What will Canada look like in the year 2020? To encourage a debate about the major challenges Canada will face in the coming decades, the Dominion Institute and the Toronto Star have invited 20 leading thinkers to write about an issue or event that they think could transform the country by 2020.

Dr. David Walker

Mary awoke to find her breathing to be much easier, no doubt due to the recent reprogramming of her implanted nanomed dispenser. The new technology was certainly light years ahead of the way in which chronic diseases were managed even a decade ago and Mary was grateful she qualified for it.

Simple really, when you think about it, and not very different from the technology that kept her fridge stocked and her air quality monitored.

Minute monitoring chips were now contained in most products and appliances. Her food program monitored consumption and fridge inventory, communicating directly with the food supplier who restocked on a regular basis.

Shopping, when not done electronically, was simpler when not requiring check-out: A device assessed prices as you walked out of the store and deducted the money from your bank account, identified by a unique identifier often implanted in your wrist.

As it applied to medical care, there was little need now to visit a doctor or lab for tests, and wait for results and the prescribed medication. Thanks to developments in nanotechnology and software innovation, Mary's bodily functions were constantly being measured by miniscule implanted chips.

Her biometrics were silently and invisibly computed in real time, and her nanomed simply created and infused the correct medication for what was required. Activity profiles were also transmitted to the bio-engineering section of her disease management unit; and occasional reprogramming was undertaken without the need for frequent personal interaction.

Changes in what used to be called "health care" in the developed world had been profound. An aging population that demanded constant fine tuning along with extremely expensive interventions had brought about a significant overhaul of the system.

System overwhelmed

The realization that, organized as it was, the system could not meet demand was a seminal moment in public policy development and the now infamous "Kingston Conference" of 2009 had identified the precepts and constructs of a new approach. These worthy principles and the changes that followed had only recently been usurped by significant socio-political action.

However, in the decade following 2009, building on earlier reforms to primary care, multidisciplinary alternatives to physician-based care had been amplified.

Physician assistants, nurse practitioners and other providers had joined doctors and nurses in large teams that were responsible for the care of defined populations, and were required to meet specific performance standards.

The health metrics of individuals and the target population were constantly monitored. Funding and reimbursement were tightly linked to outcomes and health status, not to items of process such as visits or procedures.

What had been hospital-based care was also radically altered, with similar substitutions to skill activities such as anesthesia, pain management, endoscopy, and a variety of intervention and surgical procedures.

Many of these procedures were now done in low cost environments, often in the primary care setting, and hospitals were reserved for complex, higher risk, multidisciplinary activities.

One of the "Kingston Conference" principles addressed the woeful lack of information systems and management in the system as it was. And a combination of massive public and private investment in information technology was undertaken.

In just over two years the system became truly measurable and, to a far greater extent, intelligent. The investment in IT allowed a true picture to be taken of needs, capacity, productivity, effectiveness and quality. The effect was profound.

The bad old days

It became immediately apparent that the "system" in place was incredibly inefficient. Mary recalled the experiences of her father who, at the age of 75, developed a sore hip and limp. Bill visited his elderly physician, who practised alone, although it took some weeks to see him as the doctor only worked part-time.

Bill was given a requisition for an X-ray, but lost it and had to return for a replacement. He visited a radiology facility for the X-ray, and then waited for his next appointment to hear that it showed some hip arthritis, and that a CT scan had been recommended. This the GP ordered and, after another visit, it was decided that the opinion of a consultant was required.

The GP's favourite orthopedic surgeon, his golf partner, had a long waiting list to be seen. But Bill was reassured he was the best and worth waiting for.

Months elapsed during which Bill suffered considerable disability and became unable to maintain his attempts at fitness by walking and swimming.

He eventually saw the surgeon who told him he needed an operation and new hip, but that he should be assessed for fitness to withstand surgery first. Puzzled this hadn't been done during his long wait, Bill revisited the GP who arranged for him to see an internist, whom he saw some weeks later.

An electrocardiogram prompted a rather quicker transit to a cardiologist, who performed a stress test, which, not surprisingly, was negative.

Armed with papers and reports, Bill went back to the surgeon who felt it was now time to proceed and placed Bill's name on the waiting list. Some months passed and Bill was twice given dates for surgery.

On each occasion he arranged for Mary to take time off work to help him. But on both occasions his surgery was "bumped" due to unanticipated workloads in the trauma department and a shortage of nurses.

When Bill was finally called in, the hospital had neither record of his pre-admission work-up nor history. And both had to be repeated since his internist and cardiologist were away on holiday and the information could not be accessed.

The surgery was eventually performed, successfully, and Bill began a long path of rehabilitation, made necessary by the two-year degradation in strength and fitness caused by his disability.

Medicine in the electronic age

The advent of sophisticated information technology allowed inefficiencies in the system to be identified and new protocols developed.

