Almost two months ago, Natasha Richardson, well known actor and wife of Liam Neeson, died following Dr. Brett Taylor a fall at Mont Tremblant ski resort north of Montreal. Richardson apparently sustained what appeared to be a minor head injury and declined an offer to be taken to the hospital. Sometime later, her symptoms increasing, she was taken to a local emergency department, then subsequently by road ambulance to Montreal where she died of a subdural hemorrhage.

Shortly after that incident, Dr. Cory Franklin of Chicago asked in the media "Could actress Natasha Richardson's tragic death have been prevented if her skiing accident had occurred in America rather than Canada?" Canada, he notes, "de-emphasizes widespread dissemination of technology like CT scanners and quick access to specialists like neurosurgeons." He decried the hour-long road ambulance trip as taking too much precious time. By implication, he suggested that CT imaging capability in the local emergency department and a dedicated helicopter transfer system would have made the difference in Richardson's case. He quotes physicians who work near ski hills in the U.S. describing the ideal response to a similar injury in their area.

Frankly, the man should know better. Franklin is director of intensive care at Cook County Hospital in Illinois, a centre known worldwide for its expertise in trauma. That means he has seen his fair share of death and injury, and should know that even in cases where the patient chart is available and the case is well known, determining the factors involved in an unexpected death is difficult. When the only sources are news reports, any comments made can be most charitably described as outright speculation.

I am not going to make the same mistake; I don't know what might have contributed to Richardson's death. It is worth pointing out, though, that there is a CT scanner in Sainte-Agathe-des-Monts, the first centre to which Richardson was sent. I would also note, having myself fretfully waited for transports to the emergency department where I work, that road transport is often faster than helicopter. In smaller centres, an ambulance is usually immediately available, and the care team that accompanies the patient is local and has already examined and stabilized the patient. The helicopter team has to fly into the area, spend time examining and assuring themselves that the patient is ready for transport, then fly back out. In our province, which has a dedicated life flight helicopter service, hospitals less than an hour away almost always send their patients by road.

Franklin wants to use Richardson's unfortunate death to criticize the Canadian system of central resource planning and delivery, and more importantly to support the U.S. health-care system's user-pay economics.

"American medicine is often criticized for being too specialty oriented with hospitals duplicating too many services like CT scanners," Franklin writes. " ... those criticisms ignore cases where it is better to have resources and not need them than to need resources and not have them." A populist bit of prose, but the real issue is whether the U.S. health-care system results in better health, that is, which system is more productive.

Room to improve

Do we need reform in our health care system? You bet. But let's stay away from the temptation to take a single high-profile case and trumpet (wild) hypotheses as valid argument. Instead, let's take a look at the evidence.

There are several sources for this sort of comparison, but for this review I chose a report entitled "Health at a Glance," prepared for the Organization of Economic Cooperation and Development (OECD) in 2003. Some of the information below is found elsewhere, in an article by Arjumand Siddiqi and Clyde Hertzman in Social Science and Medicine from 2006, and another from the American Journal of Public Health by Karen Lasser, David Himmelstein and Steffi Woolhandler in 2006. Other sources are noted as I come to them.

Which country spends more on health? Canadians spend less per capita, about 57 per cent of what is spent in the United States. As a percentage of GDP, Canadians spend just under 10 per cent, while Americans spend just under 14 per cent. It might surprise Canadians that governmental spending on health care is also higher in the U.S. Despite the absence of universal health insurance and a single-payer system, criticized because it is thought to be expensive and inefficient, the U.S. government spends nearly 10 per cent more per capita than ours. Yet despite this, three times as many Americans report a problem paying for health care (seven per cent of Canadians versus 21 per cent of Americans).

'There are more Americans without health-care insurance than there are Canadians'

Because health-care access is user pay, and because income and race are entangled, health-care inequities based on race are also more extreme in the U.S.

A dismal statistic: there are more Americans without health-care insurance (more than 40 million) than there are Canadians. More money does not equal better access to care; system design clearly has to be addressed.

While we spend less on health care, we spend more on social programs and do a better job of redistributing our wealth. Siddiqi and Hertzman write (and technology and helicopter salesmen should take note) that redistributing wealth within a society trumps spending more money on health care.

