The geographies of crisis: exploring accessibility to health care in Canada

There is increasing concern in Canada that the health care system is in a state of crisis. It is argued that reductions in federal government transfers to the provinces have resulted in a health care system characterized by under‐funding in key areas and policy decisions based more on provincial fiscal concerns than the health needs of their constituents. Provincial governments have responded to reduced levels in federal funding by undertaking aggressive restructuring tactics such as the closure of hospitals and the deinsuring of medical services from provincial health plans. The end result of this restructuring, as argued by the media, consumer groups and indeed some health researchers, is a state of crisis' (i.e., lower levels of accessibility, long waiting lists, overcrowding in hospitals and increasing costs of medication). One crisis theme often mentioned is that fiscal decisions of various kinds are reducing economic and geographic accessibility, one of the five principles of the Canada Health Act (CHA) that defines the very essence of the Canadian health care system. Using data from the 1998‐99 National Population Health Survey (NPHS), this paper explores the extent to which an accessibility crisis exists within the Canadian health care system by examining access to health care services and the barriers encountered in trying to access services in each of the ten provinces. The results show that approximately 6.0 percent of Canadians report access problems, with values ranging from 4.5 percent in Newfoundland to 8.3 percent in Manitoba. Regional variations in barriers to accessing care were also observed. In particular, geographic accessibility appears to be a main barrier to care in Atlantic Canada while economic accessibility emerges as a main barrier to care in Western Canada. We discuss these findings in the context of the current debates on the Canadian health care system ‘crisis’. De plus en plus de Canadiens s'inquiétent que leur systéme de soins de santé soit en état de crise. On défend l'idée selon laquelle la réduction des paiements de transfert aux provinces par le gouvernement fédéral serait responsable de l'état d'un systeme de santé caractérisé par un sous‐financement dans les domaines‐clés et des décisions politiques de santé basées, non pas sur les besoins des membres de la société canadienne, mais sur la fiscalité provinciale. Les gouvernements provinciaux ont réagi à la réduction du financement fédéral par une tactique de restructuration agressive (fermeture d'hôpitaux et retrait de services médicaux des programmes d'assurance de santé provinciaux). Selon les médias, les groupes de consommateurs et même les chercheurs en soins de santé, cette restructuration a eu pour effet un système en état de ‘crise’ (diminution de l'aecès aux services, longues fetes d'attente, hôpitaux surchargés, augmentation des coûts des médicaments etc). Un des thèmes récurrent est celui des décisions flscales de toutes sortes qui entraînent une baisse de l'accessibilité financière et géographique. Cette accessibilité est pourtant un des cinq principes de la Loi canadienne sur la santé définissant l'essence même du système de santé au Canada. Utilisant les données tirèes de l'Enquête nationale sur la santé de la population, 1998‐99 et examinant l'accès aux services de santé et les obstacles rencontrés dans les 10 provinces canadiennes, cet article évalue dans quelle mesure une crise d'accessibilité existe au sein du système de santé canadien. Les résultats démontrent qu'environ 6.0 pour cent des Canadiens ont rencontré des problèmes d'accessibilité, avec des variantes allant de 4.5 pour cent à Terre‐Neuve jusqu'à 8.3 pour cent au Manitoba. On observe aussi des variantes régionales dans les obstacles rencontrés. L'accessibilité géographique en particulier semble un obstacle mqjeur dans les régions de l'Atlantique, alors que l'accessibilite financière semble être un obstacle majeur dans l'Ouest du Canada. Ces résultats sont présentés dans le contexte des débats actuels sur l'existence dune, ‘crise’ dans le système de santé au Canada.     

The Kosovo war: a recapitulation

This article has four objectives: first to make a case for the significance of the Kosovo war in contemporary history; second, to present an overview of the crisis itself and the military confrontation which was its consequence; third, to survey the initial controversies aroused by military action—and, specifically, the debates surrounding NATO's Operation Allied Force; and finally, to reference the longer term significance of the Kosovo war in terms of the themes covered by the remaining contributions which make up this volume.     

Conceptualizing Social Exclusion in Rural Britain

Most studies of living conditions in rural areas have offered essentially static snapshots. Social exclusion is a multi-dimensional, dynamic concept which emphasizes the processes of change through which individuals or groups are excluded from the mainstream of society and their life-chances reduced. This article considers social exclusion in the context of the principal forces operating on and within rural areas of Britain, including global restructuring and the changing role of the State and supra-national institutions. A framework of four systems of social exclusion and inclusion is proposed, following Reimer (personal communication, 1998), according to the means by which resources and status are allocated in society. This is used to structure a presentation of the results of several recent empirical studies which provide evidence of the processes and system failures lying behind social exclusion in rural Britain. A number of research issues are identified concerning how these processes vary between areas, how they connect to the broader forces operating at macro and meso levels, and how local action is associated with attempts to resist social exclusion.     

