36 Steps on the Road to Medicare: How Saskatchewan Led the Way 9780773589575

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36 Steps on the Road to Medicare

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36 STEPS ON THE ROAD TO MEDICARE H o w S a s k a t c h e w a n L e d t h e Way

C. Stuart Houston and Merle Massie

McGill-Queen’s University Press Montreal & Kingston • London • Ithaca

© McGill-Queen’s University Press 2013 isbn isbn isbn isbn

978-0-7735-4285-3 978-0-7735-4286-0 978-0-7735-8957-5 978-0-7735-8958-2

(cloth) (paper) (epdf) (epub)

Legal deposit fourth quarter 2013 Bibliothèque nationale du Québec Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free McGill-Queen’s University Press acknowledges the support of the Canada Council for the Arts for our publishing program. We also acknowledge the financial support of the Government of Canada through the Canada Book Fund for our publishing activities.

Library and Archives Canada Cataloguing in Publication Houston, C. Stuart (Clarence Stuart), 1927–, author 36 steps on the road to medicare : how Saskatchewan led the way / C. Stuart Houston and Merle Massie. Includes bibliographical references and index. Issued in print and electronic formats. isbn 978-0-7735-4285-3 (bound).–isbn 978-0-7735-4286-0 (pbk.).– isbn 978-0-7735-8957-5 (epdf).–isbn 978-0-7735-8958-2 (epub) 1. National health insurance – Saskatchewan – History–20th century. 2. Medical policy – Saskatchewan – History – 20th century. I. Massie, Merle, 1971–, author II. Title. III. Title: Thirty-six steps on the road to medicare. ra412.5.c3h72 2013 c2013-904662-3 c2013-904663-1

368.4'20097124

CONTENTS

Abbreviations vii Acknowledgments ix Foreword xiii Introduction xvii 1 2 3 4 5 6 7 8 9 10

Saskatchewan Hospitals: Off to a Slow Start 3 Dr Seymour and Public Health 18 Municipal Doctors and Municipal Hospitals 25 Dr Ferguson and Tuberculosis 41 Sigerist and Pensioners’ Care 69 Swift Current Health Region 79 Medical College and University Hospital 93 Provincewide Hospitalization 96 Innovations in Psychiatry 105 High-voltage Cancer Treatment 118 Epilogue 138 Notes 147 Index 181

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A B B R E V I AT I O N S

act aecl apha bcg ccf dot hbc hspc iode lsd mb bch mrcp nrc nwmp rm rpn sab

Associated Canadian Travelers Atomic Energy Canada Limited American Public Health Association Bacille Calmette Guérin vaccination (tb) Co-operative Commonwealth Federation Directly Observed Therapy Hudson’s Bay Company Health Services Planning Commission Imperial Order Daughters of the Empire D–lysergic acid diethylamide Bachelor of Medicine, Bachelor of Surgery Member, Royal College of Physicians National Research Council North West Mounted Police Rural Municipality Registered Psychiatric Nurse Saskatchewan Archives Board

Abbreviations

sarm Saskatchewan Association of Rural Municipalities sca Saskatchewan Cancer Agency sdcmh Saskatchewan Division, Canadian Mental Health Association shsp Saskatchewan Hospital Services Plan sla Saskatchewan Lung Association sti Sexually Transmitted Infection uhd Union hospital district von Victorian Order of Nurses

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ACKNOWLEDGMENTS

stuart houston I was indebted to many people prior to 2002. Early in the process, Eleanor McKinnon, private secretary to Premier T.C. Douglas; Malcolm Taylor, former secretary to the Health Services Planning Commission; and Hon. Walter Smishek, former minister of health, provided interviews. Hon. Sylvia Fedoruk wrote the foreword and critiqued the chapter on high-voltage radiation. Joan Feather and Lester Jorgenson critiqued the chapter on the Swift Current Health Region, and provided additional information. Dr Colin Smith critiqued the chapter on psychiatry, and Drs Ian McDonald and Frank Coburn provided interviews. Pat Matthews gave me biographical material and a photograph of her late husband; Mrs William Burak provided a small photo of her late husband. The Saskatchewan Archives Board provided most of the photographs. Michael West provided permission to use the copyrighted photograph of Malcolm Taylor. The portrait of Henry Sigerist came from the Alan Mason Chesney Medical Archives at the Johns Hopkins Medical Institutions.

Acknowledgments

Associated Medical Services Inc., through its Hannah Institute for the History of Medicine Program, kindly gave permission to use material from R.G. Ferguson, Crusader against Tuberculosis (1991). The Canadian Medical Association Journal and the Annals of the Royal College of Physicians and Surgeons have each allowed use of portions of four of my articles published in their journals, as cited individually in the references. Dr John W. Aldrich and Dr Brian C. Lentle have allowed extensive use of the Houston and Fedoruk chapter in their 1995 book that marked the centennial of Röntgen’s discovery of xrays. The Canadian Broadcasting Corporation program Ideas kindly allowed use of three excerpts from the radio program of 5 December 1990. Zennon Slowski and Dr Donald S. Houston solved my computer problems. The entire manuscript was read critically in 2002 by Allan E. Blakeney, Mary I. Houston, and J. Frank Roy, and by doctors Ronald M. Bremner, Louis Horlick, Stan Houston, and Robert Lampard. I am grateful for their insightful comments and corrections. With the help of my co-author, Merle Massie, this revised manuscript adds several critical dimensions to the medicare story. The origins and impact of the Swift Current Health Region and Saskatchewan’s psychiatric innovations have received expanded attention. We have reoriented Saskatchewan’s roots in First Nations and fur trade experience. Other additions include coverage of the Red Cross Outpost Hospitals, poliomyelitis, the air ambulance, the Matt Anderson plan, a more in-depth look at Saskatchewan’s advances in cancer treatment, and a tribute to Sylvia Fedoruk. Stuart expresses his personal assessment of the implementation of medicare in 1962, and its continued influence,

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Acknowledgments

in the epilogue. The revised manuscript was improved by Erika Dyck and Greg Marchildon. Any residual errors or omissions are the responsibility of the authors. merle massie I would like to thank Stuart Houston for allowing me to have a part to play in this revised version of Steps on the Road to Medicare. As a historian, I emphasize the social context behind the remarkable achievements listed here. Stuart is an exceptional collaborator – he kept me fascinated, and often in stitches, with his assessments of Saskatchewan people, places, and events. The revised version holds Stuart’s central narrative voice, but fills out the story of Saskatchewan’s adventures in health care transformation.

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FOREWORD B Y S Y LV I A O . F E D O R U K

Saskatchewan has been a leader in many aspects of health care. These developments arose from the co-operation and mutual help necessary among pioneer settlers, sparsely distributed in a relatively hostile environment. House-raising, barn-raising, and the building of community amenities such as schools and curling rinks made it logical for other co-operative developments also to occur. These accomplishments took place in an atmosphere of community, creativity, and trust. Individuals with foresight such as Drs Seymour, Ferguson, Blair, and Johns helped Saskatchewan to lead the world. In 36 Steps on the Road to Medicare: How Saskatchewan Led the Way, Stuart Houston reviews many of the exciting events in a story that reflects the strengths of Saskatchewan people. Stuart, himself, is truly a part of Saskatchewan history. He served on the executive of the Canadian Society for the History of Medicine from 1979 to 1987, including two years as

