Sunday, November 05, 2006

Two Tier Health Care

In much of his writing, Noam Chomsky makes frequent use of paired examples, a simple but powerful device. Often, this takes the form of taking two historical events that occured at roughly the same time and that, from the perspective of elementary human morality, carry roughly the same weight. The striking difference in how the two instances are treated in action and discourse eminating from U.S. state relations and from the dominant media are used to draw conclusions about foreign policy and about the reporting of foreign policy.

The paired example I wish to draw upon is much smaller in scale, closer to home, and slightly different in purpose. Chomsky often uses paired examples as a way to gain insight into the causes of the differential treatment between, say, massacre X and massacre Y, in a way that disarms the specious liberal apologetics that often accompany U.S. complicity in such things. I, on the other hand, could make much the same point as I'm making here just by talking about how wrong it is for a toddler to have to wait so long to have a basic health need attended. However, the paired example landed in my lap, so I will use it.

My example has to do with teeth -- namely teeth belonging to L, who is the pre-schooler that fills my days, and teeth belonging to E, who is L's one-year-older cousin.

A couple of weeks ago, L had several instances of hitting the roof and crying intensely while chewing. His first visit to the dentist back in February or March did not actually result in the dentist getting much of a look into his mouth, and an unscheduled visit to a dentist when we were out of town during the summer was mainly focused on some surface decay around an area on his front teeth that had been damaged earlier. After this chewing distress happened a few times and we were able to establish from him that it was his teeth that hurt and he wasn't just biting his cheek or something, we decided to take him in to our family dentist as soon as possible. The dentist got a better look this time -- despite regular brushing, all of his back teeth were seriously decayed. Our dentist called over to a paediatric dental surgeon also in the downtown, and he wanted us to go over and see him that same afternoon. We did. He prescribed anti-biotics and booked an appointment to actually do the surgery, which would require a general anaesthetic. It was originally scheduled to happen three months from now, though we were told we were being given high priority for cancellations. In the week following that appointment it became much more necessary to manage L's pain -- sometimes acetominophen and ibuprofen got the job done, but other days they most definitely did not. A visit to the paediatric dentist this past Tuesday did not yield any new tools for pain management. Then, this past Thursday morning, we got a call that there had been a cancellation for Friday. We followed the pre-op orders, arrived on time, waited nervously, and soon enough L had one tooth pulled, three partial root canals, and some sealent applied. (We also took some relief from our parental guilt at letting things reach this stage at the paediatric dentist's bemused comment that he had never seen teeth that shape before.) It is only two days later, but L is doing much better, and is happy to be able to eat "smooth and crunchy food!" (as he anticipated excitedly the morning before the surgery). We have to go back for another session in December to finish cleaning things up, but everything that was causing pain has been taken care of in slightly more than a week since we first noticed the problem.

I don't know as many details of E's case, but I do know the most important ones. For one thing, it was her top front teeth rather than her back molars that were the problem. I can't provide a technical picture of differences in severity between the two cases, but I have no reason, given the work that ultimately was done, to believe that E's situation was any less severe. Yet she had to wait three months to even get an intial appointment with a paediatric dentist. And she had to wait something like eight months after that to get the surgery done. Over this time, the nerves in the affected teeth eventually died, so it was not like she was in serious pain for that entire time. All four teeth had to be pulled.

What could explain these significant differences in experience?

Well, I can't dismiss the possibility that there are local differences in the availability of services. We live in different cities, and that can make a difference when it comes to access to medical care from a specialist. However, I find it hard to believe that the service situation in Sudbury is that much more generous than is to be found in the southern Ontario city E lives in -- northern Ontario has a longstanding reputation of lacking medical professionals of all sorts, and in fact the job that brought my partner to this city exists precisely because of government efforts to address some of that lack. So I don't think this is the answer.

But, really, I don't actually need to think very hard about this question; I know the answer. The answer is that we, L's immediate family, have good dental insurance, cash on hand, and regardless of the actual non-traditional elements of our practices we have at least the appearance necessary to qualify the family for "picket fence privilege" in the eyes of others. My sister -- E's mother -- was, on the other hand, living as a single mother on welfare at the start of E's ordeal. By the time E's surgery actually happened she was, if I am remembering correctly, in a partnership and off welfare, but certainly the former status would have played a big role in setting the course of events.

Here in Sudbury at the initial family dentist appointment to which I took L, we were told that there were two options for the surgery: We could have it done in a hospital or we could have it done at the clinic of the paediatric dentist we ended up seeing. The former would be covered by Canada's socialized medical insurance, but the waiting list is close to a year. The latter would have a somewhat shorter waiting list (3 months, as it turned out) but it would have to be covered by private insurance, except for the anaesthesiologist, who might be covered by private insurance but would more likely have to be paid in cash -- insurance and cash that my sister did not have. It is impossible to know for sure what factors were at work that helped us get to see the paediatric dentist for an intial look on the same afternoon as our visit to our family dentist instead of three months later, and in getting top priority for a cancellation, to cut the wait for surgery from 3 months to 1 week. Certainly basic human kindness was at work, and I don't want to disrespect that. But things like having good insurance and having a family form that can perform dominant versions of privileged normalcy can be huge in getting those kinds of breaks, too. As well, I know enough from my work with the Sudbury Coalition Against Poverty and other anti-poverty groups in other cities to know that people living on welfare often get treated very differently by health professionals than people with access to financial resources associated with being "middle-class." I obviously can't know whether that dynamic was at play in either of the situations discussed here, but I know it is very common.

This, then, is two tier medical care: It is determining how long a toddler will have to suffer with sore teeth, and how likely it is that those teeth will be saved or lost, based on what kind of job and how much money their parents have, with potentially some influence from the family form of their parents as well.

I'm extremely glad that the worst problems with L's teeth have been taken care of, but this is a really disgusting situation. I cannot imagine the state I would've been in early last week if I knew that it was going to be close to a year before he could have his teeth fixed.

1 comment:

SR said...

...he had never seen teeth that shape before.

Just to clarify -- the dentist meant that the three-dimensional shape of L's teeth is unusual, not that the 'shape' (ie. 'condition') of his teeth was unusually horrifying. :) When I was telling her about it, my Mom interpreted it as the latter, so now I'm all self-conscious about making sure people know it's the former!