwise objective and impartial process and therefore of little relevance.
The insurance companies, whose financial health depends on accurate actuarial data, see things somewhat differently, however, and structure their premiums accordingly. Drivers under thirty, along with new drivers of any age, are and traditionally have been considered the highest accident risk group and pay the highest premiums, as those us us whose memories do not coincide with the OSMV concept ruefully recall. Premiums tend to decline with advancing middle age, experience and more responsible driving habits, and seniors not infrequently get the best rates available after decades of accident-free driving. Traffic fine rates, not surprisingly, follow a similar trend.
Standardized and usually computerized tests, such as the age-based driver assessments required in BC, are at best controversial, for years a subject of many debates. They are also a rapidly developing industry. They are widely employed in the education sector as an alternative to more traditional but also more cumbersome exams, by corporations, the military and police, for medical and psychological evaluations, and similar applications. Their one-size-fits-all design makes no allowance for culture, background, ethnic origin, much less for individual characteristics. One should not be misled about the intent and limits of this type of testing, although they quite often serve a well defined purpose, not necessarily the one stated.
They have considerable appeal for managers and administrators of various stripes and not entirely by accident, as they are generally designed for ease of application, some with built-in instant scoring systems. They are efficient, cost effective, self-contained and can therefore be applied by almost anyone. But most of all they are impersonal, require no engagement with the person tested, the “subject”, no interaction – in fact that’s inadvisable, decisions, judgments, no responsibility, an anonymous process perfectly adapted for faceless bureaucracies, corporate or government. They confer power and authority conveniently free of responsibility.
Their cookie cutter design and application also tends to breed conformity and compliance, behavior patterns that are considered desirable in a corporate or institutional culture, and to discourage individualistic thinking, especially where this tends to be bit skeptical or critical. This may account, at least in part, for the differences in opinion about them between teachers and school administrators, for example. Teachers, who know their students from ongoing day-to-day contact as individuals, as real persons, tend to understand the possible psychological damage this type of test holds for those who do not readily fit the box, and are therefore somewhat less favorably inclined towards indiscriminate processing of the student population than the administrative hierarchy, more removed from it and governed by a different set of criteria. Whatever the merits of standardized tests may be, real or imagined, one benefit is indisputable and common to all of them: they generate substantial profits for the corporations who develop and market them.
When Drivewise calls you a few days later to arrange a road test, it’s an indication that you haven’t failed the cognitive test entirely, but nor have you passed it. You fall in the mid-section that gets a crack at the road test. You breathe a sigh of relief, finally something real, you can handle this, even if the car they give you and you’re obliged to use for the test is nothing like the old clunker you’re used to. You decide not to let all that high-tech wizardry intimidate you, underneath it all it’s just another car.
Surprisingly, or perhaps not, it seems you did quite well. Your examiner confirms this, but also advises you that she will not make the pass or fail decision, that is up to the Superintendent of Motor Vehicles, you’ll get a letter. You sign again that you’ve been advised this may take weeks and that it is strongly recommended that you not drive in the meantime, and you wait for the letter. It may never arrive of course, and you know this and secretly hope it won’t as you continue chewing your nails. You’re usually advised only if further testing is required or your license has been revoked. There is not necessarily any notification when you pass your road test and can continue to drive. After all, where’s the fun in that?
Public safety, the reason tirelessly quoted to justify these age-related assessments, is undoubtedly a valid consideration. Few would disagree with the proposition that anyone with physical or mental impairment, temporary or permanent, sufficient to turn him or her into an unsafe driver should not be operating a motor vehicle, regardless of age. But the notion that all of us wake up meshuggah on the morning of our 80th birthday, gaga, too barmy to drive any more unless we can prove otherwise by way of some rather dubious psychometric narrishkeit is a bit more difficult to swallow.
Examples of careless, even reckless or deliberately risky driving, of disregard for traffic regulations, whether accidental or intentional, that can be observed almost very time one is on the road for any length of time are not hard to come by. They’re commonplace, we needn’t review them here, we all have stories to tell. That they are mostly attributable to octogenarians, as surely they must be if that is the only age group to need systematic review of its driving skills, is perhaps less easy to accept.
Alcohol and speed, the province’s own statistics clearly indicate, are the leading causes of fatal crashes on the roads and highways, certainly greater than age-related dementia or cognitive impairment which, in fact, seems so insignificant that statistics for it are not even available. Yet BC, like other provinces, is very much in the business of selling alcohol, along with the paternal advice to drink responsibly, of course, and not to drive when drinking. The statistics illustrate its effectiveness. But are customers of the provincial liquor stores and the pubs and bars that are supplied by them regularly assessed for their driving habits? (It now appears that the provincial government is getting out of the business of selling alcohol, but not because of any compelling concerns over public health and safety or other ethical considerations.)
Provincial gambling casinos , however, will continue to offer glitz, glamour and the lure of easy money to large numbers of people, along with free-flowing liquor and ample parking thoughtfully provided for appreciative customers bent on carefree diversion. As clients leave, perhaps after heavy losses – for in the end the house always wins – and enough liquor to soothe the pain and head for their cars, are they routinely asked to submit to a safe driving assessment as they exit for the roads and highways? Or at any time? Are there no risks here of unsafe driving, not to mention the huge social problems and costs associated with problem drinking and gambling, addiction, accidents other than traffic-related ones, domestic violence, illness, lost work hours, broken families, crime? In these cases, is the admonition to gamble/drink/drive responsibly effective enough to make any public safety considerations unnecessary? Or do the huge financial windfalls associated with these recreational social activities outweigh any concerns for public health and safety? Does scapegoating seniors provide a useful diversion from these more serious concerns?
These, along with others that suggest themselves in Parts II and III, might be useful questions to ask your provincial politicians as they come knocking at your door during the next election campaign. Come to think of it, no need to wait for that, why not go knock on their doors now, ask those questions and demand answers? If enough of us do this often enough and use our votes to make the point it could even bring about some changes, for there are many of us and our numbers are increasing. Grey power, if we start using it effectively, can influence election outcomes and policies. Politicians understand this and may just listen.
II
Home Sweet Home
You’ve seen them, the glossy brochures and magazines for seniors, the handouts available from government departments and institutional or commercial enterprises that promote the good life in BC’s retirement havens, you’ve done your homework. A picture is worth a thousand words and you’ve seen lots of them in the glamorous promotions. Elegant care facilities set in appealing natural or urban environments, the attractive images of healthy and handsome seniors aging gracefully, enjoying their choice of active but relaxed designer lifestyles, rewarding and satisfying, offering opportunities for friendship, even romance and affection, but with no hint of carnal desires, of course, that wouldn’t be seemly in the media world of appearance and illusion that we now live in, and is reserved for younger lifestyle promotions, in spades. You’re convinced, you pack your bags.
