June 2006

The Family Doctor Crisis
I read Alastair Brown’s excellent article on the challenges of the rural physician (“The Cost of Care,” April) with both admiration for Dr. Mihu’s dedication and concern for the future of Canada’s rural doctors. General practitioners in the United Kingdom are the highest paid in Europe, taking home around $100,000 (Cdn.) after tax. The allure of financial comfort, coupled with relatively gentle working hours, makes general practice an enticing proposition for med-school graduates in the UK.

Unfortunately, increasing salaries will not be sufficient to attract Canadian med-school graduates to rural medicine. An additional solution might be to work on the image of the rural physician and family doctor in order to inspire medical students about the work of these generalists and to expose them to it. If medical students in Canada are anything like those in England, many will have a dim view of family doctors, these jacks of all trades and masters of none. Family medicine is not “sexy.” It is seen as old-fashioned and devoid of the glamour that surgery, emergency medicine, and other specialties possess. Because the majority of family physicians work in communities, hospital-based medical students have scant opportunity to be inspired by them. Their understanding of what family doctors actually do, and the role they play in the community, may be limited, or worse, false.

I work outside the field of clinical medicine but have a reasonably clear view of it, and I have often felt that family medicine is undervalued and misunderstood. It suffers from its low-tech image of treating common colds and little old grannies, and gets too little credit for its integral role. A primary vehicle for improving its deteriorating status, I suggest, should be Canada’s medical schools.

Daniel K. Sokol
Researcher in Medical Ethics
Imperial College London
London, United Kingdom

Rural physicians are truly the last “general” practitioners, and their jobs become exponentially more difficult as medical knowledge evolves and the shortage of doctors worsens. The financial pressures described by Alastair Brown have been made worse by skyrocketing medical-school tuition ($16,207 at the University of Toronto this year, set to increase this fall), which has made a $100,000 debt the norm rather than the exception. Financial assistance has barely begun to catch up. As a result, students from rural communities (i.e., those most likely to return there to practise) may be shut out.

Fortunately all is not bleak. In Ontario, new modifications and alternatives to the fee-for-service model are providing incentives for group practice, preventive care, and after-hours care, and they are doing a better job of recognizing the complex needs of elderly patients. And telemedicine, which involves two-way video technology, holds out the promise of reducing the need for travel, thus improving the access people living in remote areas have to specialists.

The pace of change has been slow, but as I prepare to begin residency training in rural family medicine at the University of Western Ontario, I am looking forward to meeting the challenges of helping preserve the “social aspect of medicine.”

Stephen Keleher
Toronto, Ontario

I am finishing my last year of medical school at the University of Toronto and plan to practise rural family medicine. Canada is in desperate need of rural and family physicians. Only 10.3 percent of Canada’s doctors work in rural or remote areas, caring for up to a third of the population. Health Canada’s Ministerial Advisory Council on Rural Health recently stated that “there is a fundamental mismatch between the health care needs of people living in rural Canada and the availability of health care providers and health services.” At last count, Canada was short 1,175 rural doctors.

Research shows that growing up in a rural area and entering medical school with plans to become a family physician are the most important predictors of a doctor practising in a rural area. However, data published in 2002 revealed that students of rural origin are seriously under-represented in Canadian medical schools. Currently only 11 percent of Canadian medical students come from rural backgrounds—one-third as many as would be predicted by demographics.

From 1992 to 2003, the number of Canadian medical students choosing family medicine as a career fell from 44 percent to 25 percent, rising slightly, to 28 percent by 2005.

Extensive efforts have been made across Canada to promote training and practice in rural settings. Ontario reimburses medical students up to $1,500 per month for participating in a rural elective. These efforts are important. Due to the relatively small number of students from rural areas in medical school, urban students must be exposed to the rewards of rural medicine. Physicians raised in urban settings account for two-thirds of new physicians in rural areas.

This past February, students from each of Canada’s seventeen medical schools met in Toronto to discuss the state of family medicine in Canada. They established a Family Medicine Interest Group at each of their respective schools, with the goal of increasing the number of Canadian medical students choosing family medicine. Similarly, another group of Canadian medical students are creating a National Rural Medicine Student Committee and held their first meeting this April at the Society of Rural Physicians of Canada’s annual conference. The University of Toronto has both an Interest Group in Family Medicine and a Rural Health Initiative, and has delegates on both national committees.

