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Tony Tremblay is Professor of English at St. Thomas University and founding editor of the Journal of New Brunswick Studies/ Revue d’études sur le Nouveau-Brunswick.  The current issues focuses on the health of New Brunswickers and may be found at
 
In Canada, health care is the shared responsibility of federal and provincial/territorial governments. Canadians pay taxes, the federal government collects and redistributes those to provinces and territories, who in turn deliver health and other social services. This points to a paradox in our health system that is both a strength and weakness: the banker and lawmaker has a very limited role in service delivery.
 
Health care in Canada is mostly “public” in that it is accessed on the basis of need rather than locale, status, or ability to pay. Citizenship is the requisite for service, from which came the idea of “universality”: from coast to coast to coast, uniformity would be the core value that governed wait times, human resource expertise, infrastructure, and other aspects. The quality of one’s health care should not be dependent on where you lived, nor on your income or status, but because you were Canadian. All else being equal, universality of care was the goal.
 
“All else being equal,” however, exists only in theory.
 
Not only are there regional differences that affect the delivery of services, but there are differences of demography, population density, income distribution, and literacy within each province. In other words, Canada’s uneven social, economic, political, and cultural landscapes are determining factors in the provision of health services.
 
Canadians understand those factors and live accordingly. They choose, if they can, to reside in areas of better care, better hospitals, and more physicians. They make employment, higher education, and career decisions on the basis of public health livability indices such as recreational infrastructure, childcare, safe neighbourhoods, fiscal stability, good schools, and progressive health policy.
 
Politicians know this, too, which is why our health system is under almost-constant negotiation between federal and provincial/territorial governments and between users and service providers.
 
The New Brunswick Context
 
New Brunswick’s status as a “have-not” province means that its ability to meet the goal of universality as outlined in the Canada Health Act is especially challenging. While wealth transfers exist to level the playing field, so exists the expectation of uniformity of service regardless of fiscal inequality.
 
The implications of this fact in New Brunswick for physician and medical staffing, infrastructure and equipment costs, health education and research, and other aspects of health, are staggering. Provinces with the fewest resources are expected to deliver services that are the equivalent of provinces with the most. That is the Canadian contract.
 
The rhetoric that comes from some quarters of “have” provinces makes the challenges that “have-not” provinces face even more difficult, for that rhetoric employs either-or absolutes that limit the choices poorer provinces can make.
 
What is to be done, then, when uniformity remains both law and assumption, but transfer payments from rich to poor provinces are contested or reduced? The current government in New Brunswick has responded in the following ways.
 
First, and most controversially, it began in August 2017 to disassemble its office of the Chief Medical Officer of Health, claiming in language that we are now (unfortunately) accustomed to, that such a move would “enhance” public health in New Brunswick by transferring functions of the office to departments of cognate function. Roughly a hundred personnel responsible for public health inspections, agri-food, population health, and other health enforcement functions now reside in the departments of Justice and Public Safety, Social Development, and Environment and Local Government.
 
What is the consequence of dismantling a team of public health professionals? The expertise, though scattered, remains, but without the same capacity to anticipate, plan a response, and work as a unit to manage the kind of major health crises we’ve seen in other parts of Canada and the world. As the deputy minister of health himself admitted, Ontario and British Columbia residents have a health service that New Brunswickers can no longer afford but must struggle with reduced capacity to provide.
 
Similar streamlining affected other health services in New Brunswick. In September 2017, the provincial government announced that Medavie Health Services New Brunswick, a private not-for-profit corporation, would be awarded a ten-year (untendered) contract to manage a new health entity that combined Ambulance New Brunswick, the Extra-Mural [Nursing] Program, and Tele-Care 811. The change effectively privatizes the management of those services in the province while taking authority away from New Brunswick’s two “public” health networks, Horizon and Vitalité.
 
It is too early to know if such consolidation of public health services under the management of a private company will deliver the outcomes promised; however, concerns about staffing and transparency are already mounting. Stories of chronically low numbers of paramedics, slow deployment of ambulances, and family members taking sick relatives to hospitals in the back of trucks and SUVs have been circulating, as have worries about the fact that, as a private company, Medavie does not have to provide an accounting of its operational outcomes.
 
These are troubling signs for New Brunswickers.
 
In an age of increasing costs and the growing appeal of austerity—not to mention the continued (and reasonable) expectation of uniformity in the delivery of health care to Canadians—how does a small, structurally poor province like New Brunswick provide health services? Short of becoming an open site for nuclear waste disposal, thus bowing to the pull-up-your-socks crowd who accuse us of living off the hard work and environmental risks of others, the choices we have are limited.
 
Two of those choices—accepting second-class health care or moving to richer parts of the country to receive it—contravene the spirit of both Canada and the Canada Health Act.
 
Whatever the outcomes are, this is the context within which we will have to make them.