The realities that lie behind the image projections are less attractive, however, the pictures less pretty. They’re not unknown, just less ubiquitous than the promotional handouts, you have to look for them. For example in Victoria’s brave and informative Focus Magazine and its series of articles about elder care in BC by Rob Wipond, or in the 440- odd page report by BC Ombudsperson Kim Carter which takes a probing look behind the scenes and was promptly swept under the carpet, the report not the ombudsperson, by the (neo)liberal BC government. Not surprisingly it caused barely a ripple in the ocean of compliant Canwest Global corporate media covering the province, now become Shaw Media, or in the ubiquitous tidal pools of Black Press community papers. (For information on how to access the Carter report and Wipond articles as well as other sources of information please see the appendix at the end of Part III.)
Care homes for BC seniors, it appears from these and other sources, are a complex mix of private, public, subsidized, partially subsidized and unsubsidized facilities under the umbrella of BC’s Health Act administered by the BC Ministry of Health (MOH) which also holds the purse strings, by and large. As the buck, and with it authority and control originates there, it would be reasonable to assume that it also stops there, and with it responsibility and accountability, but this isn’t necessarily so. There is a good deal of bureaucratic buck passing between various levels of delegated authority and responsibility which, together with a bewildering maze of regulations and some convenient loopholes, results in a care system that does not readily appear to be designed with the best interests of BC’s seniors in mind. In fact, the Carter report comes with no fewer than 176 recommendations, an indication perhaps that all may not be well with elder care in Lotusland. This “unprecedented” number of recommendations, as the MOH calls it somewhat reproachfully in its otherwise bland and soothing reply to the report, nevertheless provides a pretty good indication of what is wrong with BC’s approach to providing support services for its aging population.
The main agents for delivery of elder care are the provincial Health Authorities (HAs), five in all for different regions of the province. There are no binding directives to ensure uniform quality of care, the authorities are pretty much at liberty to develop their own guidelines and standards. The inclusion of other actors in the senior care scenario, licensing and medical officers, operators of care facilities, which in some cases is the HA itself, directors of mental health facilities and, ultimately, the MOH, all with various levels of decision-making authority, does little to clarify accountability.
Services are available to seniors through both home and different kinds of institutional care, private, public, subsidized or not. Information to explain this complex system and how to navigate it is not readily obtainable in overview form. Despite its length, the very readable, plain-language Carter report is perhaps the clearest and most complete guide to the structure of the system available, as well as providing considerable insight into its day-to-day operational realities.
Home care is by far the preferred method of support by seniors and their families, as well as being the most economical and cost-effective for both seniors and the public purse. It also appears to be the least favored by the province. Availability of home care services has been uneven since their introduction in the 1980s, and has declined overall since its peak in 2009/10. In those last 5 years the number of seniors supported by subsidized home care has declined by about 20% to 30%, depending on the source, while overall the senior population has increased by nearly 20% since 2002. There are also no legally binding provincial standards for quality of home care, although the 1990 Continuing Care Act authorizes the MOH to develop these. As a result, quality of home care varies widely in different jurisdictions and is difficult to monitor. Complaints are frequent but rarely voiced for fear of reprisals.
By contrast, the BC MOH in its Feb. 2012 publication “Improving Care for BC Seniors: An Action Plan”, states that spending on home health services is expected to increase in 2011/12 by almost 86% compared to 2001, and that 23% more clients are receiving home care professional services than in 2001, but does not explain how it arrived at these figures.
Assisted living facilities are available to seniors still able to direct their own care. Accommodation consists of apartment-style housing, with hospitality and personal care services available if required. These facilities can be owned and operated by HAs, non- profit or for-profit organizations and can be subsidized or entirely at the expense of the residents. Costs and quality vary widely from one facility to another. Along with their application for subsidized care, seniors must provide a declaration of income. Subsidized residents are required to contribute up to 70% of their after-tax income. Costs can run up to $5,000 a month for seniors paying out of their own pockets. Services include meals and housekeeping, laundry, recreational opportunities, 24 hour emergency response and, usually, assistance with medication. Waiting times for subsidized assisted living care currently run from four months to one year.
Residents are considered tenants by facility operators, and thus subject to rent increases, damage deposit requirements, not infrequently subject to additional charges they weren’t advised of until after they moved in, and eviction without notice. All this pretty much at the operators’ discretion, as there are no clear regulations governing these facilities. However, the biggest concern of seniors and their families is the quality of assisted living services. Again, the province has the authority to regulate this, but so far has chosen to limit its control to storing and administering of medication. Non- binding policies guide staffing, food services and housekeeping, with predictable results.
Complaints procedures are complex, with different provincial authorities involved depending on their nature. Often there is no third party agency to turn to, they can only be directed to the facility operator. Complaints or concerns about the health and safety of residents can be addressed to the Office of the Assisted Living Registrar, part of MOH. Funding for this office was cut by 29% between 2005 and 2010, while in the same period the number of assisted living units tripled. Inspections of facilities are infrequent, with only 18% inspected in seven years since 2004 and even then usually by prior advice. Enforcement occurred twice in the same period.
Residential care provides 24-hour nursing care and supervision for seniors with complex care needs and no longer able to live on their own. Demand for residential care beds exceeds supply, with waiting lists up to three months. As usual with BC senior care, organization, standards and regulatory controls can vary dramatically from one kind of facility to another, and are fragmented, haphazard, even problematic.
Subsidized community care homes account for the largest number of residential facilities and are regulated under the Community Care and Assisted Living Act. Extended care and private facilities make up the balance and are governed by the Hospital Act. The distinction is important, with major implications for patient care. However, patients and their families are often unaware of the differences and at any rate are not able to select a facility of their choice - at best they can state a preference - they must accept the first available bed, often on 48-hour notice, or lose their place in the queue. Residents in community care facilities can expect to pay up to 80% of their net income for services and must agree to this in advance, although they are often not advised of the actual amount until after admission. Costs for those in private facilities typically are $5,000 a month and up, but beds are more readily available.
Objective standards for quality of care, such as health and hygiene, meals, medication, social, recreational and cultural needs of residents, are generally prescribed for community care facilities, but not under the Hospital Act. One major concern is the use of restraints, where this Act provides no controls for private or extended care facilities, nor does it call for reporting or documentation of their application.