While these efforts are encouraging, what is really needed is further primary care reform in order to compensate family physicians and rural physicians adequately. As long as there is a significant pay discrepancy between specialists and family physicians, the shortage of family physicians in Canada will continue.

Canadians deserve access to family physicians. We must continue to encourage federal and provincial governments as well as Health Canada policy-makers to address this fundamental issue.

Jonathan Kerr
Toronto, Ontario

I commend Alastair Brown for discussing the realities of family practice in rural communities, specifically Kinmount, Ontario. As a recently retired physician from neighbouring Minden Hills, I can vouch for the difficulties one meets in such a practice. Patients are often elderly and poor. Communities tend to lack public transportation, which would make follow-up visits easier and more affordable—patients commonly suffer from multiple chronic illnesses. Dr. Mihu and her colleagues nevertheless carry on with great skill and empathy under these conditions.

The financial situation is even more difficult than Brown indicates for doctors in very small communities. Ontario billing code A005, stated to be the bread and butter of a doctor’s income, rarely applies. Because they receive their patients directly, without a referral from another doctor, they generally receive $30.20 per visit under code A007, as opposed to the $56.10 per visit a physician who had received a referral from another doctor might receive. This substantially reduces the take-home income for physicians like Dr. Mihu, from Brown’s estimate of roughly $70,000 for forty-hour weeks. The sixty-hour week for family doctors noted elsewhere in the article is common, but for many rural doctors is even greater.

It is not easy under those circumstances to recruit new doctors into family practice in small rural communities, however attractive these communities might otherwise be.

Jaan Roos, MD
Minden Hills, Ontario

In the BC Kootenays, we were greatly amused by Alastair Brown’s declaration of health-care hardship for people who had a hospital—presumably full service—only twenty kilometres away. Here on the east shore of Kootenay Lake, we are a thirty-minute ferry ride plus a fifty-kilometre drive away from the hospital in Nelson. Ferry service ends at 10:20 p.m. and resumes again at 7:10 a.m., so nighttime emergencies must go instead to the Creston hospital, which is seventy kilometres away along a narrow winding road.

However, the hospital in Creston is understaffed, short at least four doctors. The demands of their practices and the ER result in chronically overworked staff. The hospital is rumoured to have considered closing its ER between 8 p.m. and 8 a.m. If this happens, we would have to drive an additional ninety kilometres to Cranbrook in the event of a nighttime emergency. In order to draw attention to our plight and raise money for emergency medical response training and doctor recruitment, on June 3 and 4, residents of the east shore will be holding the World’s Longest Rummage Sale, stretching from Sirdar to Riondel, about seventy kilometres. We’re making a Guinness World Record attempt and hope to garner sufficient funds and notoriety to alleviate our predicament. Until then, were eating apples daily.

Nancy Galloway
Crawford Bay, British Columbia

Israel’s Split Decision
The first poster illustrating David Berlin’s article (“Israel’s Divided Soul,” April) says it all. Herzl, founder of Zionism, which was conceived of as a secular movement for the establishment of a Jewish state, is shown standing in front of two, not one, Stars of David, the ultimate symbol of Judaism. Indeed, more than the division between secular and religious Zionism, Berlin beautifully depicts the distinctive agendas, styles, and torments that characterize the internal divisions within the religious camp, usually thought of as univocally monolithic.

Common wisdom concerning Israel has it that religious Zionism thwarts any chance of resolution of the conflict with the Palestinians, while secular Zionism can entertain a mutual existence in the torn land. Berlin bows to this mantra when he writes, “it appears that the forces of secularism, not religious idealism, will shape the future of Israel and its relationship with Palestine.” In only two places—three if we include the subtitle of the article itself—does he explicitly formulate the idea that gives this article added value. First, almost apologetically, he tells us, “it might be argued that Zionism...has overstayed its welcome.” Then, at the end of the article, Berlin asks Elyakim Haetzni if there is not an “internal contradiction in Zionism.” His question is the leading question of the article—“Has the Zionist dream played itself out”

This internal contradiction involves the oft-mouthed oxymoron “Jewish, democratic state.” Thinking that religious Zionism was defeated—it did fail but has definitely not been defeated—in the August disengagement from Gaza and again this past March in the Israeli elections is missing the point. The secular Zionist camp, which is touted as supporting “rolling back Jewish settlements,” has imbibed the central idea of Zionism, be it religious or secular: as much of the land as possible should be made available to Jews.

