Austerity, Transportation and Health Equity: Emerging impacts of the closure of STC

Background:

On 31st May 2017, after 70 years of service, the final bus of the government-owned Saskatchewan Transportation Company (STC) took its last trip from Regina. At the time of its closure the company served 253 communities and transported about 200,000 Saskatchewan residents yearly. STC was abruptly shut down as part of the March 2017 budget that saw cuts to several other public institutions and services including libraries, post-secondary institutions among others – although some of these cuts were later reversed after significant public outcry.

At the time of the company’s closure, the STC was an integral part of life in Saskatchewan and played a pivotal role in transporting many essential equipment and supplies used by the various health regions, small businesses and farmers in the province. For example, the bus transported vaccines, blood products and medical equipment (Saskatchewan Transportation company, 2010).

ACCORDING TO THE GOVERNMENT, STC WAS CLOSED:

• To allow the private sector to takeup former STC routes
• Because of a general decline in intercity transit usage throughout Canada
• To save $85m within a five-year period
• Because of a 77% decline in provincial bus ridership over the last 35 years

ACCORDING TO RESIDENTS, THE STC CLOSURE HAS

• Increased barriers to healthcare especially in rural Saskatchewan
• Increased stress, depression and other mental health challenges for people in isolated communities
• Increased risk of accidents and personal safety issues among the vulnerable
• Increased travel costs, especially for low income residents
• Created an emotional toll and strain in maintaining family relationships
• Isolated entire communities and made access to various services in big centres more difficult
• Increased inefficiencies in the healthcare system and disrupted care processes
• Increased stress for healthcare and other workers•Forced people to purchase vehicles which creates environmental concerns

THE WAY FORWARD: SASKATCHEWAN NEEDS:

• An audit of the healthcare system to understand the real costs and wastages caused by the STC closure
• A province-wide bus system operated not for profit but to increase access to services for residents and reduce carbon emissions
• Activists and advocates to continue to mobilize and play a role in amplifying closure effects
• To hold politicians accountable for the stress, suffering and harms caused by the loss of STC

Understanding STC Closure Impacts

The government offered a number of reasons to justify the March 2017 austerity budget in general and the need to shut down the STC in particular. These included: i) to reduce the province’s budget deficit ii) the decline of intercity bus travel in Canada iii) a 77% decline in bus ridership in Saskatchewan over the last 35 years iv) that the private sector would pick up former STC routes v) that all efforts to limit the provincial subsidy had been exhausted (Johnson, 2017).

(Source: Saskatchewan Transportation Company, 2017)

Citizens, activists and advocates have raised concerns on the potential impacts of closing a company that formed such an integral part of life in Saskatchewan. The government was also critiqued for failing to create a clear mitigation plan to address the effects of closing the STC. Indeed, the STC closure may be interpreted not as a unique Saskatchewan issue but as part of a global rise in austerity (budget cuts) driven by a neoliberal ideology that aims to reduce public provision of various services (Alhassan and Hanson, 2019).

A Study of the Cuts

We conducted a qualitative research study between July 2019 and March 2020 to gain an in-depth understanding of the closure of STC. The research aimed to 1) understand the political rationale for closing STC; 2) explore the impacts of the closure of STC on people, communities and various systems; 3) reveal how any impacts of closing STC might differ for different people in the province (for example rural compared to urban residents, seniors compared to young people etc.); and 4) create a framework that connects budget cuts and health.

Understanding STC Closure Impacts

The research involved interviewing 100 Saskatchewan residents from over 15 cities, towns and villages across northern, central and southern Saskatchewan. Six (6) focus group discussions were held with 24 health sector workers (program managers, doctors, nurses), social service workers (benefit navigators, social workers) activists (women’s organizations, disability rights activists, activists against STC closure etc.) and Indigenous stakeholders to understand the system-level effects of STC closure beyond individual stories obtained from the 100 interviews. Other data sources used in the research but not reported here have included 47 days of parliamentary Hansard on the closure, 751 newspaper articles and archival sources.