Hygiene is lax at best, with bathing generally provided only once a week. While this alone may raise some eyebrows, it becomes even more significant considering that toileting is available only at certain times. Many seniors in residential care are incontinent and and have no option other than to relieve themselves in their underwear or diapers, in fact are encouraged to do so when they are unable to wait for the appointed hour. The implications for personal hygiene need not be described in detail.
Food preparation varies, with some meals prepared on site, others brought in from far- flung places like Toronto and “rethermed”, which may not always meet the expectations raised by the promise of gourmet meals in the glossy brochures.
Assistance with eating is similarly unregulated and its lack was the likely cause of the recent choking death of a toothless resident. By comparison, Ontario requires on-site food preparation, a full-time cook, dietician and nutrition manager, all having to meet specified training levels.
There are no legislated requirements for minimum staffing or staffing mix other than vague guidelines with their interpretation left to facility operators as they see fit. By contrast care for children, another vulnerable sector of the population, calls for specific, measurable staff-to-children ratios.
Guidelines for complaints are lax and essentially leave it up to operators to decide on how to handle them, unlike Ontario again, where there are strict, legislated complaints and reporting procedures to follow by operators. Follow-up to complaints is not available to the complainant unless it is requested under the Freedom of Information Act, a lengthy and costly process. Monitoring and inspection of facilities and the services they provide is haphazard, usually by mutually convenient arrangement, and toothless.
“Reportable incidents”, which range from unusual or aggressive behaviour or falls to various kinds of abuse or neglect (physical, emotional, sexual, financial) and disease outbreak, attempted suicide or death are typically poorly reported, often with delays of days or even weeks, or not at all by private or extended care residential facility operators, who are not bound to do so by any legal requirements. There are clear standards for administering, record-keeping and monitoring of all prescribed medication in community care homes, but none for private or extended care facilities.
Admission, generally, is by consent of the senior seeking it or his/her legal representative. But if there is “imminent risk” and no representation, it can also occur involuntarily under the Mental Health Act. This provides for immediate admission to a mental hospital in cases where the patient requires urgent treatment and care, but is unable to provide consent. The authority to issue the required certificate rests with a physician. There are ethical and practice guidelines for this process, but their observation is largely a matter of individual preferences and practices. Essentially, initial certification depends on a single medical opinion as to whether someone needs “protection” to prevent “mental or physical deterioration” to commit someone to a mental health facility.
In practice and the absence of clear definitions or procedural directives in key areas, the Mental Health Act can be used somewhat arbitrarily, for example to effect admission to a residential care facility, as length of stay in mental health facilities is limited under the Act and authorization becomes more difficult to obtain as length of stay increases beyond a day or two.
Some differences arise from this form of admission, however. As with other hospital care under the public system, there are no costs to the patient for care in mental hospitals. Upon transfer to residential care residents are normally charged the usual fees, are there against their will, have not agreed to pay the fees, are not at liberty to leave, and may have treatment imposed on them without consent. In BC involuntary committals under the Mental Health Act have increased 50% from 2002 to 2011. They have doubled on Vancouver Island, Canada’s retirement paradise.
Involuntary treatment, especially by various forms of restraints, is not reserved for the relative minority of residents admitted under the Mental Health Act, however. The system is quite democratic, when it comes to considerations of this nature all are equal.
The two most common forms of restraints used in residential homes are physical and chemical, and are applied to the patient. Others, various kinds of mechanical and electronic restraints, such as password devices used on doors, prevent residents from entering or leaving some areas in the building or the building itself.
The uses of physical restraints -- tying residents to their beds, chairs, etc. -- are inconveniently evident, awkward and in practice not often applied without prior consent of resident or guardian, and require reporting, at least in community care facilities. Still, Canadian nursing homes use physical restraints at a rate three times that of the US, and five times that of European countries such as Switzerland.
The use of chemical restraints, a potent and sometimes lethal cocktail of antidepressants, sedatives, opioids, hypnotics, and antipsychotics, is less problematic and more widespread. They can be administered by any qualified staff – doctors, registered and practical nurses – and pretty much at will, thanks in large part to the quite convenient PRN provision in provincial legislation. PRN stands for the latin “pro re nata”, or “as needed”, “as circumstances require”.
The absence of any legally enforceable standards for PRN medication leaves the door wide open for convenience uses. Originally developed to control serious mental illness such as schizophrenia, especially the potent, mind-altering antipsychotics are used widely in BC nursing homes to manage behavioral “problems” ranging from anxiety and restlessness to various forms of dementia. Or just any form of inconvenient behavior that gets into the way of the smooth functioning of the daily care and service routines of the often understaffed and underfunded facilities and overtaxed care workers.
While routine use of powerful psychotropics such as antidepressants and antipsychotics may be somewhat casual, their effects decidedly are not. They are well- known for causing the very symptoms they are supposed to control: restlessness, agitation, anxiety, although to the casual observer the person so treated may indeed appear calmed down, at least for the moment. The subjective experience differs, however, as patients have indicated.
These are relatively minor concerns, however. Routine and prolonged application of especially antipsychotics can lead to more severe mental and physical damage, such as disorientation, cognitive impairment, extreme weight gain, diabetes, loss of muscle control and muscle rigidity, even death, usually as a result of heart attack.
Still, their use continues unabated, facilitated not only by liberal recourse to the PRN provision, but also by the even more effective tool of incapability. Usually conducted by a medical doctor, the assessment as to whether someone is capable or not to manage their own affairs can have devastating results. In the absence of any clear standards or directives, doctors most commonly resort to the Mini Mental Status Examination (MMSE), developed originally to measure cognitive impairment and screen for Alzheimer’s disease. The MMSE can be applied not only to seniors confined to a care home setting, but also on other occasions, such as a hospital stay for a physical illness or injury. Essentially any behaviour that doesn’t conform to the expected norm can trigger it, and doctors can pull it out of their bags at their discretion.
The 20 or so questions of the test are relatively simple, and focused largely on abstract memory functions such as naming current dates, locations, repeating random words, and the like. If you have a memory that tends more towards visual or concrete experiences, if you are the type that knows exactly where your favourite restaurants are and can easily find them but don’t necessarily recall all their names or street addresses, or can find your way to where your friends in your apartment building are without necessarily knowing the numbers on their doors, if it matters more to you to know how to find and use things than their labels, you may have some difficulty with this test.