Foreword

president. His published works in medicine and the history of medicine number 288, including four books, seventeen chapters in books, and sixty-nine original scientific articles. His published works in ornithology and natural history number 681, including eight books, forty-three forewords or chapters in books, and 292 original papers. His interest in ornithology is legendary, especially in bird-banding – he and his wife, Mary, have banded over 147,000 birds of 211 species, with 3,800 recoveries or encounters. Stuart is professor emeritus of medical imaging at the University of Saskatchewan. Our paths have intertwined over many years. We both took our schooling in the Yorkton area of Saskatchewan in the 1940s. For about twenty years, until my retirement in 1986, Stuart and I collaborated in teaching radiation physics, the “Stuart and Sylvia show,” to first-year medical students at the University of Saskatchewan. When I was chancellor, it was my privilege to present him with a DLitt degree (1997), although he had taken no classes and written no exams. Most of the medical students appreciated him – he is the only medical doctor to have been elected honourary president of the Student Medical Society three times, including in his last full year of teaching and practice. Stuart received Saskatchewan’s highest honour, the Saskatchewan Order of Merit, in 1992, and was made an Officer of the Order of Canada in 1993. In 1997, he was the fourth recipient of the Gold Medal of the Canadian Association of Radiologists. His most recent honourary degree was a DCnL, in 2002. The Honourable Sylvia O. Fedoruk, oc, som, dstj, ba, ma, dsc, lld, dhuml, fccpm

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Foreword

authors’ note Sylvia Fedoruk died, independent to the end, in her home, on 26 September 2012 at age 85. As an undergraduate, Sylvia received the Governor-General’s medal “as the most distinguished graduate of any college,” together with the Spirit of Youth award for her achievements in athletics and student governance. She was both the top academic and the top female athlete: a member of twelve university championship teams in basketball, track and field, golf, volleyball, and hockey. Canada’s first women’s world curling title came later. Sylvia’s entire academic career was spent on the campus of the University of Saskatchewan, where she was director of physics services for the Saskatchewan Cancer Foundation, chief medical physicist for the Saskatoon Cancer Clinic, and professor of oncology. She was the first woman member of the Atomic Energy Control Board of Canada. In 1986, Sylvia Fedoruk was the first female chancellor of the University of Saskatchewan (1986–89). Two years later, she served six years as the first woman Lieutenant Governor of Saskatchewan (1988–94). She received five honourary doctorates, the Queen’s Jubilee Medal (1977), and the Taras Shevchenko Award of the Ukrainian Canadian Congress. In 1986 she was made an Officer of the Order of Canada and was awarded the Saskatchewan Order of Merit. In 2009, she was inducted into the exclusive Canadian Medical Hall of Fame. Rarely if ever has any woman anywhere been such an achiever in so many different fields – and never has that achiever re mained to the end so humble and so modest.

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INTRODUCTION Medicare is considered to be the most valued social programme in Canada today. Canadians have rated it as their most important concern, ahead of programmes in employment and social welfare … medicare is an essential part of Canada’s national identity and part … of what it means to be Canadian.1

Most of the steps that led to medicare were forged in Saskatchewan. The events described in this book changed the course of health care throughout Canada. There is a certain danger in listing all the times Saskatchewan was “first,” leaving us open to charges of hero-worship, bragging, and jingoism. In this revised edition, my co-author Merle Massie and I enumerate these “firsts,” with one caveat: we do not say that all of these firsts are, therefore, key “steps” on the road to medicare that should be followed by other jurisdictions around the world. Some were. Others showcase Saskatchewan’s vivid and path-breaking leadership. Yet we hope those connected with Saskatchewan will be proud of the recurring themes of co-operation, innovation, and rapid response to need throughout Saskatchewan’s ninety-seven year history of health care. But one question must somehow be addressed. Why was Saskatchewan so consistently the leader? Why not Alberta? Manitoba? Nova Scotia?

Introduction

Allow me to begin with a vignette from my own experience. As an amateur medical historian who in most years meets with the men and women of the Canadian Society for the History of Medicine, I understand full well, from the experiences narrated by friends at these meetings, the need to question conventional wisdom, folk legends, and mythology. I had been told many times that Premier Tommy Douglas of Saskatchewan had okayed development of the world’s first betatron to treat cancer after one visit from Allan Blair and Harold Johns, probably in 1946. This story was surely partly legend, and perhaps apocryphal folklore. Or was it? So, when I had the chance to hear the truth first-hand, I seized the opportunity. T.C. Douglas was coming to Saskatoon to give a speech at a major New Democratic Party (ndp) banquet on 18 February 1983. I phoned Peter Prebble, my ndp Member of the Legislative Assembly, and asked whether I could be booked for a short interview with Douglas. Peter phoned back to say that his schedule was full, but that if my wife, Mary, and I would come to the banquet, we would be assigned to drive Douglas back to his lodgings at the Bessborough Hotel. We accepted this unusually innovative offer with alacrity. I had met Douglas only a few times. The first time, when I was a student, he was a guest in my family home in Yorkton, together with his personal advisor and assistant Morris C. Shumiatcher. I have a vivid memory of these two men standing beside the fireplace after supper, my six-foot-four father towering over both. Early in Douglas’s career as Co-operative Commonwealth Federation (ccf) premier of Saskatchewan, my father had been on the committee that negotiated payments to doctors for treating impoverished people receiving social assistance. Later, Dad served as one of three doctors nominat-

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Introduction

ed by the Saskatchewan College of Physicians and Surgeons on the Thompson Advisory Planning Committee on Medical Care. The interim report of the Thompson committee recommended a system of universal health coverage, financed by direct taxation and general revenues, and run by a non-political commission. Doctors would be paid on a fee-for-service basis, rather than by salary as in a state medicine system. Premier Douglas recommended the commission “because it was requested by the doctors, and because it would assure no political interference.”2 This was surely one of many examples of Douglas’s pragmatism. As a high-school student, I had typed some of Dad’s letters and briefs during his time on this commission. As I drove Douglas back to the hotel in 1983, he asked after my parents and spoke well of both, the rancor of the so-called doctors’ strike in 1962 notwithstanding. Time was short and Douglas needed to go to bed. I asked my well-prepared questions, and as I remember it, the conversation went as follows: csh: Do you remember the day that Harold Johns and Allan Blair dropped into your office to ask for permission to buy a betatron to treat cancer? tcd: Yes, clearly, as if it were only yesterday. csh: Is it true they came unannounced, without an appointment? tcd: Probably. I had an open-door policy, guided by my trusted secretary Eleanor McKinnon. [Later an interview with Miss McKinnon in Regina confirmed that unscheduled visits were the rule. Douglas made it a policy to help any Saskatchewan citizen. The system worked best without fixed appointments.]3 csh: Is it true that you listened to their “pitch,” asked for an approximation of the probable cost, and that they then

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Introduction

walked out of your office with a virtual carte blanche to proceed? tcd: Yes. csh: Is it true that you made this decision without consulting your treasurer, Clarence Fines, or any member of your cabinet? tcd: Absolutely. csh: Is it true that you made this important decision without consultation with any other medical doctors or physicists, or any outside agency? tcd: I believe that to be true. csh: How did you justify making such a momentous decision on the spur of the moment? tcd: Well, after all, I was both premier and minister of health. csh: How did you have the courage to do this without consultation with anyone at all? tcd: Well, it was easy. I had complete confidence in the knowledge and the integrity possessed by both men. They assured me that highvoltage radiotherapy offered great promise in the treatment of cancer. Dr Allan Blair had come from Toronto to head up the leading cancer agency in North America. And Harold Johns! Why, when I attended Brandon College, Alfred Edward Johns was my mathematics teacher and my favourite professor. He had been a missionary in Chengtu [Chengdu], West China, until 1924. His son, Harold, had been born in China. I was both poor and undernourished. The osteomyelitis in my femur was chronic, would periodically break down and issue pus, and this ran me down. The Johns family took pity on me and often had me over for Sunday supper in a deliberate attempt to put

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Introduction

some weight on my frame. It was evident that their son, Harold, showed unusual promise. So, with my close personal knowledge of both men and my complete faith in their integrity, my permission did not seem to me to be a gamble at all. I told this story in March 2002 to Shirley Douglas on a phonein program on cbc radio, and she thanked me for it.4 I don’t think she really believed her father had been that rash, making so important a decision so quickly. But the story as told above is an example of a visionary in action. Douglas was a leader, the “right man in the right place at the right time,” who moved events forward. This helps to explain why, on 29 November 2001, T.C. (Tommy) Douglas easily topped a month-long national cbc television poll as “The Greatest Canadian.” He was one part of the answer to “How Saskatchewan led the way.”