'American infant mortality rates are 40 per cent higher'

In terms of resources, not surprisingly, Canada does better in some comparisons and loses in others.

For example, we have fewer doctors per capita than the U.S., but Americans report having greater problems finding a family doctor. Americans see 40 per cent more doctors, probably because they are referred to so many specialists. Perhaps a consequence of this, Americans have more than double the number of surgical procedures (82 versus 34 per 1,000) than we do.

Canada also has a lower mortality rate. American infant mortality rates are 40 per cent higher (seven versus five per 1,000), a fact that an article published this month in the International Journal of Epidemiology blames on "substantial differences in health-care services, population health status and health policy."

American adult female mortality rates are 33 per cent worse (80 versus 60 per 1,000) and their adult male mortality rates are a whopping 50 per cent worse (150 versus 100 per 1,000). The inverse of all this is that we have longer life spans, by an average of more than two years.

Some of this is due to differences in population health; we drink a bit less than Americans, and twice as many adult Americans (roughly 30 per cent) are obese, with obvious health implications. Canadians are also a lot less successful in our attempts at violence. One study in 2004 shows a difference in children's death rates (American rates being higher) that is likely due to less stringent firearm regulation in the U.S.

Transport time to hospital is another good indicator. Roudsan and his colleagues looked at the parameters of ambulance care and transport in, among others, Montreal and King County in Washington State. In Montreal (where Richardson was taken), 100 per cent of victims arrived by road ambulance; whereas in King County, 15 per cent arrived by helicopter. But, Montreal's ambulance crews were on the scene sooner, spent less time there, and had shorter transport times. That's right, a U.S. system with dedicated air transport had transport times averaging 23 minutes, compared to Montreal which averaged 10.

Waiting for care

So where do we fall down? Two places: wait times and the care given to First Nations people. Roughly five per cent of Americans waited longer than four months for surgery, according to information in a 2002 article by Cathy Schoen. In Canada, that number was 27 per cent, more than five times higher. The main problem here is bed block; the inability to get our aging inpatients into care facilities that offer a social life, a degree of autonomy, and social respect while freeing up that hospital bed for the guy who has been waiting in the emergency department for 48 hours on a cot. Or for the woman who needs breast cancer surgery. Or the retiree who needs a knee replacement.

'The addiction to shiny new toys … results in a failure of the fundamentals'

Also, Canada's First Nations people have dreadful health care. One 2001 study of Canada, the U.S. and New Zealand showed that the health care of First Nation people in Canada was worse than in either of the other two countries. The absence of good care to First Nation citizens is a national shame.

So what's the bottom line? Americans spend way more money, yet despite this have poorer health outcomes than Canadians.

The addiction to shiny new toys, such as dedicated helicopter transports and a CT scanner in every pot, results in a failure of the fundamentals, such as ensuring your population can access care. Many of the "toys" are put in place despite absence of solid proof of efficacy; as we have seen, air ambulance services don't necessarily mean that transport times are shorter. Rather, because the American consumer chooses which hospital gets funded, purchase and use of high-tech equipment becomes, essentially, a marketing decision.

This is the value of central planning and resource allocation. Is it innately bureaucratic? Is it slow to respond to local needs? Does it make health a political football that tends to ignore politically marginalized populations like the First Nations people? Absolutely yes, to all those questions. But is it more democratic than market forces? Does it mean better overall access to care? Does it result in a healthier population? The answer to those questions seem to be an unequivocal yes.

And this demonstrates the problem with knee-jerk commentary on individual, high-profile cases. If we listen to Dr. Franklin, we will spend our money on solutions for problems we haven't got. Our mortality rates for trauma? Better than yours, bud. Our emergency-care systems are respected worldwide, our transportation systems are good and improving, and our access to technology is amongst the best on the planet.

We don't need more of all that, at least not as badly as we need more elder care homes and a more organized, surgeon-friendly triage system to get patients to the operating room on time. Oh, yes, and more money spent doing what has worked so well for us in the past, funding our education and improving our social programs, and limiting the supply of weapons. None of that is made obvious by simply jumping to conclusions over the next high-profile tragedy.

The message to politicians? Unplug our bed lock. Spend money on shortening wait times. Get our First Nations people the facilities they deserve. Don't let the myopic tunnel vision of U.S. pay-to-breathe health care throw our babies out with the bathwater.