ACTS OF THOUGHT AND RE-ENACTMENT IN COLLINGWOOD'S PHILOSOPHY OF HISTORY

This article explores one of Collingwood's most puzzling claims—that, in re-enacting a past act of thought, I can revive not just the propositional content of that act but also the very act of thought itself. This aspect of Collingwood's ideas has been largely ignored, and, when not ignored, it has been almost universally rejected. After all, we might ask, how can it be that two acts of thought—one, say, had by Carol in the library on Wednesday and another act of thought had by Harold in his study on Thursday—are literally identical? I explore this baffling claim and, in particular, Collingwood's argument that acts of thought can have the identity of a continuant. I try to show how the idea of the identity of the continuant might be used to remove some of the puzzlement in Collingwood's claim about literal identity between acts of thought; I thus show how Harold, on Thursday, might be able to experience the exact same act of thought that Carol had on Wednesday.     

NEW APPROACHES ON THE ARCHAIC TRADE IN THE NORTH‐EASTERN IBERIAN PENINSULA: EXPLOITATION AND CIRCULATION OF LEAD AND SILVER

A wide‐ranging study based on compositional and isotopic analyses of minerals and manufactured objects from the north‐eastern Iberian Peninsula and their respective archaeological and cultural contexts demonstrates significant lead mineral exploitation in the El Priorat area (Tarragona province) linked to Phoenician trade (seventh–sixth centuries BC). This exploitation continued, despite losing intensity, until the Romanization of the territory. Our project also aims to determine the nature and origin of the lead and silver supply in the northern Iberian territory surrounding the Phocaean enclave of Emporion, especially with regard to the demands of the colonial mint. The behaviour pattern of the circulation of lead, silver and copper in Catalonia in the period studied indicates a plurality of contemporary supply sources, although, at least from the fifth century BC onward, minerals and metals from the south‐eastern Iberian Peninsula take on considerable importance.     

Archaeobotanical evidence for early Dilmun diet at Saar, Bahrain

A flotation machine was used to process large quantities of earth at the Saar excavation in the 1990 and 1991 seasons. Carbonised seeds and charcoal were recovered from a wide range of contexts dating to about 1900 BC. While overall quantities were low, enough contexts were productive to allow quantification. Date stones were the most frequent crop remains, with smaller amounts of free-threshing wheat and hulled six-row barley. This confirms evidence from other sources (textual, dental) for the importance of dates as a staple food in the Early Dilmun period. A survey of ethnographic and archaeological evidence for date husbandry in Bahrain suggests that the date-palms and cereals were grown in irrigated date gardens similar to those found today.     

HELLENISTIC GLAZED WARES FROM ATHENS AND SOUTHERN ITALY: ANALYTICAL TECHNIQUES AND IMPLICATIONS

The original intention of the project, conceived in the context of the British School at Rome's excavation and survey programme in the Bradano basin (based on Gravina) was to establish the composition patterns of Hellenistic glazed wares from sites in southern Apulia, and then to use these to trace the trading patterns of the area, against a control group of sherds from the Athenian Agora. It proved possible to distinguish Attic from Apulian sherds by their nickel and chromium content, and average-link-cluster-analysis by computer showed that Gnathian ware from Taranto could be distinguished from seven other south Italian groups, suggesting that speciality wares were made of clays from special beds. Because of the geological homogeneity of the area no further distinctions could be made, but some sherds were also analysed petrologically and by heavy mineral analysis, for a methodological comparison. The very homogeneous geology, coupled with the fineness of the wares showed these methods to be at the limits of their usefulness. Only very generalized conclusions could be drawn concerning the origin of the pottery from the petrological evidence; the micro-mineralogical data showed that interesting differences existed between pottery from the main Apulian sites, but these could equally have reflected natural variations occurring within fairly homogeneous clay deposits.     

THE AGGREGATED SPATIAL CHOICE MODEL VS. THE MULTINOMIAL LOGIT: AN EMPIRICAL COMPARISON USING MIGRATION MICRODATA

Frequently, in spatial interaction analysis, researchers are forced to use destinations that are zonal aggregates of the ‘real’ destinations perceived by the participants in the interaction process. Previous simulation studies demonstrated that, under certain circumstances, the aggregated spatial choice model can outperform the popular ordinary multinomial logit model, both in explanatory power and predictive ability. In this paper, the two models are compared with interprovincial migration microdata for the time period 1990-91, obtained from the 1991 Canadian census. Since this is not meant to be a migration study, the analysis is limited to out-migrants from Ontario. The results indicate that, at least with the data used, the multinomial logit model performed reasonably well. The paper, however, highlights some practical advantages that can accrue from the use of the aggregated model. Dans l'analyse de l'interaction à référence spatiale, il arrive fréquemment que les chercheurs soient contraints de se servir de destinations qui regroupent les?vraies?destinations perçues par les participants dans le processus d'interaction. Les études en simulations antérieures ont démontré que, dans certaines circonstances, le modèle groupé des choix à référence spatiale peut donner de meilleurs résultats que le modèle ordinaire commun du logit multinomial, sur le plan de la capacité d'explication comma sur celui de la valeur de prévision. Dans la présente étude, on fait la comparaison entre les deux modèles en utilisant les microdonnées sur l'émigration interprovinciale en 1990-91 obtenues par le recensement de 1991. L'analyse ne porte que sur les émigrants de l'Ontario puisqu'elle ne vise pas particulièrement l'étude de l'émigration. D'après les résultats, le modèle employant le logit multinomial fonctionne relativement bien, au moins avec les données utilisées. Toutefois, l'étude souligne certains avantages pratiques pouvant inciter à se servir davantage du modèle groupé.