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36 Steps on the Road to Medicare

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CHAPTER 1

S A S K AT C H E WA N H O S P I TA L S Off to a Slow Start

To maintain a little balance in an unabashed book of firsts, it seems only fair to admit that the area that became Saskatchewan in 1905 was slow off the mark – the advent of hospitals was delayed in comparison with adjacent Manitoba and Alberta. Of course, health care, for thousands of years, had been in the hands of medicine men and women in what became Saskatchewan. They had practical knowledge of effective herbal remedies, and a cultural and spiritual connection to community and to the land. When smallpox, that scourge of the North American First Nations, hit Saskatchewan in the winter of 1781–82, traditional medicine was of no use. The fur trade community at Cumberland House organized itself as a de facto field hospital. “Indeed, I have no Medicines to Give him that is fit for that Disorder,” lamented Hudson’s Bay Company (hbc) Master William Tomison on 30 December 1781. Still, Tomison took in the sick, “& they have due attendance Night & Day &

36 Steps on the Road to Medicare

yet there is but little hopes of their recovery, most of them being greatly Starved before they came here.”1 Smallpox returned in 1816. Cowpox vaccinations, developed in Europe, were used in western Canada among the First Nations, stemming what could otherwise have been a severe outbreak. A third epidemic appeared in 1870. The hbc took the lead, through its posts, in providing the vaccine and teaching residents arm-to-arm vaccination techniques.2 It should come as no surprise that, given the fur trade origins, the first hospital established in what is now Saskatchewan was along the fur trade highway of the Churchill River at Ile-àla-Crosse. Three dedicated Sisters of Charity (Grey Nuns), Sisters Agnes, Boucher, and Pépin, arrived there in 1860 with Bishop Grandin after an arduous journey of fifty-seven days in an open barge from St Boniface. This was only fourteen years after Father Taché (later Bishop Taché) set up his mission among the First Nations and a few French-speaking trappers. The three sisters established a convent, a dispensary, and a mission school.3 In 1873 they began the formal operation of a hospital.4 Later, with the construction of each North-West Mounted Police barracks, a building was set aside as a hospital. Fort Walsh in the Cypress Hills was first in 1875, followed by Qu’Appelle in 1881, Regina and Maple Creek in 1883, and Battleford and Prince Albert in 1884.5 When Dr Augustus L. Jukes was appointed senior surgeon to the North-West Mounted Police in 1880,6 and stationed at Fort Walsh, he appointed a pharmacist as hospital steward. In 1885, two temporary military hospitals were created to care for wounded men evacuated from the battles of the Riel Rebellion. The first was a frame building with forty beds erected at Moose Jaw by the government. The head nurse was Hannah Grier Coombs, known as Mother Hannah, who later founded

4

Figure 1.1 Saltcoats cottage hospital (sab r-a23797)

the Anglican Sisterhood of St John the Divine. The second, Saskatoon’s temporary base hospital with up to eighty patients, was staffed by Dr James Bell of Montreal, Miss Millar (head nurse of the Winnipeg General Hospital, on loan), Nurse Phoebe Parsons, and Nurse Elkin. When the last Saskatoon patients were evacuated to Winnipeg by river barge and steamer, via Grand Rapids, the southern half of present-day Saskatchewan was again without a hospital.7 The first public hospital, at Saltcoats, was too far ahead of its time. Built in 1896, it opened in 1897 with a resident medical superintendent, a matron, and three trained nurses (figure 1.1). An early tragedy sullied its record on 4 January 1898. Nurse Biggins went to the basement carrying a coal oil lamp, which hit an overhead beam, broke, and set her clothes on fire. She died the next day. By year’s end, only forty-nine in-patients

5

36 Steps on the Road to Medicare

had been treated, but 374 days of free treatment had been provided. With its record of bad luck, and so many patients unable to pay, the hospital was closed in 1899.8 When the railroad reached “Pile of Bones” in 1882, it became the capital city of the North-West Territories. Canada’s governor general, the Marquis of Lorne, was asked to give the new village a more suitable name. Since he was married to Queen Victoria’s daughter, he christened it Regina in honour of his mother-in-law. Despite their town’s designation as a capital city, Regina citizens requiring hospital care were forced to take the train east to Brandon or Winnipeg until late in 1889. That year the first general hospital in the North-West Territories opened in Medicine Hat, with forty beds and a $5 hospitalization (insurance) option as part of their 1889 fundraising project.9 Regina patients alone accounted for 1,623 days of in-patient care in the Medicine Hat hospital in 1895.10 For nine years, Regina had only the Mary E. Truesdell Nursing Home, founded in August 1889. In 1896 the Regina branch of the National Council of Women began to raise money for a cottage hospital, with nurses supplied by the Victorian Order of Nurses (von). The cottage hospital opened in 1898 (figure 1.2). Meanwhile, in Prince Albert, the Victoria Hospital began with a small building in 1899 (figure 1.3). Its Ladies’ Aid, among other contributions for the hospital, received nightshirts and a tablecloth, as well as a brace of Sharp-tailed Grouse, two dozen eggs, and six cakes to feed the patients.11 At the end of 1899 there were two hospitals, each with seven beds, to serve about 90,000 people in fast-growing Saskatchewan.12 In 1899, the foundation was laid for a new twenty-five-bed hospital on Hamilton Street, just south of 14th Avenue in Regina. The von contributed $1,500, with the proviso that the new hospital be named the Regina Victoria. Lady Minto, wife

6

Off to a Slow Start

Figure 1.2 Victorian Order of Nurses Hospital, Regina (sab r-b535)

of the governor general, formally opened it in September 1901 (figure 1.4). A nursing training school began at once, with three students in the first class. The hospital continued to expand and was taken over by the City of Regina in 1907. It has been the largest hospital in Saskatchewan ever since. The third permanent hospital in southern Saskatchewan, the Queen Victoria Hospital (figure 1.5), opened in my hometown of Yorkton in 1902; the drive for $1,800 was sparked by one of my heroes, Dr T.A. Patrick. The von contributed $3,000. Here began the second school of nursing. One of the graduates of this unaccredited school in 1917 was Margaret Fraser. After her husband died, Margaret Fraser Myles took upgrading and returned to be matron of the Yorkton hospital in the late 1920s. She then moved to Aberdeen, Scotland, where she became the author of the world’s best-selling Textbook of Midwifery, ten editions of which appeared between 1952 and 1985.13 The Moosomin hospital, the first between Brandon and Regina, also opened in 1902 (figure 1.6).