What We Found

The research revealed that the closure of STC has had a set of interrelated effects on various individuals and communities. Some of these effects are described below:

Healthcare access barriers

Research participants reported missing and or cancelling hospital appointments or deciding not to seek healthcare after several failed attempts to find rides to attend hospital appointments. One participant who had lost all hope in seeking care said:

“if I was to be diagnosed next week with cancer, I’m not going to be working the phones to get a ride. I’m just going to sit at home… There’ll be no treatments”

(71-year-old woman from Big River Saskatchewan)

Mental health effects

Research participants reported mental health challenges caused or worsened by the closure of the bus. These issues ranged from shame in having to constantly ask for help, stress in trying to arrange rides and feelings of loneliness and isolation as a result of inability to connect with family members or loved ones. One research participant who was unable to visit family in the north due to the closure described the mental health effects:

“[i]t’s definitely affecting my mental health. My emotional well-being. I do my best to walk the Red Road and my medicine wheel, the mental, the spiritual, the physical, the emotional, is all affected by this. It really, truly is. So, it’s really depressing that I can’t see my family.”

(36-year-old woman living in Saskatoon)

Personal safety

Participants described safety-related impacts both in terms of physical safety while travelling, but also safety, especially for women fleeing domestic violence. Other participants described sliding into ditches while travelling due to icy roads, hitchhiking to attend medical appointments in larger centers or walking several days to travel between cities. Interview respondents also described challenges in driving while on medication and how this puts them and other road users at risk. In one of the focus groups, a program manager described the risk people in smaller communities face while seeking treatment for addictions services:

“We have had people who have walked significant distances to get to [our treatment] center. Like we’re talking like spent majority of days walking on highways, either hitchhiking or walking to get here.”

(Health worker in Focus Group Discussion)

Broken family relationships

Anumber of research participants, especially divorced parents who used the bus to transport minors described challenges visiting their children while others described being unable to participate in family gatherings such as birthdays, thanksgivings, funerals and other occasions due to the closure.

Family driving burden

Family members described many challenges in trying to ensure that their parents, siblings or children (especially those who cannot drive due to disability or age) continue to access needed services. Family members are forced to take time off work and to drive several hours to help out those unable to drive.

One participant noted:

“I have had to take time off work at the hospital to drive 300 km to [get my mother] and bring her back the same day so she can attend a physician appointment in Saskatoon”

(52-year old woman living in Saskatoon)

Isolated and marginalized communities

The closure of STC has served to isolate, disconnect and marginalize many small communities. According to participants, these are communities that already feel marginalized and forgotten. One of the healthcare workers commented on this saying:

“I just think it’s another example of trying to move all of our services into the bigger cities [and] isolate us even more so that we do disappear off the map. But that’s kinda how it feels. It’s really tough to have older adults and young families living in rural Saskatchewan. If they can’t get to the cities for basic healthcare needs, it’s not fair.”

(Healthcare worker in Focus Group Discussion)

Environmental effects

Research participants expressed concerns on the environmental effects of the decision to close STC. In total, 4% of research participants indicated that they had purchased a vehicle because of the STC closure. Being forced to buy a vehicle according to one participant is a serious ethical issue:

“[w]henever I look at my car or think about my car, I’m not happy about it… It’s like if a vegetarian was forced to eat meat.”

(21-year old man living in Prince Albert)

Health system effects

Research participants especially those in the health sector, described how the absence of the STC is affecting health service delivery. The absence of the bus has created several inefficiencies and wastages, causes stress to health and social service workers as they try to deliver services as best they can and in some cases disrupts the care process making clinical decision making more complicated. As one healthcare worker from a rural area noted:

“Medications showing up -it’s frozen; we can’t use it. Or in the summer it’s too hot, we can’t use it. We’re throwing out thousands of dollars of medication.”

(Healthcare worker in Focus Group Discussion)

Apart from throwing away medication because they arrive at odd times through private couriers, in some cases wait times are increased for patients who have to come with caregivers.

These caregivers end up using health resources leading to further wastage. Care processes are also disrupted because of the absence of the bus because:

“There’s emails every single day at work, looking for somebody going to Regina to take a package. I mean it’s every single day, not just our department, but every department …I mean we can’t even send a lab work to Regina on a Saturday. It sits in our lab department until Monday morning. How are you supposed to make a clinical decision on somebody’shealth care when you can’t get your lab results in five days?”

