This book would be frightening enough if Colleen Fuller had focused exclusively on documenting the extent to which Canadian governments are cutting public, non-profit health services while promoting both for-profit care and individual responsibility for illness. But what makes the book even more disturbing is the evidence she presents on the undermining of democracy.

It is no secret that the overwhelming majority of Canadians support their public health care sys-tem. Indeed, every government elected in Canada over the past decade has pledged to defend medicare in the recognition that no government could get elected without such a pledge. Even Mike Harris has promised more government involvement in care. As Fuller tells us, those seeking to make a profit in care have recognized that one of the most difficult barriers they face is the widespread faith in a public system or what the Conference Board of Canada despairingly described as the "growth in an entitlement mentality."

Much less well-known are the ways the government practices Fuller identifies serve directly and indirectly, and sometimes deliberately, to privatize the system. This is happening despite strong popular support for public care and in spite of public claims to the contrary. Privatization is not restricted to service delivery, Fuller explains. It extends far beyond particular services to the development of health policy itself.

Corporations are increasingly invited not only to the policy table but also into partnerships with government, partnerships that mean a loss of democratic control, reduced public access, increased costs and more public money going to mainly for-eign profits. As Fuller puts it, "a great strength of Canada's publicly funded hospital sector has been the ability of governments to exercise control over priorities, budgets and types of services offered by individual facilities. Increasingly, those priorities, budgets and services are being set by international investors concerned about the rate of return on their ventures."

The corporate interest in changing Canadian attitudes about public care and in privatization of services is not surprising, Fuller explains, given that health care is such a profitable business. Take the example of Columbia/HCA, a corporation with annual revenues greater than those of every province except Ontario and Quebec. Canada offers to these health industries a relatively untapped, and conveniently close and culturally similar, source for huge profits in care. It also offers them a great deal of public money to pay for this care, money that is increasingly under private control.

At the same time, Canadian employers are facing increasing health care costs as governments cut back on services and employees rely more heavily on work-related health benefits. The health industries promise to fill the gap with "managed care" packages that are purported to control costs for employers while ensuring quality care. Employers are attracted in spite of the evidence, as Fuller points out, that U.S. experience challenges this claim of cheaper and better health under managed care plans.

This combination of government withdrawal and corporate initiative means employers outside the health industries may also find privatization attractive, even though Canadian employers have enjoyed a clear competitions edge as a result of medicare. And as employers spend more on care, they have begun to claim a larger role "in the design and operation of these programs." They have also begun to organize around health care policy, and found positive responses in government ranks.

The government attraction to privatization is less obvious. As Fuller makes clear, all the evidence suggests that Canada's system not only makes employers more competitive; it is also more accessible, more efficient and more attractive to Canadians precisely because it has worked much better than the mainly private system to the south.

So why support a move away from public care? Fuller finds much of the explanation for the new government commitment to privatization in the pressure from the large corporations in the health sector and in their potential for enormous profits. According to Fuller, the federal government "has made it a priority to assist the industry in attracting

both domestic and foreign investment to finance the growth and concentration of Canadian health companies."

Industry Canada, rather than Health Canada, is taking the lead, stating unequivocally that "Governments have an important role to play in setting the business climate at home" for health industries. Reductions in public care funding create the space, and the demand, for these businesses. At the same time, the federal government is spending the money on the emerging health industries that do not offer public care. In other words, the privatization is subsidized by the same taxpayers who are being denied care.

Fuller goes on to expose other contradictions resulting from these public policies. Instead of moving towards the kind of integration, continuity and cost control that could be possible under a more thoroughly public system, she contends, "we are moving in the opposite direction. Public control over where the health care dollar goes (and for what) is regionalized and fragmented, while the private sec-tor is consolidating and integrating into powerful national and global entities." Similarly, governments have promised both to lower health spending and increase for-profit involvement, processes which Fuller says "appeared to cancel one another out."

Perhaps the most shocking contradiction Fuller reveals is the promotion of Canada as a site for clinical trials. While many insurance companies in the United States refuse to insure participants, she maintains, Canada's public system means there are no similar constraints on the use of patients as guinea pigs. If the trail fails, patients will be provided with public care.

In her discussion of the federal partnerships in the business of health information technology, Fuller says "It is ironic that our governments are promoting the importance of information to the health and well-being of Canadians but are keeping us in the dark about the implications of corporate control and the option of a strong public role in the collecting and safeguarding of data." Her book sheds light not only on this darkness but on a full, and rather frightening range of other areas where public health care, and democracy, are at risk.

She also thinks it is ironic that as Canadians "are advised to assume more 'personal responsibility' for their health status and health care, they are losing many of the tools necessary to such an undertaking." Caring for Profit, however, offers a new tool for all those committed to public care by exposing the processes of privatization that are well underway.

Pat Armstrong teaches in the School of Canadian Studies at Carleton University, and is co-author with Hugh Armstrong of "Universal Health Care: What the United States Can Learn from Canada" and "Wasting Away: The Undermining of Canadian Health Care."