7

Figure 1.3 Victoria Hospital, Prince Albert (sab r-a1679)

Figure 1.4 Regina Victoria Hospital, Regina (sab r-b386)

Figure 1.5 Queen Victoria Hospital, Yorkton (Howard M. Jackson)

Figure 1.6 Moosomin Hospital (sab r-a218)

36 Steps on the Road to Medicare

Figure 1.7 Lady Minto Hospital, Indian Head (sab r-b10943)

The fifth and sixth hospitals opened in Maple Creek in 1904 and Indian Head (figure 1.7) in 1905. Both had nursing training schools. Maple Creek began as an eight-bed cottage hospital, but moved into a twenty-bed brick building in 1908. Nursing training continued until 1925 at Indian Head and 1935 at Maple Creek.14 When Saskatchewan was proclaimed a province in 1905, there were six hospitals in operation, four of them with nursing schools. Their seventy-five beds served over 250,000 peo-

10

Off to a Slow Start

ple. In the 1901 census, populations of the main towns were as follows: Regina 2,249, Prince Albert 1,785, Moose Jaw 1,558, Moosomin 868, Yorkton 700, Battleford 609, and Maple Creek 382. By 1906 two more centres had grown to more than 1,000 in population: Saskatoon with 3,011 and Indian Head with 1,545 inhabitants. Two of the eleven new towns with between 500 and 918 people in 1906 (Battleford 824 and Swift Current 554) soon built hospitals. Thus each centre with a population of 500 in 1900 or of 1,000 in 1906 had a hospital by 1912. In 1906, a twenty-eight-bed, four-storey general hospital opened in Moose Jaw (figure 1.8), just in time to care for victims of a typhoid epidemic. The building was steam-heated, but it had no elevator. That year a small rented building opened as a hospital in Lloydminster,15 and the Presbyterian Church opened the Anna Turnbull Memorial Hospital (figure 1.9) near their mission house in the hamlet of Wakaw.16 With the 1906 typhoid epidemic in the rapidly growing town of Saskatoon (which grew from 2,000 to 3,000 during the year), the eight beds in Nurse Sisley’s nursing home (figure 1.10) were quickly filled; cots were set up in surrounding buildings and even in the open grounds. The overflow of typhoid patients was taken to the new Roman Catholic rectory on Fifth Avenue, where Oblate Fathers Vachon and Paille cared for them around the clock. Propitiously, two Sisters of Charity from St Boniface came through Saskatoon in September. Although on a fundraising mission, they were pressed into service. In temporary quarters they cared for thirty-four severely ill typhoid patients, four of whom died. On 22 February 1907, the Grey Nuns purchased Dr J.H.C. Willoughby’s private home on Pleasant Hill, just west of the Saskatoon city limits. They opened it with seventeen patient beds on 10 March 1907 (figure 1.11).17 A three-storey

11

Figure 1.8 General Hospital, Moose Jaw (sab r-a7260)

Figure 1.9 Anna Turnbull Memorial Hospital, Wakaw (sab r-a12696)

Figure 1.10 Nurse Sisley’s Nursing Home, Saskatoon (A. Becker)

brick building was added in 1913 (figure 1.12). A new Saskatoon City Hospital opened with fifty-six beds in April 1909; its official history claims it as the first municipal hospital in western Canada (figure 1.13).18 In 1907 the Grey Nuns Hospital was founded in Regina and the twenty-three-bed Lady Minto Hospital, operated by the von, opened in Melfort. The Women’s Missionary Society of the Presbyterian Church established a small hospital in Canora, which

13

Figure 1.11 Dr J.H.C. Willoughby’s home, Saskatoon (A. Becker)

Figure 1.12 St Paul’s Hospital, Saskatoon (sab r-b1358)

Off to a Slow Start

Figure 1.13 City Hospital, Saskatoon (sab r-a3511)

expanded to become the thirty-bed Hugh Waddell Memorial Hospital in 1914. The Lashburn Hospital was built with a $10,000 bequest. In 1909, it offered the first hospital insurance scheme: a $5 ticket entitled one person to three weeks of hospitalization.19 The growing need for hospitals in other cities and towns was filled by Roman Catholic sisters. Sisters of Charity came from the Maritimes to open the twenty-five-bed Holy Family Hospital in Prince Albert in 1910, and Sisters of Providence came from Montreal to found Notre Dame Hospital in North

15

Figure 1.14 Notre Dame Hospital, North Battleford (sab r-b5148)

Battleford in 1911 (figure 1.14). In 1912, Sisters of St Elizabeth came from Austria to launch St Elizabeth’s Hospital in Humboldt and Sisters of Providence from Kingston opened the thirty-bed Moose Jaw Providence Hospital in 1912.20 That year, general hospitals opened in Swift Current (figure 1.15) and Weyburn (figure 1.16).21 By 1912, in terms of availability of hospitals, Saskatchewan was beginning to catch up with its two neighbouring provinces.

16

Figure 1.15 Swift Current Hospital (sab r-a3351)

Figure 1.16 Municipal Hospital, Weyburn (sab r-b129)

CHAPTER 2

DR SEYMOUR A N D P U B L I C H E A LT H

Maurice M. Seymour is the pacesetter in our story. Born 7 July 1857, in Goderich, Ontario, Seymour was one of three children of Captain Maurice Bain Seymour, who hailed from Ireland, and Maria MacDonald, who came from Scotland. He began his studies at Assumption College, Windsor, Ontario, in 1873 and then obtained his medical degree from McGill University in 1879. Rather unusually for those times, he took two years of postgraduate study before he went into practice.1 After employment with the Canadian Pacific Railway during its construction in 1881–83 and service in the Riel Rebellion in 1885, Seymour practised in the beautiful Qu’Appelle Valley, forty-five miles northeast of Regina. He moved to Regina one year before Saskatchewan’s formal birth and was appointed Provincial Medical Health Officer on 10 April 1906.2 He spent the rest of his professional life in charge of public health in the new province. For his first seventeen years, public health had a low profile, as a mere branch within the large and powerful Department of Agriculture (under Hon. W.R. Motherwell), and then within Municipal Affairs. In 1909, Seymour was instrumental in preparing the Public Health Act, which established a Bureau of Public Health.3

Dr Seymour and Public Health

Whatever his title and whichever government department he worked within, Seymour laid a solid, achievement-filled, and logical foundation for public health. His enforcement arm was the Royal Northwest Mounted Police. In the new province in 1905, Seymour saw that financial aid, 50 cents per patient day, was needed for the six hospitals – in Prince Albert (1899), Regina (1901), Yorkton and Moosomin (1902), and Battleford and Indian Head (1905). One of Seymour’s strengths was his ability to react rapidly to provincial needs by drafting forward-looking legislation that would receive support from members of both political parties. Some of his actions were firsts for Canada. Responding quickly to the needs of the Rural Municipality (rm) of Sarnia #221, which had used $1,500 of tax money in 1915 to retain Dr Schmitt in that community (see chapter 3), the legislature the very next year amended the Municipalities Act to allow use of municipal taxes to build a hospital, hire a nurse, or expend up to $1,500 to hire a doctor – a first in North America. Seymour also drafted Saskatchewan’s Venereal Disease Act in 1920, with a revision in 1923. This was not a first in Canada, for Alberta had passed its own act and had begun offering free treatment in 1918. Venereal disease (vd, now known as sexually transmitted infection or sti) was relatively common, particularly syphilis. Saskatchewan offered free diagnosis and treatment. On a single day in 1924, in Regina, the vd clinic treated 100 adults, half of them for syphilis and half for gonorrhea, and five children for congenital syphilis.4 In 1912, only one birth in twenty occurred in hospital. By 1923 this figure had risen to one in six. Sadly, childbirth continued to take a toll on mothers. In 1926, Saskatchewan had the highest maternal mortality rate in Canada.5 Nevertheless, to help with the financial costs of hospital births, Seymour designed a “Maternity Grant” of $25 in 1914 as a boon to farm 19

