Written on the Landscape: Health and Region in Canada

Canada’s health-care system is a cornerstone of the welfare state and, equally, a cornerstone in the country’s national identity. Whether discussing access to services, the politics of providing particular kinds of services such as abortion, the distribution of health-care providers, the care and treatment of chronic disease, or new global threats to health such as SARS, few topics stir the passions of Canadians like health care. Recent reports such as Revitalizing Medicare (Rachlis et al. 2001) and the Romanow report (Commission on the Future of Health Care 2002) suggest many strategies for sustaining and reforming health care and, while they differ in their orientation and approach, both affirm Canadians’ affection for Medicare. It is, however, equally important to acknowledge that this affection is the product of an imagined Medicare, one that emphasizes a story of access and equity. To use Michael Bliss’s phrase, this imagined Medicare is the result of a “brief but very important golden age of Canadian medicare” (2002, 38). This golden age emerged from the reconstruction of health care from the early 1950s to the early 1970s, which took many forms including the implementation of the national health grants, the passage of the federal Hospital Insurance and Diagnostic Services Act (1957), and legislation for physicians’ services (1966); but a complete analysis must address how this golden age quickly evaporated in the face of mounting costs and regional disparities. Indeed, the Romanow report itself highlighted major regional discrepancies in the quality of health care.

The idea that place matters for health services and health outcomes is not a particularly novel notion. In introducing the inaugural issue of the journal Health and Place, editor Graham Moon wrote that the journal sought to publish research “which contributes to an understanding of how, why and whether place and context really matter when it comes to health and health care” (1995, 1). Canada, it would seem, provides a veritable laboratory through which one can explore this question. In a general sense, the health-care system provides “comprehensive” coverage for inpatient, hospital-based services and for outpatient physician services. Among the early civics lessons Canadians learn are the divisions of power under the Constitution Act, which places health (with some important exceptions, such as responsibility for Aboriginal health) firmly under provincial jurisdiction. Each of the provinces and territories is responsible for managing and delivering health services within its jurisdiction. The focus on federal or provincial responsibilities, however, obscures the fact that much of the real activity of health care takes place in an even more local setting, in the town or municipality or, more recently, in the health regions that were established in most jurisdictions during the administrative reorganization of the 1990s.

It is perhaps not surprising, then, that health services are uneven across Canada and health outcomes can vary tremendously from setting to setting, even for the same procedures. There is, for example, abundant evidence that a woman’s chance of having a caesarian section is higher in some facilities, while similar women in other facilities may avoid the procedure (Anderson and Lomas 1985). Data from 2001–2002 demonstrate that primary caesarian section rates ranged from a low of 12.4% in Manitoba to 21% in Prince Edward Island. Provincial statistics obscure even higher variations: in the Region 6 Health Corporation in New Brunswick (centred on Bathurst), primary caesarian section rates reached 25.5% (CIHI 2004). Since 1994, the Institute for Clinical Evaluative Sciences (ICES), based at the University of Toronto, has generated a great deal of publicity, raised the ire of some hospitals, and prompted critiques from different quarters, through their clinical atlas initiatives and report cards on various clinical services. The institute’s objective was to collect and analyze data on a variety of performance measures, paying particular attention to individual institutions and geographic setting. One of its recent initiatives highlighted the unequal distribution of ischaemic heart disease across Ontario. Eastern and northern Ontario bore a higher burden of disease, and there were other geographic disparities. While about 30% of the regional variation could be explained through traditional lifestyle...