One might ask, moreover, how realistic it is to remember the current day of the week and date, or their floor or room number for persons shut off from the real world in an institutional environment where people tend to lose their orientation in time and space as rigorously regimented days and weeks resemble one another in dreary succession, and where moreover they might well be too drugged out to care anyway. The results of this test and those of others, as we have seen, are questionable at best. But when one considers their nature and the circumstances under which they are often administered, one may be forgiven for wondering who has lost his or her grip on reality here, the person assessed or the one who applied or designed the assessment.
Even under more favorable conditions this type of assessment is hardly appropriate for indiscriminate use. If you don’t readily fit expected behavioral norms, for example, if you have your own way of doing things or think outside of the psychometric box, if you’re an individualist rather than a conformist, if you have a critical, questioning mind, are a doubter rather than a believer, then this type of test may not work to your benefit.
Standardized, one-size-fits-all tests are necessarily based on averages, psychometric evaluations based essentially on a statistical approach to measuring mental ability and function. They tend to average things out, the average becomes the norm and if you don’t fit it you are by definition not normal. These types of tests have some usefulness and validity as statistical screening tools, but should never be applied as the sole measure of mental function. That can only be seriously assessed by prolonged observation of behavior in real-life situations. But then that’s a bit inconvenient compared to a10 or 15-minute question and answer routine.
There are one or two other inconvenient facts that call into question this widely used assessment of capability. It can be very difficult for a conscientious physician to differentiate between genuine cognitive impairment and depression, especially in these perhaps less than uplifting institutional settings. And if depression is sufficient reason to pronounce people incapable of managing their own affairs, then many more than just the old or very old are candidates for incapacity. Add to that that the MMSE wasn’t even designed to measure incapacity, and you may again wonder who has lost their grip on reality here. According to a 2009 report by the School of Social Science of the University of Victoria to BC’s Public Guardian and Trustee, “Too often the MMSE is treated as though it were a test of incapacity. This is a misuse of the tool and provides inadequate information upon which to base a decision about capacity”.
Clear enough, even to those of us who are supposedly losing our marbles, but not to the BC government, it seems, fixated as it is on tests that can’t do what they are used for, or the liberal and convenient use of legislation for purposes it was not intended for, e.g. the Mental Health Act for forced admissions to residential homes and the extensive use of potent antipsychotics as chemical restraints under the PRN provisions, a practice recognized as having very serious health outcomes and strongly recommended against. Might this indicate a bit of cognitive impairment here on someone’s part, or at least a serious attention deficit? Should they be driving?
A letter to the BC MOH asking whether any changes to legislation governing the use of antipsychotic and other psychotropic medication as restraints, forced admissions under the Mental Health Act and application of the MMSE to determine incapability are being considered yielded no clear reply to these questions, other than indications that these issues have been and continue to be studied and reviewed, and references to existing studies and reports. These are included in the appendix. The report “A Review of the Use of Antipsychotic Drugs in BC Residential Care Facilities” is of particular interest.
Whatever the psychometric wisdom that guides the MMSE process may be, the results are real enough. Fail it and you will have lost your legal right to make any decisions about your life, your money, your treatment and medication. Your guardian, if you had the foresight and opportunity to appoint one in time, will now have that responsibility. Except, well, if he or she should object to the care and attention afforded you with the help of antipsychotics or other psychotropics, in which case s/he may well be perceived to be denying you appropriate medical treatment and be relieved of his/her duties. But not to worry, at this point the afore mentioned Public Guardian and Trustee will step in and apply due diligence to the management of your health and affairs, and ensure seamless continuity of care.
The province spares no expense to make you comfortable. In 2006, BC spent $76 million on antipsychotics alone, pretty generous, considering the total population is only about 4.5 million, with about 20,000 or so in nursing home care. Almost half of all the seniors in BC’s long-term care facilities are given antipsychotics, roughly double the already high Canadian or US average, four times that of some European countries. The country’s retirement haven, Vancouver Island, is leading even the province and most of the world with a 51.5% application rate.
Repeated application of these potent drugs over the course of a year or so can and does cause brain damage – about a third of institutional care patients show symptoms such as tremors, usually associated with Parkinson’s disease. Death rates double as a result of heart attacks attributed to prolonged use. This is not new information. For about a decade now Health Canada has repeatedly warned about and recommended against the use of antipsychotics as restraints and for the treatment of dementia-related symptoms. Its data bank links 3200 deaths to the use of antipsychotics.
Other jurisdictions, according to MOH’s own reviews and studies, are also aware of the considerable risks associated with the use of these potent drugs and are taking or have already taken steps to limit it.
Ontario, for example, planned to hire 700 additional health care workers in 2011 to provide better care for patients with dementia. The intent is to keep more people at home and out of long-term care facilities, and to reduce the use of medication and restraints for patients already institutionalized.
The US government acted more decisively. As far back as 1987 it already introduced regulations to establish the right of nursing home residents to be free of restraints used for discipline or convenience. They also are quite clear that uncooperativeness, restlessness, wandering or unsociability do not justify the use of antipsychotics. At the same time the Federal Drug Agency (FDA) issued warnings about the use of antipsychotics and the increased risk of death caused by their use on elderly people.
While the news that all is not well with BC’s senior care services has evidently travelled as far as the provincial legislature comfortably installed in the showpiece architecture along Victoria’s picture postcard Inner Harbour, the need to act on it more decisively does not yet seem to have occurred to those able to enjoy the view from the top.
III
Follow The Money
Follow The Money
Lord, do not forgive them,
for they know exactly what they are doing.
José Saramago
Before they became an endangered species, largely extinct already in corporate media but still surviving precariously in isolated pockets as independents, investigative journalists used to play an amusing game they called “follow the money”. It consisted – and still does for those who want to try their hand at it – in following a money trail to see where it led. The end of the trail could come as a surprise or it might have been predictable, but getting there was rarely boring. Anybody able and willing to ask some searching questions can play it actually, but few do.
It usually begins by asking who are the players in a given scenario, who benefits from it and who loses? In the case of BC elder care the key actors are those who use the services, those who pay for them, those who provide them, and those who profit from them. The users are the seniors inside the care system, by choice, persuasion, or compulsion. They are also the payers, completely or in part depending on the choices they were able to make and on their financial status, with the balance paid for from the public purse to which the users also contributed throughout their lives and still do. The providers of the services are the operators of the care facilities, various governmental agencies responsible for their provision and supervision, medical and paramedical professionals and personnel and, less directly, the pharmaceutical and insurance industries.