36 Steps on the Road to Medicare

women in particular, providing $15 for the attending physician and $10 for clothes and bedclothes for the baby.6 In 1920, seventeen mothers applied; in 1921, 125; in 1922, 253; in 1923, 286; and in 1924, 427.7 By 1923, there were 2,253 hospital beds in a province of 770,000, or 3.4 beds per thousand population. Since people were often quite sick before they entered hospital, it is not surprising that the average stay was 12.7 days.8 One of the biggest public health problems was tuberculosis (tb). Soon after Seymour’s son was treated at the famous Trudeau Sanatorium at Saranac Lake, New York, Seymour organized the public meeting on 17 February 1911 that formed the Saskatchewan Anti-tuberculosis League. He persuaded the league to build its first sanatorium in an attractive coulee nestled in the Qu’Appelle Valley, facing Echo Lake and protected from north winds. At that time, bovine tuberculosis caused 25 per cent of tb deaths among Saskatchewan children; 18 per cent of 456,000 cattle tested were positive for tb.9 Eventually, Seymour achieved uniform, free tuberculin testing of cattle. On the advice of Dr D.A. Stewart of Ninette, Manitoba, Seymour hired Dr R.G. Ferguson to run the province’s tuberculosis program (see chapter 4). With typhoid fever, bovine tuberculosis, and summer dysentery all taking a toll, the Canadian Public Health Association appointed Seymour chairman of a countrywide study of milk problems in Canada from 1924 through 1926. Seymour’s group sent fifty-two questions to every Canadian city with a population over 20,000 and published the results.10 They reported that Canada’s per capita milk consumption was 0.4 litres/day (compared to New York City at 0.3). More deaths in Canada were due to milk than to any other food. For example, there were 42 deaths from 619 instances of typhoid

20

Dr Seymour and Public Health

Figure 2.1 Dr Maurice M. Seymour (sla)

and scarlet fever and an unknown number due to tuberculosis, all presumed to have been transmitted by milk. Dr E.W. Staple ford, president of Regina College, told a hearing about the deaths of 8 of his 204 students and 1 of his teachers from raw milk delivered daily from a farm a few miles outside Regina. Stapleford described “nine coffins being carried out.”11 Saskatchewan led in the tuberculin testing of cattle. In April 1917, the City of Saskatoon was the first in Canada to inspect

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36 Steps on the Road to Medicare

and license all dairy herds supplying the city; cows were tested by the Dominion Health of Animals Branch. Five other Saskatchewan cities and four towns followed. An additional thirty-one towns and seventy villages had organized preliminary inspection and licensing. Seymour recommended pasteurization of milk (heating to 142–145°f for thirty minutes, then cooling until delivered), but his suggestion was difficult to implement during hot summer days. Diphtheria was another serious problem; in 1917, Seymour began giving out free antitoxin to be dispensed by the medical profession. Seymour was not an unduly modest man (figure 2.1). In 1926 he published his Atlantic City presidential address to the Conference of State and Provincial Health Authorities under the title “The Seymour Plan.” He asked general practitioners to immunize against diphtheria in September and October, smallpox during November and December, and typhoid during January and February.12 He tried to make public health simple and easy to understand, with such slogans as “Do not spit” and “Swat the fly.” Cancer increased steadily during his tenure, until it edged out tuberculosis by exactly one death in 1924. That year, however, Saskatchewan had the lowest general death rate of any portion of the British Empire.13 Seymour was a member of the North-West Territories Med ical Council from 1885 to 1905 and served twice as president. He organized the Saskatchewan Medical Association in 1906. He was one of the first in Canada to obtain a diploma in public health from the University of Toronto. In 1915 he served as president of the Canadian Public Health Association and as vice-president of the American Public Health Association (apha). In 1923 he represented Canada at the Health Section, League of

22

Dr Seymour and Public Health

Nations. In 1925 he was elected president of the Conference of State and Provincial Health Authorities. He was honoured as a fellow of the Royal Institute of Public Health in the United Kingdom, a fellow of apha, and a recipient of an honourary lld degree from the University of Ottawa in 1925. Dr Lillian Chase described him as “a great organizer, a man of varied gifts and charming personality, [who] enjoyed the esteem of all.”14 Why was Seymour so successful? In part the answer is personal: he was a capable administrator, with unceasing energy. His greatest strength was his ability to harness Saskatchewan’s highly developed co-operative spirit. He could achieve support from municipal councils (in enforcing health laws for the common good, even when this might seem elsewhere to impinge too much on personal freedom); teachers (one year he sent a letter to each teacher in the province); clergymen (when launching a vaccination campaign, he would ask that an announcement be read from the pulpit on the preceding Sunday); rural Homemakers’ Clubs (who assisted, gratis, the doctors and nurses during his vaccination campaigns), and weekly newspapers (which published his weekly article on health). Seymour’s success was also based on the province’s strength: while he was in charge of public health, Saskatchewan grew to be the third most populous province in Canada, flowing with investment, agricultural wealth, and new people. Seymour was not superannuated until 1 November 1927, at age seventy, when he became medical advisor to the government on public health matters. His greatest gift to the people of Saskatchewan was his unbelievably rapid response to the grassroots development of municipal doctors and municipal hospitals. He also laid a sound foundation for Saskatchewan’s future leadership in health. Policy analyst Robert McLaren declared that Seymour, in serving Saskatchewan so long and so well in

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36 Steps on the Road to Medicare

his specialty of public health on the provincial, national, and international stages, serves as the prototype of a proactive public servant fostering services to enhance the well-being of the citizenry.15 He died on 16 January 1929, at seventy-one, fifteen days after Saskatchewan initiated the first universal free treatment for tuberculosis, the next stepping stone on the road to medicare.

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CHAPTER 3

MUNICIPAL DOCTORS AND MUNICIPAL HOSPITALS

Saskatchewan’s early population growth required new innovations in municipal medical services, and from 1915, laid the foundation for modern medicare. Both municipal doctor plans and municipal hospital schemes found traction first in Saskatchewan.

1. The first municipal doctor in North America: Dr Henry Schmitt of Holdfast, 1915 One major step on the road to medicare occurred in the Rural Municipality of Sarnia. The Holdfast history book, History and Heritage, quotes the motion passed by the council of the rm of Sarnia #221 in January 1914: “That Council advertise for a doctor … Also first correspond with Dr Schmitt of Newton, Illinois, in regard to locating here.” Perhaps Schmitt wrote to Holdfast in response to advertisements, which talked of “The Last Great West” and the “Beautiful Last Mountain Valley

36 Steps on the Road to Medicare

Figure 3.1 Dr H.J. Schmitt, graduation photo (Mary Bradshaw)

where crop failures are unknown,”1 or the contact may have been made by a farmer who had moved from Illinois, lured by the promise of free land in Saskatchewan. In the Sarnia Council minutes of 25 June 1914 it is recorded that Dr Schmitt was “appointed Medical Health Officer for the village [of Holdfast] to take effect on 1 July and that Dr Chapman of Dilke [should] be notified to that effect.”2

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Municipal Doctors and Municipal Hospitals

According to the Holdfast history, “Dr Schmitt covered great distances to minister to the sick” (figure 3.1). Since the rm of Sarnia included nine townships and most roads were prairie trails, his early mode of travel was horse and gig in summer, and horse and cutter in winter. In 1915, he bought a Model T Ford for summer travel when roads permitted.3 That year Dr Schmitt had difficulty collecting enough money from the impoverished farmers and considered moving on to the larger and more prosperous community of Craik.4 Because the people of the municipality were much concerned, the Sarnia council agreed to vote funds from tax money to pay a retainer to Dr Schmitt. This agreement was the first municipal doctor arrangement in North America.5 To keep Schmitt in the community, the rural municipality paid him a stipend of $1,500 in 1915 and $2,500 in 1916.6 Minister of Agriculture the Honourable George Langley, in charge of health matters, wrote to rm Sarnia, “We watch your experiment hopefully but skeptically.” But as the Holdfast history recorded, Langley “need not have worried. Every settler in the area would soon attest to the fact that Dr Schmitt’s services far outweighed the remuneration he received.”7

2. The first municipal doctor legislation in North America, 1916 In 1916 the Saskatchewan Legislature, influenced by provincial Commissioner of Health Maurice Seymour, enacted the Municipal Hospital Act, permitting rural municipalities to make a grant to physicians to supplement their income, such grants not to exceed $1,500. This made legal what rm Sarnia had already done. In 1919, legislation was enacted whereby a rural municipality might engage a physician on a salary – not to

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36 Steps on the Road to Medicare

exceed $5,000 – to provide medical care to the residents of the municipality. In 1932, provision was made whereby portions of municipalities might engage the services of a physician, or two or more municipalities could co-operate. By 1935, provision was made in the Town and Village acts for an assessment of up to $2 per head of population, according to the last Dominion census, to engage a physician. In 1937, a further change permitted the raising of a sum of $5,000 for a surgeon. Finally, in 1941, the Rural Municipality Act was amended to permit physicians to be paid on a fee-for-service basis from public funds. how successful were the municipal doctor plans?