(Healthcare worker in Focus Group Discussion)

Healthcare workers described the stress involved in trying to keep services running without adequate transportation services. In most cases the government pays for these inefficiencies by paying more for delivery, health workers pay by being stressed and patients pay by receiving sub-par services.

Discussion:

Three issues are important for understanding STC closure:

1. Impacts go beyond former users

2. Closure impacts vary for different people.

3. The work of activists and advocates matter.

STC closure effects beyond former users

A fundamental insight from this research is the idea of a ‘web of dispossession.’ The closure of the STC does not only affect the individual former users but affects for example family members who bear a heavy driving burden to ensure former users continue to access services. The closure also affects entire communities whose libraries used the bus or small towns that are now completely isolated. Beyond individuals, families and communities, the closure affects the health system through inefficiencies and disrupted care processes and perhaps through the environment and climate change as more people are forced to buy vehicles leading to more emissions. This means that people who may perceive themselves as unaffected by the closure may find themselves caught up in the ‘web’ of closure effects as they interact with various systems.

Health equity effects of the closure

The closure of STC does not affect everyone equally. The closure assumes that everyone has (access to) a vehicle, can drive or has relatives who are able and willing to drive and therefore excludes many people with disabilities, seniors, low-income residents and other vulnerable people who for various reasons are not able to travel due to the closure.

Activism and advocacy matter

Activists and advocates have played a crucial role in highlighting closure effects. These efforts give voice to the most marginalized who suffer closure effects quietly. Activists, academics, health and other professionals need to continue to speak out on closure effects to promote accountability, improve access for the marginalized and help reduce the negative effects of the closure especially among the most marginalized members of society.

Recommendations

The closure of STC has had many negative effects on people in Saskatchewan. The evidence is clear-current private alternatives have not been successful in ensuring access to various services especially for people living in rural and remote parts of the province. This necessitates the creation of a bus system that is accessible, affordable and safe –focusednot on profit but improving access especially to the most vulnerable. These are the pillars that marked STC, and they need to be reignited. Several inefficiencies in the health system are attributable to the closure and this calls for a large-scale audit to increase understanding of the social and financial costs of the closure.

The closure of the STC has caused systemic inefficiencies, needless hardships and barred the most vulnerable from participating in basic aspects of social life such as visiting family. These negative effects reveal the connections between austerity (budget cuts)and health, and call for more mobilizing, advocacy and activism against budget cuts especially by those interested in promoting population health and equity.

Authors

Jacob A.K. Alhassan is a PhD candidate in the department of Community Health and Epidemiology. Dr. Lori Hanson is an associate professor in the Department of Community Health and Epidemiology and director of the Division of Social Accountability, College of Medicine, University of Saskatchewan.

Acknowledgements

The authors acknowledge the contribution of members of Stop the Cuts in conceptualizing and implementing the research study. The authors also acknowledge the contributions of Drs Sylvia Abonyi (PhD), Charles Smith (PhD), Cory Neudorf (MD) and Rachel Engler-Stringer (PhD) who have acted as a thesis advisory committee.

Other resources on STC and Transportation in Saskatchewan

Video: Transportation as a Social Determinant of Health

Podcast: Transportation and Health Equity Series

References

Alhassan, J. A. K.,& Hanson, L. (2019). ‘It feels like I’ve lost my independence…Now I just feel like I’m a prisoner trapped in my own city’ – Politicizing the transportation-health nexus: Evidence from the Canadian province of Saskatchewan. Journal ofTransport and Health, 14 (supplement). 100635. Retrieved from here.

Johnson, J. (2017). Government Ends Saskatchewan Transportation Company (STC) Subsidy—Bus Company To Be Wound Down | News and Media | Government of Saskatchewan. Retrieved July 13, 2018, from News and Media website: Saskatchewan Transportation Company. (2010).

Saskatchewan Transportation Company : 2011 Annual Report.

Saskatchewan Transportation Company. (2017).

Saskatchewan Transportation Company Annual Report 2016-2017.