Who profits? Those who provide the services, to varying degrees. Physicians can do quite well inside the system, other care providers less so. Operators of especially for- profit facilities will be able to chalk up financial gains, as they must to stay in business. The big winners, however, are insurance companies who sell long term care insurance at substantial premiums and for many years before any benefits are called for if at all, and above all Big Pharma, and in a big way. Seniors for them are a huge and expanding market, worth endless billions.
Pharmaceutical corporations spend many billions of dollars every year to promote their products for every conceivable application, not only where these can be useful but also where they are not or even counter-indicated. Their latest marketing strategy does not hesitate to invent new disorders, especially mental and emotional, in urgent need of treatment with, of course, the necessary products, duly patented to protect intellectual property rights, conveniently available from the very same corporations that created the need for them.
Many if not most of the big manufacturers of pharmaceutical products have already paid fines in the hundreds of millions for promoting unethical uses of their products, applications that is for which they are not only inappropriate but potentially harmful, even fatal, such as their use as chemical restraints. Still the practice continues, with fines and settlements just part of the cost of doing business in which the stakes are high enough to justify the risk of sanctions that usually can be painlessly absorbed, typically no more than 1-3% of profits. Worldwide, pharmaceutical corporations chalk up $82 billion annually in sales of medications for treatment of mental health disorders alone.
Promotions also extend to medical professionals in the form of generous supplies of “samples”, lucrative drug trial contracts, luxury vacation packages, gourmet lunches and the like, but most of all in the constant bombardment with “advice” on how and when to use these often inadequately tested pharmaceutical products.
Add to that the repeated and continuing cutbacks in government research facilities and government funding of independent drug trials and evaluations, and it becomes apparent why doctors are increasingly dependent on manufacturers for evaluations of their own products. Lack of funds is the usual reason given for cutbacks in independent research and evaluation, but this has been exposed repeatedly by respected independent social research institutions as little more than budgetary legerdemain. The real reason for their being shut down is probably closer to the consideration that their at times less than enthusiastic findings tended to get in the way of doing business, and governments these days are apt to have a rather cozy relationship with corporations. Under one executive exchange program or another, they may in fact well have industry representatives sitting on the management tables of the public sector boardrooms, part of a well-established revolving door policy between governments and corporations.
The widespread, often unnecessary and at times dangerous overuse and abuse of medications also explains, to some extent at least, why fatalities due to medical error are as high as they are, and in no small part due to incorrect medication. Medical and pharmaceutical errors, along with infections acquired in institutional care, are among the leading causes of in most cases preventable deaths in Canada and elsewhere, competing with heart disease and cancer. Other factors are the usual and in large part cost/profit-related: overwork, understaffing, factory medical procedures, privatization, lack of accountability. There are no federal or provincial reporting rules for medical errors or adverse events such as infection outbreaks in Canada at present, leading to possibly substantial underestimates of these problems.
The trends are similar in the support sectors such as food and cleaning services for hospitals and care homes, which lean toward contracting out to corporate, sometimes transnational service providers. The almost always disastrous Public Private Partnership (PPP) arrangements – disastrous that is for the public purse, the private partner normally gets a guarantee of profits for 25 years or so, often regardless of performance or even in the case of non-performance – seem to be a particular favorite with provincial and federal governments, who have been known to coerce often more reluctant municipal governments into acceptance.
Lobbying, political campaign contributions, well organized media campaigns, support from right-wing think tanks and similar marketing strategies thoughtfully provided by those who tend to benefit financially from the provision of elder care and general health services help to explain more and more deregulation and lack of oversight by governments, decreases in the frequency and duration of testing and evaluation of new pharmaceutical products before their release and increases in the periods granted to protect intellectual property, i.e. monopoly rights, all of which translates directly into sales and profits and, incidentally, corporate directorships, board positions and the like for retired politicians.
Along with chemical restraints, standardized psychometric testing, although of questionable value as an assessment of mental function, is unquestionably effective as a profit-making tool, as we have seen. Moreover, it can be used to justify and facilitate the use of psychotropics simply and effectively, and with presumed but misleading one-size-fits-all objectivity.
Not to be overly sentimental about this, in the global marketplace seniors, like mostly everything and everyone else, are just another commodity to be traded or in some way turned into profit. Although this poses some challenges at times, ingenuity and entrepreneurship usually succeed in turning them into advantages.
The SIMARD MD test referred to in Part I provides a useful example to illustrate the point. Co-developed by Dr. Bonnie Dobbs, Director of the Medically At-Risk Driver Centre of the University of Alberta, the SIMARD MD is the mandatory first step in senior driver assessment in BC and elsewhere, and is administered by a medical doctor.
Dr. Dobbs, by coincidence, was also the chief researcher for the BC government’s “BC 2010 Guide in Determining Fitness to Drive”. In that same year it became mandatory for BC seniors failing the highly controversial SIMARD MD test, as many do, to also take the DriveABLE test, although this had and still has not undergone peer review. DriveABLE is marketed by Allen R. Dobbs, founder and CSO of DriveABLE Assessment Centres, a fellow researcher in this field at University of Alberta and the husband of Dr. Bonnie Dobbs.
According to the Elder Advocates of Alberta Society the SIMARD test has been taken by number of community leaders and educators, all actively employed, including one MLA (Member of the Legislative Assembly), all of whom failed it. A year before the DriveABLE test was made mandatory in BC, experts at Monarch University in Australia, where the test was also being promoted, found that “DriveABLE is more likely than any other test options to misclassify drivers as unsafe when they are in fact safe”. These findings seem to have gone unnoticed by BC’s Office of the Superintendent of Motor Vehicles (OSMV). DriveABLE continues to be a standard assessment tool in BC and is promoted successfully elsewhere. It is now gaining a foothold in Ontario, some US jurisdictions, Australia and New Zealand, and continues to be used in Alberta of course, where it was introduced, a remarkable marketing and financial success story.
This should not come as a surprise. Both the SIMARD MD and DriveABLE are engagingly convenient tools. It takes ten minutes or so for an efficient physician to put a patient through the SIMARD for an almost instantaneous assessment of his or her cognitive abilities, the kind of evaluation that before the advent of standardized testing would take not only considerable skill, observation and judgement, but also carried with it a measure of responsibility and liability on the part of the physician. Now, with the help of standardized testing, a physician can reduce the process to a few minutes and need not feel any sense of involvement or personal responsibility for what is after all accepted as an “objective” assessment, and has no liability as long as the pretty straight-forward application of the test is carried out correctly. Moreover, doctors can charge $180 or so for the procedure.