The report of the Committee on Municipal Physicians, presented by Dr D.S. Johnstone, a Regina surgeon, to the Canadian Medical Association annual meeting in Regina in 1927 provides a snapshot of Saskatchewan’s success. That year there were thirteen municipal doctors in Saskatchewan, practising in twelve localities: Holdfast, Craik, Beechy,8 Bethune, Birsay, Brock, Chamberlain, Freemont, Leroy, Lintlaw, Rush Lake, and Senlac. Most municipal doctors were paid between $3,500 and $5,000. All medical needs of ratepayers and their hired help were covered. The Johnstone committee stated that Craik and Holdfast were “old and well settled municipalities, where the practice was quite able to sustain one or more doctors in each municipality – it was apparently a straight case of going out to hire a doctor in the hope of saving money [and] attendance fees.”9 The municipal doctor system attracted the interest of the Committee on the Costs of Medical Care in the United States. They sent C. Rufus Rorem, an economist, to study the situation in 1929 and 1930. His studies resulted in an eighty-fourpage book in 1931.10 Rorem’s map (figure 3.2) showed the

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Municipal Doctors and Municipal Hospitals

Figure 3.2 Rorem’s map of where municipal doctors were located in Saskatchewan (courtesy University of Chicago Press)

location of the thirty-two municipalities with municipal doctors in Saskatchewan.11 Twenty employed a total of twenty-one fulltime doctors; twelve other municipalities had part-time agreements with sixteen physicians.12 Seven municipalities engaged municipal doctors for the first time in 1929, while another four did so in 1930. In 1930, Saskatchewan had 558 licensed practitioners and a total hospital bed capacity of 3,357, but only one of the municipal doctors had a hospital to work in. Of

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36 Steps on the Road to Medicare

Saskatchewan’s inhabitants, 69 per cent lived on farms, 9 per cent in 377 villages, 7 per cent in 80 towns, and 15 per cent in eight cities with a population of 5,000 people or more.13 Rorem found that most doctors were pleased with the system because their incomes were assured. Annual salaries ranged from $2,800 to $5,000, but the doctors were responsible for paying automobile and office upkeep. The statistics collected by Rorem, who did not name any of his informants, showed that one doctor made 426 country calls in a year, necessitating travel of 5,580 miles by automobile. Most municipal doctors pocketed an initial charge of $1 to $3 for the first call; they were allowed to charge mileage for such visits and an extra $7 for obstetrical care. One municipality allowed a doctor to charge $7 for simple fractures, and another allowed a fixed fee of $5 for minor operations. One insurmountable difficulty facing municipal doctors was the complete rigidity of the Federal Income Tax Division, which insisted on treating the entire income as salary. Even though each doctor had to maintain an office, equipment, and an automobile, these costs could not be deducted as expenses because the Income Tax Division viewed municipal doctors as salaried employees. The medical profession was unable to obtain any redress of this unfair practice, except for a few municipalities, which reimbursed expenses separately from the stipend.14 Despite this, most doctors who had previously been in private practice reported that bad debts had so reduced their cash incomes that they were better off with the annual salary of the municipal scheme, although they worked harder after the impediment of the patient’s financial status was removed. One doctor told Rorem, “I am lucky to be on a salary.” Several stated that freedom from financial worries improved the quality of their service to patients and that patients co-operated by

30

Municipal Doctors and Municipal Hospitals

seeking services earlier in an illness. On the other hand, some doctors felt insecure because they could be dismissed on three months’ notice. Several felt that state medicine would not be appropriate outside the special rural situation. One doctor mentioned three families who tended to abuse the scheme, but admitted that they would have been a nuisance to a doctor under any payment system. Physicians agreed that the plan did not interfere with the doctor-patient relationship, and that they could spend more time on prevention, such as vaccination programs. Each municipal doctor served as medical health officer for the municipality and the villages within it. One reported that this was the first year in which there were no cases of diphtheria in his municipality, a situation he attributed to his intensive vaccination program. Municipal officials were even more enthusiastic; one of them said, “If you get a good man who is interested in his work and the health of the municipality, the system cannot be beat.” Another said, “The municipal physician’s system is here to stay, for the simple reason that it works out to the benefit of both parties concerned.” One official reported that this was the first time he had seen all taxpayers satisfied over a rise in taxes.15 In one municipality the candidate for reeve (the rural equivalent of mayor), who ran for office in 1928 on a platform of discontinuing the municipal doctor plan, was defeated by 231 to 30 votes. In another municipality, at the annual ratepayers’ meeting, a taxpayer moved that the council dismiss the present municipal doctor, but no one seconded his motion.16 No individual patient was heavily burdened, yet the taxation basis recognized the difference in financial ability to pay, since the more land one held, the more one paid. Only a few large landowners complained.17 Once the municipal doctor system had been adopted, no community returned to a private practice basis. The

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36 Steps on the Road to Medicare

only downside was that the presence of municipal physicians had unfavourable economic effects upon the practice of independent physicians in adjoining towns and cities.18 Municipal doctors worked hard. Dr Schmitt’s successor at Holdfast in the early 1930s was Dr C.S. McLean. Each year in the early 1930s McLean drove 14,000 miles to make 1,400 house calls, saw another 1,500 patients in his office, and attended fifty to seventy maternity cases.19 A circular sent by the United Farmers of Canada, Local Council, to taxpayers of one municipality before a vote on introducing the municipal doctor system there stated: At present we are committing to pooling our wheat and other farm products. The municipal doctor scheme is in reality a pooling of our doctor’s bills … an insurance against unduly high doctor bills in any one year – an equalization scheme. Are you willing to invest $4.50 per quarter section in the health of our section of the nation? A nation’s first wealth is health, and levies to protect our first wealth should have priority over all others.20 Things got worse during the “dirty thirties” for those doctors not under a municipal plan. The minister of health reported that the “average cash earnings of 130 doctors in the drought area, over a period of two years,” was $27 a month.21 In order to retain these doctors in the province, the Saskatchewan government provided a monthly stipend of $75 to those in the most drought-stricken areas, a program that continued for five years.22 To oversee and regulate the municipal doctor system, the Health Services Board was set up, with equal representation from the province, the Saskatchewan Association of Rural