Even the “convergence plan,” which advocates dismantling settlements and outposts beyond the wall, would leave large “settlement blocs” and over 300,000 settlers in place. In that sense, the settlement project, exposed for what it is—a collaboration of all types of Zionism—has been victorious. Indeed, most of Israel is not divided.

The real division is between Israelis of Zionist persuasion who insist on an a priori Jewish majority in a Jewish state, thereby calling for religious or ethnic exceptionalism, and those who view all inhabitants of the land—Jewish, Palestinian, and others—as equally deserving of citizenship, rights, and justice. If we look to the posters accompanying the article, one stands out as strikingly utopian: building an industry of air transport, the name of the future company is—in Hebrew—Land of Israel Airways and—in English—Palestine Airways. In the 1930s, somebody thought that Israel and Palestine could coexist.

Anat Biletzki
Tel Aviv University
Tel Aviv, Israel

David Berlin helps us to see how Jewish fundamentalisms, which, parallel to Palestinian forms, have been emboldened by the failures of secular alternatives. The contradictions of the Israeli state are also cast into stark relief by the second-class citizenship of non-Jewish citizens within Israel’s borders. The Bedouin are a poignant example: in the Negev, the Israeli government runs a paramilitary “Green Patrol” dedicated to destroying Bedouin crops, confiscating their livestock, and demolishing their homes. Sharon may have deftly dissected the religious Zionists, but at the same time he has moved the rest of Israel even further to the right.

Jesse Benjamin
Associate Professor of Human Relations and Multicultural Education
St. Cloud State University
St. Cloud, Minnesota

David Berlin ignores a central and decisive factor when he tries to explain the decline of religious Zionism, namely the interdependence of religious and secular Zionism. To a large extent, religious Zionism has been a tool in the hands of secular Zionism throughout most of Israel’s short history. In fact, religious Zionism has rarely, if ever, managed to carry the torch of Zionism on its own. Religious Zionism has always depended upon the military, economic, and bureaucratic assets of secular Zionism. Even more importantly, religious Zionism could not survive without the international cover of the Western world, which secular Zionism makes possible. More often than not, religious Zionism has been an instrument in the secular project. Religious Zionism provided the majority of the settler population that helped successive secular administrations “create facts on the ground” in Gaza and the West Bank.

Berlin rightly notes that religious Zionism was ascendant after the 1967 Israeli military victory. This shows that in moments of relative security, religious Zionism can thrive and even challenge secular Zionism. But it also shows that whenever Arab and Islamic resistance to the Zionist project is robust, as it is now, whenever Israel feels besieged and the Zionist project seems in doubt, religious Zionism tends to take a back seat. That is one reason why religious Zionism is, as Berlin rightly notes, in decline.

Fouzi Slisli
Minneapolis, Minnesota

David Berlin responds:
Professor Biletzki accuses me of muffling the trumpets. While it would have suited her better had I blown the clarion call “Zionism is dead,” such is not the case, and according to the majority of Israelis, Zionism has hardly overstayed its welcome. That a fistful of left-leaning intellectuals claims otherwise does not change the facts. In the main, Israelis agree with Elyakim Haetzni’s view that “Israel is an ideological project,” and so long as this remains true, one has no choice but to first dream up a better ideology and then employ Herzl-type strategies to persuade others. But perhaps because the Israeli left (of which Professor Biletzki is a leader) has been so busy fighting, it has not found the time to get back to the drawing board.

Part of the reason why it has taken so long for an Israeli government to withdraw from territories conquered during the Six Day War has to do with the “interdependence of secular and religious Zionism,” a point alluded to when I discuss the “rights-based” argument, perhaps too briefly. When their existence in Israel is questioned, both camps resort to this argument. Secular Israelis invariably point to their “historical” rights; religious Zionists point all the way up to heaven. Both miss the point—which is, in my view, to ignore the question. While it is legitimate to negotiate Israel’s final borders in a manner that would give Palestinians a chance at the good life, it is unnecessary, even dangerous, to grace the insidious question concerning Israel’s right to exist with any sort of response whatsoever.

The other reason it has taken so long to disengage has to do with intimidation. For the longest time, Israeli governments worried about the religious Zionist reaction to a pullout. Anyone who paid attention to the threats—of suicide, of civil war—posed during the pre-disengagement period would know what I mean. In this sense, Mr. Slisli is wrong: religious Zionism was not the pawn but the puppeteer.