The government agency enforcing and overseeing the use of these test products can similarly wash its hands of any ethical responsibility with the convenient suds of objectivity, and can moreover easily demonstrate their success with the high failure rates in hand, incontrovertible proof of their effectiveness and a useful lever to pry additional funding for the program out of the public purse, apart from accolades and promotions for a job well done.
The tests are an attractive proposition for everyone concerned it seems, which may help to explain their growth in popularity, except, possibly among seniors, on whose commodified backs they are carried out.
The market value of seniors extends well beyond such specific applications, however. More importantly, they provide a useful lever with which to pry open the access doors to social services, the next major frontier to be broached for private profit.
This is unlikely to occur openly. A candidly stated intent to privatize health care is nothing less than political suicide, that is well understood. But it can be achieved quietly if more slowly with spending cuts and other austerity measures easily justifiable because of economic constraints imposed by uncontrollable events elsewhere in the global marketplace. Speeded up or slowed down in synch with the prevailing political winds, health care programs could conceivable undergo a lingering death by a thousand cuts preventable only, we’ll be told, with the help of market solutions to market problems, and these will have to come from the private sector, of course.
Make no mistake, this is already happening and has been over the last two decades or so. We’re all familiar with the resulting hospital closures, cutbacks in health care services, increasingly severe staffing constraints in the medical and nursing professions, outsourcing of support services to private contractors, creeping privatization of diagnostic services and even medical procedures as in BC, the leader in the field.
New measures to further weaken the ability of the system to provide adequate care continue to be quietly slipped in, such as the funding ceilings announced in the controversial omnibus Bill 38, introduced earlier in the year by the current CEO of Canada Inc., Stephen Harper.
A useful myth in support of the well-worn mantra that public health care is becoming too expensive and we can no longer afford it is that seniors are draining the public purse with ever increasing demands for health and pension services. The rhetoric dispensed from right-wing think tanks such as BC’s Fraser Institute and obediently repeated by corporate mass media holds that, as baby boomers age, increasing demands for health services and pensions will drive the economy to the brink and exhaust pension funds beyond the capacity of the working population to replenish them, who will then themselves be left with empty hands and funds drained by the generation that preceded them.
While this is a useful divide-and-conquer strategy to generate support for privatization the reality is a bit different, as a number of studies by independent economists and other social scientists in both Canada and the United States have shown, among them work done by the respected Canadian Centre for Policy Alternatives (CCPA). Pension funds, they indicate for example, are doing very well, especially the major ones such as those belonging to government employees, teachers, unions, doctors and others. So well in fact that it is not unusual for them to show huge surpluses and to offer salaries and benefits to their top managers of often millions of dollars a year.
Indeed some of them are doing well enough to represent tempting pots of cash for those who have the power and a sufficiently casual sense of ethics to raid them for their own benefit. A relevant example is the plundering of the federal employees’ pension fund to the tune of $35 billion by the Chretien-Martin team to balance their budget with money by rights belonging to federal employees, who contributed in no small part to it for their retirement. The case is still before the courts all these years later, awaiting a predictable outcome with the Supreme Court increasingly stacked with judges of the currently politically correct persuasion. Once the precedent is set, it shouldn’t be too long before other funds are raided with equal impunity.
Similarly health care, the socialized but not necessarily the private variety, is perfectly sustainable, as is welfare, with the possible exception of the astronomic amounts spent on corporate welfare and to salvage willfully reckless financial institutions, given responsible policies and budgetary management on the part of governments. It may be relevant in this context to recall that the Canadian economy, its productivity and gross domestic product, has grown to roughly twice the size it was in the 1960s when the public health care system was first introduced in this country. If we could afford it then, it is perhaps not unreasonable to assume that we have the necessary means for it now.
A substantial number of countries in the developed world, notably in Scandinavia, have much better social programs and health care than Canada, along with a higher quality of life as well as greater income equality, and manage to balance their budgets.
At the opposite end of the stick, the United States, the world’s richest and most powerful country, has cut spending on health care and on other social programs to the bone, is continuing to scrape away at them and blaming them for deficits, and still has greater budget shortfalls than any other developed nation. It has also turned to privatization, resulting in the world’s most expensive health care system with one of the lowest health outcomes, not to mention the tens of millions of its citizens left out of the loop completely. This, however, is the role model aspired to by its northern neighbor, at least by the corporate and financial elites who own it and its government.
There are good reasons for the depletion of government social coffers, but one needs to look elsewhere for them. Towards the billions of dollars drained from them because of tax breaks and subsidies to corporations, financial institutions and wealthy individuals for instance, or additional billions in profits stashed away in offshore tax havens ($88 billion a year for Canada, 32 trillion world-wide, 12.5 trillion by the 12 top banks alone) and thus removed from the reach of tax collectors, to the many additional billions of profits hoarded by corporations and invested in short-term financial speculation instead of returning them to the real economy to stimulate growth, the offshoring of production and resulting diminished domestic capacity, increased unemployment and its attendant social ills at home, the petro-state policies of the Harper government and its concomitant loss of manufacturing competitiveness in world markets. All of these actions impact negatively on the ability of government to provide social services, but keep the earnings of corporations, financial institutes and executives salaries and bonuses growing at unprecedented rates.
In addition, the huge environmental costs resulting from uncontrolled resource exploitation will sooner or later have to be paid for out of the public purse while profits are pocketed by the private sector, not to mention the subsidies poured into resource ventures from public funds. Exponentially increasing spending on the military, police, detention facilities, and so-called security measures in anticipation of predictably increasing dissidence, opposition and unrest at home and abroad, for that is ultimately why these are needed, are additional drains on especially the social compartment of government accounts, part of a strategy of robbing Peter to pay Paul, all driven by the dominant neoliberal ideology of wealth and power to the exclusion of everything else.
These are the kinds of policies and their consequences that are responsible to a large extent for the serious erosion of our system of values – social justice, social security and services, equity, civil liberties. They have become possible with the complicity of a succession of like-minded governments over recent decades and, it must be said, the complacency of their citizens, but they can also be reversed by governments with the political will to do so, notwithstanding their current tireless portrayal of the ship of state drifting helplessly in the powerful currents of the global market place, struggling to stay afloat. Both the causes and possible solutions, here only mentioned in passing to provide at least some necessary context, are now widely recognized and understood, much has already been and continues to be said and written about them by progressive economists and other social scientists, independent research institutes, independent journalists, and alternative media. On occasion one hears thoughtful comments even from the more enlightened of the one per cent, a few financiers and corporate owners who are beginning to realize that our current way of managing the economy and indeed the planet is simply not sustainable. A great deal of information about all this is now readily available in bookstores, libraries and on the Internet.