32

Municipal Doctors and Municipal Hospitals

Municipalities (sarm), and the College of Physicians and Surgeons.23 By October 1938, at the time of Dr R.G. Ferguson’s report on municipal doctor schemes to the Saskatchewan Medical Association, 121 of the 546 provincial doctors were under remarkably varied types of municipal contract. For example, 28 received the $1,500 retainer grant, 36 received a salary of up to $5,000 for regular medical services, and 13 had a contract to supply surgery within the competence of the doctor. In only 15 instances was a physician permitted to charge a flat $2 deterrent fee for the first call, and a reduced fee for maternity cases, fractures, and surgery. Of 546 private family practitioners in the province, 121 cared for ninety-two municipalities, two towns and forty-two villages, a total of 116,421 persons in a Saskatchewan population of 930,893 (12.5%).24 In 1937, the average amount owing the doctor by the municipality was $2,503, while one drought-stricken municipality owed its doctor $13,387.60 in unpaid salary.25 In 1941 Dr John J. Collins, a municipal doctor at Ituna, sent a questionnaire to Saskatchewan rural doctors; ninety replied. They were almost unanimous in declaring that private practice was no longer feasible. One replied, “Any system is to be preferred to the present. Collections appear hopeless. I do not know how medical men can hope to carry on out here [all year] under present and future conditions.” In 1941, municipal doctors reported a mean net income of $3,290, after expenses of $2,012, for serving, on average, 1,998 people (roughly $2 per capita). Thirty per cent of income was privately earned, mainly from treating patients from outside the municipality.26 By 1942, a model contract was drawn up by the Health Services Board of the Saskatchewan College of Physicians and

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36 Steps on the Road to Medicare

Surgeons. Each municipal doctor was to be paid at the rate of one cent per day per quarter section, $432 per township, or $3,888 for a nine-township municipality. This payment was to be for 300 days in any calendar year, the doctor to have all Sundays and statutory holidays off. This was a striking departure from tradition, whereby rural doctors were on call twenty-four hours a day, seven days a week. For country calls, the model contract suggested that doctors be paid ten cents per mile each way by car in summer, fifteen cents from 1 November to 31 March, twenty cents for snowmobile travel and thirty cents per mile each way for a horse-drawn vehicle.27 In 1944, there were at least 101 municipal doctors in Saskatchewan. By the peak year of 1947, they cared for 210,000 people, nearly a quarter of the population.28 In 1950, there were still 173 municipal doctors in Saskatchewan.29 Since the municipal doctor system offered immediate guaranteed payment, it was often preferred by young doctors in their first few years of practice. They saw it as an alternative to “starving” in a city while they built up a practice against competition, and waited months or years for patients to pay their bills. The municipal doctor system was beneficial for patients as well, since it encouraged doctors to practice in rural areas. When medicare was introduced in Saskatchewan on 1 July 1962, the need for salaried municipal doctor schemes vanished. With immediate payment from the provincial government, new doctors could begin practice in a city; as a result, totally unplanned and unforeseen by government, many a village, especially one without a hospital, soon lost its doctor. The trend for doctors to cluster in the cities accelerated. Municipal doctor schemes were developed locally in response to need. The councillors of the rural municipality of Sarnia

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Municipal Doctors and Municipal Hospitals

deserve much credit for an innovative idea quickly put into practice; Seymour merits recognition for his rapid response in making it legal. Municipal doctors were another step on the road to medicare.

3. The first legislation in North America to allow Union Hospital Districts, 1916 Municipal hospital programs paralleled those for municipal doctors, but require separate mention. In 1916, legislative provision was made “for the combining of towns, villages and rural municipalities in union hospital districts” (uhds) to erect and maintain a hospital. By 1920, there were ten uhds in Saskatchewan;30 by 1930, twenty; by the early 1940s, twenty-six.31 Alberta was not far behind Saskatchewan in this respect, with its first municipal hospital in the village of Mannville in 1919, followed quickly by hospitals in Bassano, Cardston, Drumheller, Islay, Onoway, Vermilion, and Lloydminster, the last shared with Saskatchewan.32 By 1922, hospitals were added in Hanna, High River, and Provost. Capital, maintenance, and operation costs were provided by the people in the district: the only revenue received from the Alberta government was a grant of fifty cents per day per patient.33 In Saskatchewan, the Sigerist Report in 1944 (chapter 5) gave sudden impetus to building new hospitals and to forming new Union Hospital Districts34 – forty-four new uhds were created in three years. By 1947, the seventy-eight uhds “covered more than one-third of the settled area of the province, included approximately one-third of the population, and provided about three-eighths of the … hospital beds.”35

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36 Steps on the Road to Medicare

4. The first municipal hospital legislation in Canada, 1916 As an exception to the long lists of other Saskatchewan “firsts,” priority in municipal hospital legislation was shared between Alberta and Saskatchewan in the border town of Lloydminster. Here the local hospital, opened in 1906, closed for financial reasons in 1912. David Grieve Tuckwell, editor of the Lloydminster Times, later mayor of Lloydminster 1913–15 and a new arrival from Australia, promoted the idea of a union hospital, supported by the town and six surrounding municipalities. The hospital reopened in October 1913 (figure 3.3). Rural municipality residents contributed one cent per acre; Tuckwell proudly noted that the homesteader, and his wife, family, and dependents, gained hospital accommodation for $1.60 per year, the “very maximum of protection for the very minimum of cost.”36 In 1916, Saskatchewan (first) and Alberta (second), each passed appropriate legislation. In Saskatchewan it read: “The Council of the Town of Lloydminster, the Rural Municipality of Britannia and the Rural Municipality of Wilton may enter into agreement with each other to provide money for the maintenance and extension of the said hospital and for the payment of the [hospital] expenses of their respective ratepayers and residents.”37 The legislation served as an example for other areas.38 Saskatchewan passed a more general Union Hospital Act in 1917. To improve and streamline administration, the Rural Municipality Act was amended in 1927, 1928, 1929, and 1934. The Village Act and the Town Act were amended in 1936.39 As a result of legislation, there were ten Union Hospital districts in 1920; by 1938, there were twenty.

36

Figure 3.3 Lloydminster Union Hospital (sab s-b150)

5. The first legislation in Canada to allow personal taxation for health purposes, 1934 Although Saskatchewan citizens were willing to work together to improve local medical and hospital service delivery, financing these initiatives required creativity and innovation. Previously, health service could be financed only by a tax on property. In 1934, the Rural Municipality Act40 “was amended to empower the council to fix an annual tax for non-ratepayers. This appears to be the first instance in which statutory authority was granted for the levying of a personal tax for health services … in Canada,” asserted medical historian Malcolm Taylor. This legislation made sense: why should rural ratepayers with a land base carry all the costs? Villages and towns had many citizens who did not own a farm, but needed medical and hospital care. Some municipalities began to “break the mould” on munic ipal hospital plans. The rm of Miry Creek, for example, began a hospital plan in 1937 that allowed their residents to

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36 Steps on the Road to Medicare

be hospitalized anywhere in Saskatchewan, not just at the local hospital in Abbey. By 1943 the rm of Pittville used its medical services levy to pay for residents’ medical bills with any doctor, anywhere. Both moves ran contrary to the Rural Municipality Act, but continued nonetheless (for more on these plans, see chapter 6).41 municipal medical and hospital services act: the matt anderson plan, 1939

In 1939, the forward-thinking reeve of rm McKillop at Strasbourg, Norwegian-born Matt Anderson, initiated the Municipal Medical and Hospital Services Act.42 Known as the “Matt Anderson Act,” the plan permitted payment of both hospital (up to a 21 day stay) and medical services through a $5 personal taxation, limited to $50 per family. It combined municipal and hospital plans under one act. The core of the Anderson plan involved choice of doctor: patients were not limited to the local municipal doctor, but could visit one of several doctors in Regina connected to the scheme through medical service agreements. Under these agreements, the doctors would accept 50 per cent of the Saskatchewan College of Physicians and Surgeons schedule of fees as payment in full, when visited by patients under the health plan. By 1944, thirteen rms operated under the “Matt Anderson Act,” 92 had salaried doctors under the Rural Municipality Act, and 118 rms provided hospitalization.43

6. The first Red Cross Outpost Hospital in the British Empire, 1920 A separate initiative, related to municipal hospital plans, was the Red Cross Outpost Hospital program, which started at Pad-