Mary noted that, five years later, when her father's other hip began to cause trouble he was already being monitored by his primary care team, prompted by his electronic medical record.

A scan was booked immediately, performed at the same time as his visit, in the same building. He was seen that same day by the orthopedic nurse-specialist who was in direct email contact with the surgical team.

The CT scan was attached to the email for easy viewing, just as it was available on his secure web-record. The decision was taken to replace the hip, but with new technology this was to make it a much simpler procedure.

The clinic's nurse practitioner provided web access regarding Bill's health status to the surgical team, and the following week Bill had the procedure done under local anesthesia.

A technician delivered the anesthetic while the surgery was performed by the most available surgeon in the group, in a facility protected from the unpredictable effects of emergency room and nursing shortages.

Bill walked out of the surgi-clinic later that night to begin rehab at his home by the physio team that was an integral part of his primary care group.

It had seemed that disease management reform was well under way in the early teens of the century. But stumbling economies, environmental change, continued global unrest and political instability had led to erosion in universal access, measurable and achievable standards and reasonable cost control.

The boomers divide

In Mary's case, as in so many others, serious lung disease had developed quite quickly of late as air quality plummeted. A combination of factors had allowed for remarkable global warming.

It followed an exponential and uncontrolled path, accelerating far more quickly than predicted. And the continued use of carbon fuels had led to a hotter, dirtier, world.

The political and personal fallout from these developments worried and saddened Mary. Ideological and religious conflict had rippled out from the disasters of the early part of the century.

Who would have guessed that 9/11 would mark the beginning of an unending war, one that had seen the remarkable re-siting of Israel in what once was Panama, and the ascension to power in much of the world of fundamentalist and extremist governments.

Such persistent conflict had led to new alliances: Much of Europe now identified itself with the Muslim states of the Middle East, mostly because of continued socio-cultural demographic change and the need to access oil-based energy sources. China, Russia and Japan formed an impressive socio-political bloc, leaving the now united Americas defending poor isolated Britain and Australasia.

Such ongoing conflict precluded any possibility of progress in addressing issues of global importance such as the environment or ever-diverging standards of health. As well, the recent demise of the United Nations and World Health Organizations worried Mary and her friends.

Mary's worries were personal as well. At home, a major inter-generational political divide had marked the past decade, created by the powerful influence of her generation of baby boomers. Now mostly in its seventies, this enormous demographic cohort was continuing to leave its huge footprint on society.

Shortly after the United States of All-America was formed (All America!), a new party, the "Progressive Elder" party, came into existence with the sole platform of addressing the needs of elders. It was rapidly elected to power.

Legislation protecting the rights of elders to new health and social services had alienated the generations that followed, including Mary's children and grandchildren. Heavily taxed, they resented the cohort-centric public policies of the elders.

The first indication of such selfishness had been the abandonment of mandatory retirement, allowing this wealthy generation to remain attached to well-paying senior jobs at the expense of their natural successors. The second was differential access to health care for elders, a public policy which ensured the PE party would continue to be elected despite the internecine feuds it generated.

Despite missing her family, Mary enjoyed the senior compound in which she lived with her lifelong friends, playing cards, listening to music and watching movies from her youth.

She missed her golf, but lack of water and the heat had ruined golf courses. In any event, despite her nanomed, bad air and her breathing precluded more than minimal exercise.

Scanning one of the wall screens in her unit for a report on her biometrics, Mary was heartened to see on the CNN mini-screen that the anticipated exhaustion of world oil supplies was actually beginning to have an impact on global politics.

An unlikely alliance of scientists from China and All America had continued work on alternative nuclear- and hydrogen-based energy systems and it seemed hopeful that they could be applied quite rapidly. There also had been substantial theoretical progress on the expulsion of carbon gases from the atmosphere.

Plans were afoot to undertake larger trials with the anticipated benefit being global cooling and conversion to alternative energy sources. These developments pleased Mary as she did not wish to see her grandchildren inherit the inhospitable world her generation had created.

Mary was also realistic enough to foresee the end of the influence of her generation. Its numbers and resultant power were already waning as the fortunes of the undertakers flourished.

Cremation was mandatory and ash scattering the norm, cemeteries having been converted to somewhat arid public parkland some years ago. A coalition of political parties was proposing massive tax advantages and social support for child bearing. And in anticipation of the demise of the PE government, Mary's grandchildren's generation was producing children at the rate of 5 per family. Demographers were identifying a baby boom and predicted that it would have a defining impact on society.

Dr. David Walker is the dean, faculty of health sciences at Queen's University in Kingston, Ont. In 2003-04, he chaired Ontario's Expert Panel on SARS and Infectious Disease Control as well as the subsequent Expert Panel in 2005 on the Legionnaires' Disease outbreak in Toronto.

Canada in 2020 is an initiative of Dominion Institute in association with La Presse, The Toronto Star and the CBC. Visit www.twenty-twenty.ca to read more essays and add you voice to the debate.