There is no mystery – other than the myths and distractions manufactured by those who hold power and wealth and understandably want to continue to maintain their grip on it, and by their pundits, mass media and political spin doctors – about the solutions to the economic crises we are constantly reminded about.
A number of entirely possible policy and economic strategies have already been proposed and discussed to regain control of the drifting ships of state and their budgets and in considerable detail, but here can only be considered in passing. Among them are the return to a more progressive and equitable form of taxation of wealth, both corporate and individual, to basically pre-neoliberal levels, adequate taxation of funds hoarded in off-shore tax shelters or their return to Canada, repatriation of manufacturing with its corollary of full-time employment and insured social benefits instead of the proliferation of part-time, precarious and uninsured work, an at least minimal tax, say 0.5 to 1%, on the trillions of dollars in currently tax-free speculative capital moved around the globe on a daily basis, adequately taxing resource exploitation and requiring at least minimal processing before export to create employment and income at home, reducing spending on the military, security, police and detention facilities to more reasonable and justifiable levels based on real instead of ideological issues and concerns, genuine economic stimulus spending instead of corporate welfare and bank bailouts, and above all in guiding economic development toward the creation of social wealth and equity, for the benefit of the majority and not just that of a chosen few, for governments are perfectly able to do that.
All of the corrective measures referred to above are feasible given the political will to undertake them and are therefore highly unlikely to occur, unless sufficient public pressure is brought on politicians to force them to act. They are hardly unreasonable measures for a democratic society that seeks an acceptable level of social justice for all. Several of them are on their own able to produce the income needed to sustain adequate social programs, in various combinations they would likely more than restore or even improve the quality of life the country enjoyed now already many years ago when it was declared world leader in that regard by the United Nations, before it began its steady decline during the Mulroney years, who was still able to brag about it when he first came into power.
About the same time he also declared “Canada open for business”, and with it the beginning of the neoliberal era in this country, the then still fairly new model for the entrenchment of corporate power and private capital, the auctioning-off of our natural resources at fire sale prices, for deregulation and privatization. Another promise of his, “give me 10 years and you won’t recognize this country” may have been a bit optimistic at the time, but over the longer term and a succession of like-minded politicians his prognosis has certainly proved correct. Our resources and economy are now largely foreign-owned, with capital gains being exported and environmental devastation left behind, real wages stagnant or declining, poverty and homelessness increasing at rates not seen since the great depression. Canada is now eighth on the UN quality-of-life index behind Ireland and New Zealand, the rich are showing unprecedented gains in net worth.
What’s likely to happen if we continue along this path? One likely course of events is an accelerating trend towards getting governments out of providing social services and privatizing them. We’re all familiar with the media mantras “we can’t afford it any more in these tough economic times”, “let the marketplace take care of things, it can do it better and cheaper”, “government is wasteful and inefficient and can’t do the job”, and so on. To test the accuracy of these assertions we need to look no further than to our immediate neighbor to the south.
The two most lucrative social services sectors, education and health, are already well on their way to privatization in the US. The results are well-known: education has become more unequal and exclusive, increasingly reserved for the rich, the costs of especially higher education along with interests on student loans have risen beyond the reach of even large parts of the middle class with debt burdens becoming insupportable, choices and quality of education are declining as corporate financing and with it control of curricula takes hold in all but the ivory league institutions reserved for the privileged few.
Health care services provided by our southern neighbor show similar trends. Not only has health care in the US become the most expensive in the world at almost $8000 per person, it also ranks a mere 20th place among performance achievements. Canada, by comparison, still stands 9th in health care inclusiveness, and is the 5th most expensive country at $4363/person, according to a 2011 Bertelsmann foundation report. Large sectors of the US population, among them the old and disenfranchised, have to be content with limited access to second-grade services and facilities, and tens of millions of the poor without any access at all.
As more and more vulnerable sectors of the population still protected to at least some extent by public policies are handed to the insurance industry, control of access to and quality of health care shifts to insurers, the major beneficiaries of the privatized system and, not surprisingly, the major force driving privatization. Premiums are high and continue to rise, especially for those having to resort to the services they are after all insured for, and finally climb beyond reach, if they are still available at all, for those who need them most, the old or chronically ill. Those who are no longer profitable are shunted off into the welfare system or abandoned.
This, more or less, is the not unlikely future for Canadian health care as well, as corporations and financial institutions continue their assault on that remaining social stronghold, and the barricades are quietly being removed one by one behind the smokescreens of austerity and efficiency spun by complicit governments.
The stakes are high, the temptation is irresistible. There are endless billions of profits waiting to be tapped into, endless because they are sustainable. Unlike finite natural resources which will become depleted at predictable future dates, social programs will be needed for as long as people are living in societies, at least in those worthy of that designation. They are renewable profit sources like food, another contested market sector and fertile ground on which to reap billions of profits through monopolistic market controls and lucrative market speculation in commodity futures.
There are costs attached to all of this, of course, but they are not usually a major problem. With the help of understanding governments, they are easily transferred to the public purse, while the private sector reaps the profits. In the case of resource exploitation, including industrial agriculture and biofuels, degradation of the environment which sustains us all is the price tag. Privatization of social services predictably results in diminished quality of life, growing inequality and increasing poverty, not to mention resulting adverse effects on health and public safety, especially for the more vulnerable sectors of the population, the elderly, children, the working poor. Food supply manipulation and speculation brings hunger and starvation to millions of people world-wide, an unfortunate collateral perhaps, but one that cannot be allowed to get in the way of the smooth functioning of the marketplace and the benefits it brings.
Seniors, as mentioned, provide a useful lever to pry open the doors to privatization. By creating and disseminating the myth that seniors and the services they require are a costly drain on the economy, soon to become unaffordable as increasing numbers of baby boomers join their ranks, by fermenting discontent among younger generations looking for a way out of their economic straights with the devious pretext that seniors enjoy a carefree and secure lifestyle on their backs and pocketbooks, a free ride on the taxes they pay while they are struggling to make ends meet, seniors are being scapegoated to create support for privatization of social services. That, we’re told, will take care of all the freeloaders by rewarding only those who truly deserve to benefit, those who contribute toward their retirement with their own efforts and out of their own pockets, by investing their future in volatile and risky financial markets, for example.