Canada’s War in Afghanistan
I applaud Tom Fennell and Sean Maloney (“Soldiers, Not Peacekeepers,” March), but had a hard time with the paragraph that read: “Unlike traditional Canadian peacekeeping units, which would deliver aid but not engage either side of the conflict, [Provincial Reconstuction Teams]...are frontline fighting units.” The nato mission in Afghanistan is indeed different from, say, unprofor in the former Yugoslavia. Peacekeeping missions revolve around three principles: the need for the consent of parties involved in the conflict; the need to maintain impartiality; and constraints on the use of force. Clearly, the current deployments to Iraq and Afghanistan have moved away from that model, into the realm of peace-enforcement and stabilizing operations with greater latitude regarding the use of force.

My difficulty is that whether you’re talking about Bosnia, Somalia, Afghanistan, or Cyprus, the troops that deployed were in fact front-line fighting units. Those of us who deployed to Bosnia as so-called peacekeepers were trained for war. While we operated under different rules of engagement, all of us were prepared for, and trained in, the use of force. To dismiss those units who deployed on peace-support operations under the UN umbrella as merely “peacekeeping units” is neither fair nor correct.

Maj. C.J. Young
Canadian Forces Liaison Officer (Armoured)
US Army Armor Center
Fort Knox, Kentucky

The UN now uses “peace operations” as an umbrella term encompassing peace-making, peacekeeping, peace-enforcement, peace-building, and other “bluespeak” terminology. Canada’s Pearson Peacekeeping Centre, while keeping its name, has reframed its mission and role under the much broader concept of “peace operations.”

Having declined to participate in Iraq or in missile defence, it was essential that Canada take on a military role that was of value to our closest ally and trading partner, the United States. This is our primary reason for chasing Taliban fighters in southeast Afghanistan. Having strengthened our ties, the biggest challenge for Canadian foreign policy will be persuading our American neighbours that they don’t have to invade countries to contribute significantly to international security.

Ken Eyre
Annapolis Royal, Nova Scotia

I empathize with the frustration of our Canadian soldiers in Afghanistan about being referred to as “peacekeepers” in a situation in which there is no peace to keep. Since early 2002, Canada has been involved in an active conflict that is indeed a significant departure from the traditional mediating role Canadians believed was the primary function of their armed forces. However, the fact that the Canadian public has developed a case of cold feet following the recent casualties does not mean we should reconsider the role we are playing in Afghanistan.

It is true that we are not playing an impartial role in Afghanistan, that we are engaged in a deliberate part of the US-led “War on Terror.” Our role in the region is essential for bringing stability and, eventually, peace to that beleaguered country. Our involvement in Afghanistan is consistent with the propagation of Canadian values exhibited in the rebuilding of Haiti.

To suggest withdrawal because of the deaths of Canadian soldiers does a disservice to the very cause for which those men died, and is unworthy of a state that would like to have a place on the international stage. Canada was long thought of as a middle power, but how can we hope to make our presence felt if we grow faint at the sight of blood We are committed to Afghanistan now, and the Canadian people owe it to our soldiers to provide them with all the support they require in order to do the job we sent them there to do.

Wilfrid Greaves
Lennoxville, Quebec

I note that Fennell and Maloney’s article does not ask what the Canadian military plans to do with al Qaeda and Taliban suspects who may be apprehended by Canadian troops. Will suspects be turned over to the United States to be sent off to Guantanamo Bay No need to mention that these same al Qaeda and Taliban fighters were once referred to as freedom fighters by the likes of Thatcher and Reagan. We are in trouble if General Rick Hillier is the best that Canada has to offer at this critical time.

Jerry Olson
Coldstream, British Columbia

Multi-Opinions
Allan Gregg’s focus on the crisis of multiculturalism facing various Western countries (“Identity Crisis,” March) is timely and astute. Certainly, his argument that we must pay greater attention to rethinking multiculturalism in Canada is important. Nonetheless, his call for native-born Canadians to “accept immigrants as equals” and for new arrivals to “demonstrate a willingness to join mainstream society by adopting the fundamental mores and values of the prevailing culture” is problematic for at least two reasons. First, it smacks of an assimilationism that leaves racism largely untackled. While Gregg took pains to explain the emergence of multiculturalist policy as a way to diffuse Québécois complaints about Anglo-Canadian dominance, he neglected to account for the history and legacy of racialized immigration policies, of which the Chinese head tax is but one example. Second, the article posits a cohesive national “prevailing culture,” which seems increasingly dubious given Québécois nationalism and western Canadian alienation.

