The next Duff’s Ditch must be medical

A runaway rail trolley hurtles towards five people tied to the tracks. You stand at the switch lever. If you pull the lever, the trolley veers onto a sidetrack, where one person is tied down. Do nothing and five die. Pull the lever and one dies by your hand.

A health minister needs no introduction to the weight of that choice. Every budget season, governments confront this dilemma with one cruel modification — the lever switches between today and tomorrow. Down the near track sits this year’s emergency, a crowded emergency department, a surgical backlog, a crisis demanding a decision by Friday. Down the far track, in the distance, over the horizon, waits a geriatric demographic that has not arrived yet. Each year’s budget cannot simultaneously rescue both.

Philosophers treat the trolley scenario as a thought experiment. A health minister calls it Tuesday.

The actual choice is crueller, because both tracks hold real people. The stroke patient in today’s hallway deserves rescue, as do the patients down the line. Two scholars, Guido Calabresi and Philip Bobbitt, analyzed such allocations as tragic choices — scarcity forces a society to preserve one value by sacrificing another. Their darker observation concerned method. Societies rarely make these choices in the open. The lever keeps directing traffic away from the immediate noise, toward the far track.

No health minister designed the trap and I admire those who shoulder it. The cumulative sum of those rational lever-pulls commits an entire generation to an outcome its members have never experienced and never chose, an outcome predictable to the year. Today’s wait-lists and hallway stretchers grew from pulls made decades ago. This year’s pulls are shaping the hallways of 2036.

Look down the far track, into the not-too-distant future. An 86-year-old waits there in 2036. She has no name yet, no face. But she is alive today, 76, still shovelling her own driveway, still minding grandchildren, perhaps managing well, perhaps beginning to slip. She rides the wave some call the silver tsunami, triggered by a baby boom 80 years distant and it has given fair warning every year since.

Manitoba has measured this warning. In 2012, the Manitoba Centre for Health Policy projected continuing-care needs through 2036. Most personal care-home residents are 85 or older, and the first baby boomers reach that age in 2031. The report started from a baseline of 9,540 licensed personal care-home beds and calculated that the province would need at least 5,100 more by 2036, through some mix of care-home beds, supportive housing and expanded home care. Since then, the licensed inventory has grown to 9,597, an increase of 57 beds. The wave has moved 14 years closer, yet capacity has stood still.

Successive governments share the delay. A care home for Lac du Bonnet was announced in 2012, paused, revived, paused again, and opens in 2027 under a third government: 15 years for 65 net-new beds.

The current government has real projects moving, with Lac du Bonnet under construction, expansions advancing for Transcona and Arborg, and a Bridgwater home in consultation. Against a projected need of more than 5,000, the pace still finishes the work long after the peak arrives.

Let’s price the choice honestly. If every projected equivalent is built as a long-term care bed, construction at $700,000 to $870,000 per bed implies a capital bill of $3.6 to $4.4 billion over a decade.

Now let’s price not pulling on the lever. Manitoba’s hospital patients stay 17 per cent longer than their conditions predict, the worst ratio in Canada and blocked exits are a leading reason. Patients finished with acute treatment end up stranded in the wrong setting. Not every one of them waits for a care home.

Some wait for rehabilitation, some for home care, some for supportive housing. Nearly all wait on the same ladder of missing capacity, while emergency departments gridlock behind the beds the deferral filled. The boomers committed this bill decades ago.

Manitoba has faced this lever before and pulled it the hard way. In 1962, Premier Duff Roblin began digging a 47-kilometre channel around Winnipeg to stop a flood that might wait a generation. The flood-control program was priced at nearly a year of provincial net revenue, and critics called it “Duff’s Ditch.” The floodway held when the Flood of the Century arrived in 1997 and it has since prevented tens of billions of dollars in damage. Roblin proved that voters will forgive a leader who makes tragic choices in the open, when that leader names the people on the far track in time to save them.

The next Duff’s Ditch will be dug differently — care home beds, home care hours, rehabilitation, supportive housing, and the training that must start now.

A solution sits within a single statute: a rolling 10-year capacity plan — priced, sited, staffed and reported on in public every year, so each government inherits a commitment rather than a suggestion.

The reward is invisible. Rescue done properly looks like an ordinary Tuesday — a bed available, a nurse at the bedside, a hallway empty of stretchers. The warning was given decades ago and ignoring fair warning is the one strategy guaranteed to fail. Pulling the lever will be heavy either way. The only choice left is whether the weight comes with foresight or with regret.

Dr. Rafiq Andani is a physician and writer whose book The Canadian Healthcare Paradox is due out this November.