The portrayal of seniors as the major safety hazard on the roads and highways, equally unfounded as we have seen, may well have its origin in the same headwaters of the rhetoric of polarization, the same scapegoating strategy.
Whether based on evidence and reality or not, and there are certainly those inclined to believe they are, these rhetorical stratagems are nevertheless effective. Not surprisingly so, perhaps, considering the enormous persuasive powers of the mass media with their rent-a-pundit stables, i.e. virtually all of radio, television and print including, increasingly, the CBC, and their tireless repetition of the same mantras, those mentioned and others, the same media that are now almost entirely owned by the very people and corporations who are firmly committed to private profit. Not for everyone, of course, that would be socialization of profits, an oxymoron if ever there was one.
The picture is not a pretty one, for seniors or just about everyone else, but it is not engraved in stone. I can be painted over or a new and different one can be drawn, but it won’t be easy or quick.
Seniors have natural allies in the struggle to turn things around, and they can join those already engaged in doing that. Students for one who, at least in Québec and in other parts of the world but not yet in the rest of Canada, are becoming very aware that they too are being held hostage in the same drive to privatization of social services, in their case education, and are beginning to fight back, in some instances quite effectively. Besides adding strength, energy and creativity, that particular alliance will also help to bridge the artificial generation gap opened by those with an interest in division.
Labor unions are also a natural ally, especially those representing workers in the public sector, such as the progressive and socially active Canadian Union of Public Employees (CUPE), or teachers’ federations. They also understand quite well that they are being scapegoated in the same campaign, as evidenced in the recent quite acrimonious and pivotal labor dispute in Wisconsin, which again demonstrated that the US is still the undisputed leader in the field and always a few steps ahead of us, despite the best efforts by our elites to keep pace. Forward-looking labor analysts such as Canada’s Sam Gindin have already realized that unions need to break out of their traditional and no longer effective organizational structures and way of doing things, look for allies outside their own ranks and join forces with other social movements, something they are in fact already starting to do.
There are other potential allies as well, basically any group or organization working for greater equity and social justice. Nor should seniors underestimate their own capacity to effect change. There is strength in numbers alone, for example, and those are growing and can make a difference at the ballot box if used effectively. Politicians understand this, and some are beginning to court the seniors vote.
We can also vote with our time and dollars, by more selectively making both available to ends and means which support our and similar interests. It is time to become informed and very clear on our demands, rights and options, to agree on them, to work towards a unity of purpose, a common understanding through organization and alliances, both internal and external, and then to get out the pots and pans and start banging them in the streets, in front of constituents’ offices, relevant government departments, legislatures, provincial and federal. Grey power has marched before, made demands and won them, it can do so again and indeed it must keep on doing that or be marched into a progressively less appealing future.
We are also a resource, we have considerable knowledge and experience in our ranks, a measure of expertise, even leadership, but we need to mobilize it. Conceivably, we may even be able to contribute a bit of wisdom or at least common sense to help rein in a world spinning wildly out of control, although that does not necessarily come as a normal by-product of old age, despite unfortunately largely erroneous popular belief to the contrary.
It might be useful for all of us however, young or old, to keep in mind the bit of popular wisdom that holds that people usually have the government they deserve, and deserve the government they have, and to act accordingly. ▒
(Paul Wagner is a BC senior just past the age where they are known to lose their marbles here in Lotusland. His observations above need therefore not be taken seriously. Nevertheless, he welcomes comments from those still able to count their marbles and care to send them to this blog, or to lotuslandpaul@gmail.com)
APPENDIX
Additional and recommended reading:
The report by BC Ombudsperson Kim S. Carter entitled “The Best of Care: Getting it Right for Seniors in British Columbia (Part 2)” is essential reading, at least in its summary form, for anyone contemplating retirement in BC. Well presented and written in non-technical language, it is available on the Internet in both its abridged and complete editions at http://seniors101.ca/newsletter-march-2012, or at www.ombudsman.bc.ca.
Rob Wipond’s articles for Victoria’s Focus Magazine between January 2009 and June 2012 take a revealing look at some individual case histories and provide more general insight as well. Look them up at www.focusonline.ca, or www.robwipond.com.
The Canadian Centre for Policy Alternatives (CCPA) is a solid and highly recommended source of informed comment on social, economic and political issues. Go to www.policyalternatives.ca to find out more.
The Office of the Superintendent of Motor Vehicles of the BC Ministry of Justice provides an overview of its de-licensing strategy for older drivers on its website at www.pssg.gov.bc.ca/osmv/medical-fitness/index.htm. It is a good indication of the considerable gap that can develop between rhetoric sanitized for public consumption and the calculated intimidation of its application.
A copy of the Standardized Mini-Mental State Examination (SMMSE) is available here. A review and recommendations for its application are included in the Final Report to the Public Guardian and Trustee of British Columbia by the School of Social Work, University of British Columbia, entitled “Incapability Assessments: A Review of Assessment and Screening Tools”. It is available at:
www.trustee.bc.ca/pdfs/STA/Incapability_Assessments_Review_Assessment_Screening_Tools.pdf.
The Simard MD test, the critical initial step in the driver evaluation process administered by a physician, can be viewed at http://www.driveable.com.au/PDFs/SIMARD%20administration%20info.pdf Googling Simard MD Test will produce additional information and reviews. Of particular interest are the comments by the Elder Advocates of Alberta Society found at http://elderadvocates.ca/beware-of-the-simard-md. More information, including interventions by BC MLAs and transcripts of legislature debates is available with general Google searches on the subject.
Detailed accident statistics by age and cause are available from the province’s own insurance corporation, the Insurance Corporation of British Columbia (ICBC) at http://www.icbc.com/road-safety/safety-research/traffic-coll-stats-2007.pdf
The BC Ministry of Health provided the following links:
www.health.gov.bc.ca/library/publications/year/2011/use-of-antipsychotic-drugs.pdf
http://www.health.gov.bc.ca/library/publications/year/2005/MentalHealthGuide.pdf
www.trustee.bc.ca/pdfs/STA/Incapability_Assessments_Review_Assessment_Screening_Tools.pdf
www.SeniorsBC.ca
http://www.health.gov.bc.ca/library/publications/year/2005/MentalHealthGuide.pdf
www.trustee.bc.ca/pdfs/STA/Incapability_Assessments_Review_Assessment_Screening_Tools.pdf
www.SeniorsBC.ca
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