In fact, Gregg would do better to look at the behaviour of the spectrum of Canadians to show that in whole arenas—from food to music to sports, spirituality, and relationships—Canadian identities are increasingly hybrid rather than monocultural. The one thing they do have in common is that they are making and remaking themselves on Canadian soil. Gregg’s argument for a national mythology is woefully antiquated. Instead, he should consider embracing a hybridized Canadian polity and culture that is well on its way to becoming global.

Nitin Deckha
Toronto, Ontario

It saddens me that someone of Mr. Gregg’s intellect and standing would succumb to racial stereotypes and assert that just because immigrant groups cluster in tightly knit, ethnically homogenous neighbourhoods, their “first loyalty is to their group.” Perhaps Gregg does not know that the rcmp and the Canadian military have been successful in recruiting members from these neighbourhoods—people who are prepared to put their lives on the line for their fellow Canadians. They are joined by millions of first- and subsequent-generation immigrants, including this writer, who have demonstrated their loyalty by dedicated service to their fellow Canadians in the public institutions of this country, and have fought hard for national unity and mutual respect and equality for all Canadians.

Errol Mendes
Professor of Constitutional Law University of Ottawa
Senior Advisor, Diversity
Privy Council Office
Government of Canada
Ottawa, Ontario

Gregg’s article was a frank critique of one of Canada’s “sacred cows”: multiculturalism. Perhaps what is needed most right now is a debate that extends beyond the issues of multiculturalism toward our attitude to growth. Our immigration policies have been shaped by a “need to grow” and are guided by a belief that an ageing workforce and declining birth rates are portents of economic problems. Growth is now equated with prosperity, and instead of thinking smarter, we think bigger. But this is 2006, not 1906, and in our rapidly shrinking world, bigger is not better. Do we want to create New Yorksized centres out of Montreal, Toronto, and Vancouver Or, rather, do we want to assure quality of life in our cities

Flexible work arrangements, which include better use of older workers and more inclusion of First Nations and other underemployed segments of the population, are not given due consideration. Instead, we have an immigration policy that plucks highly skilled individuals from developing countries and underemploys them when they arrive in Canada.

Gregg is correct when he states, “There must be also cross-fertilization between ethnic groups and civic nationalism has to be clearly defined.” In order to achieve that goal, the third-generation immigrant is crucial. So like the python that has swallowed the pig, we need time to digest what we have. But I fear that when we experience an oil shock, a decline of the housing market and economy, the veneer of our political correctness will be stripped away. I just hope we don’t experience what other liberal democracies have, and see our cultural mosaic unravel.

Ian MacVicar
Chilliwack, British Columbia

It is curious that Mr. Gregg makes no mention of interracial marriage, which is the ultimate refutation of his gloomy prophecy of a future populated by mutually antagonistic multiple solitudes. Rather than celebrating our so-called diversity, we should be applauding the heroic vanguard who fearlessly build bridges of love across the chasms of culture and race. Tolerance for interracial marriage should be regarded as a key Canadian value, such that any would-be immigrant who is intolerant of it should not be welcomed. Canada’s future rests not with the narrow-minded, traditional purists of the past but with the children of interracial marriages, who are the harbingers of a new society, a new way of thinking about humanity. Genetic synthesis is liberation from fear.

Stuart Nurse
Vancouver, British Columbia

Truly Demented
Marni Jacksons designs for dementia (“Imaginings,” March) are cruel, but the funniest read since the Brontë sisters’ novels.

Gerd Raeithel
Munich, Germany

Editor’s Notes

Bombs Away Update
In his column “Bombs Away” in the May issue, Daniel Sanger wrote about the firebombing of a greengrocer on Avenue du Parc in Montreal and the resulting climate of suspicion that descended on the usually friendly commercial strip. In early April, after the issue had gone to press, the store began receiving deliveries in anticipation of reopening. On April 6, it was firebombed again.

Read On, Curious Mind
The Walrus invites you to delve further into the issues and topics we cover each month by consulting annotated bibliographies to each of our articles, now available online at walrusmagazine.com.

Tusk, Tusk
The owner of the lodgings in the Field Note “Unsafe Grounds” (May) is an active, not former, member of the Leeds constabulary. Incorrect information also appeared in Jacob Schiff’s letter to the editor in the April issue. The correct letter is posted on our website. The Walrus regrets the errors.