38

Municipal Doctors and Municipal Hospitals

dockwood, Saskatchewan in 1920 – a first in the entire British Empire. Following the First World War, the Red Cross (using funds left over from the war effort) designed cottage hospitals in conjunction with soldier settlement communities. These communities, often in remote rural areas, needed local medical services but were unable to support municipal hospitals through land taxation. Pioneer homesteaders without patent on their land did not pay municipal taxes. Land taxes require ownership. In this scheme, the community would provide the building and look after its maintenance; the Red Cross would find and pay for the staff and supplies. A resident charge nurse, not a doctor, triaged the patients and planned care. Patients with serious illness or injuries were transferred to a hospital or doctor in the nearest large centre. Other patients were capably and routinely stitched, set, delivered, or dispensed by the charge nurse. Patients were expected to pay if they could, but often paid through barter, or fees were waived. Most maternity patients took advantage of the provincial Maternity Grant. Over time, twenty-four outpost hospitals operated in Saskatchewan. By 1946, over 37,000 inpatients and 27,000 outpatients, as well as 8,800 births, had been recorded in Red Cross hospitals. As communities matured and roads improved, outpost hospitals either transformed into municipal hospitals, or closed (see figure 3.4). The outpost hospital initiative allowed poor pioneer and remote communities with a limited taxation base access to medical care, which in essence placed medical care as a right, not a privilege of local wealth.44 By 1948, eighty-eight municipalities provided their residents with hospital service at municipal expense. Sixty-six financed this through a property tax and twelve utilized the Municipal Medical and Hospital Services Act, which allowed a personal tax.45 By 1954, there were 104 union hospital districts.46 As

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36 Steps on the Road to Medicare

Figure 3.4 Paddockwood Red Cross Outpost Hospital, 1948, with nurse Ruth Dulmage Shewchuk in front. (sab Ruth Shewchuk collection)

historian Malcolm Taylor noted, “the construction and maintenance of hospital facilities and the prepayment of medical and hospital services through municipal tax levies – are a tribute to local initiative and the understanding of the importance of health services … a remarkable development not duplicated on such a scale elsewhere in Canada.”47 Once again, Saskatchewan residents worked together to give health a top priority, to a degree not seen in the rest of the country.

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CHAPTER 4

DR FERGUSON AND TUBERCULOSIS

In fighting the disease that for many years took the greatest toll on health and productivity, Robert George Ferguson was one of the most consistent and effective leaders in North America. Sixth in a family of sixteen, he was born 12 September 1883 near the Red River at Joliette, North Dakota, only seventeen miles south of the forty-ninth parallel. At age nineteen he was delegated by his family to choose a farm in Saskatchewan, of similar size to the one being vacated in North Dakota. He selected one at the south edge of Yorkton and moved his parents, brothers, and sisters there. Four years later his father died. George managed the farm in summer and attended Wesley College in Winnipeg in winter, obtaining his ba in 1910, intending a career in the ministry. When his husky voice, the result of childhood diphtheria, did not allow him to preach three sermons each Sunday, he chose medicine as next best, graduating with his md in 1916 (Figure 4.1).1

Figure 4.1 Dr R.G. Ferguson, graduation photo (sla)

Ferguson’s interest in research stemmed from his student experience in Dr S.J.S. Pierce’s laboratory in Winnipeg, making typhoid vaccine for Canadian troops in the First World War. His interest in tuberculosis had been stimulated by his work, while still a medical student, with Dr D.A. Stewart, medical superintendent at the Ninette Sanatorium in Manitoba. Stewart had so much faith in Ferguson’s integrity and ability that he left him, still a final-year medical student, in administrative charge of the sanatorium for a few weeks to go on his honeymoon.

42

Dr Ferguson and Tuberculosis

Ferguson’s first year in medical practice in Winnipeg under Dr A.B. Alexander was the best possible preparation for his later career, with first-hand responsibility at the King George, the infectious disease hospital, and the King Edward, the city’s tuberculosis hospital. During 1916–17 he developed his three postulates of tuberculosis control: 1 Early discovery means early recovery 2 Reduce the level of infection in the community 3 Interrupt the transmission of the tubercle bacillus As Dr G.D. Barnett later commented, these three postulates became the foundation on which the Saskatchewan program was built. In July 1917, Ferguson was appointed acting superintendent of the new sanatorium at Fort Qu’Appelle, Saskatchewan (Figure 4.2), on the recommendation of Dr Stewart. Almost immediately the site became known as Fort San; a full post office by that name existed in the administration building from 1926 to 1966. As the only doctor, Ferguson was on call twenty-four hours a day; he was known to sit up all night holding the hand of a dying patient. In 1919, he attracted two equally dedicated assistants, Dr Harvey Boughton and Dr R.W. Kirkby, whom Ferguson later promoted to direct the new sanatoria in Sask atoon (15 April 1925) and Prince Albert (7 January 1930), respectively. At that time, tuberculosis was epidemic among the First Nations population. It was also much the commonest cause of death in white adults between the ages of twenty and forty-five,2 killing or disabling more able-bodied wage earners and homemakers than did heart disease, cancer, or other infections. Before the widespread advent of x-ray machines, symptoms were insid-

43

ious and non-specific; many patients were in the advanced stage before a correct diagnosis was made. Poverty, overcrowding of large families in small prairie shacks, and malnutrition favoured tuberculosis and in turn led to more poverty. The disease spread through coughing and by the unregulated sale of milk from infected cows.

7. The first grassroots public support for an anti-tuberculosis campaign, 1917–48 Nowhere else in North America did the attack on tuberculosis, or perhaps any other single disease, have as much grassroots support. In spite of the apparently unpromising outlook, Ferguson galvanized, educated, and cajoled an entire province.

44

Figure 4.2 Fort Qu’Appelle Sanatorium, 1918 (sla)

He harnessed the co-operative spirit needed for survival in a new province with poor roads and harsh winters. Rural communities were fertile ground for his persuasive talents. Under his guidance, schoolchildren, teachers, nurses, doctors, service clubs, municipalities, and the provincial government co-operated in a costly but seemingly effective effort, unequalled anywhere else on the continent. The aims were to raise money for the Antituberculosis League and to keep public concern alive. Often the responses were simple, but symbolic. Groups of farmers’ wives, scattered throughout the province and organized as Homemakers’ Clubs, would each donate dozens of eggs or chickens

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36 Steps on the Road to Medicare

to feed patients. The Imperial Order Daughters of the Empire, better known as the iode, made tuberculosis its main concern; members raised money to build the children’s pavilion, furnish the schoolroom, buy books for the library, pay the bills of indigent children, and build and staff a preventorium, where mothers could be isolated from their infants from birth.3 Radio announcers donated their time to put on weekly amateur shows. There was an annual tuberculosis essay contest for schoolchildren. Prospective teachers were taught about tuberculosis at the Normal School, the name then given to the Teachers’ College. Twice, snowstorms led to important, long-term fundraising activities. Ferguson’s timing in each instance was impeccable. In 1934, his car was stuck in the snow and he walked to a railroad car on the track nearby. In it were members of the newly formed Associated Canadian Travelers (act), a group searching for a public service project. When they heard Ferguson’s needs, they agreed to help in the annual Christmas Seal campaign. On another occasion, other act members, stormbound with Ferguson in Nipawin, agreed to try amateur radio broadcasts as a means of raising money, and eventually broadcast these over six stations for more than thirty years. The act raised $813,000 to combat tb between 1934 and 1955.4 In a predominantly rural province, Ferguson, as a son of the farm, understood farmers and spoke their language. He represented the anti-tuberculosis campaign by means of an agrarian metaphor in his 1942 annual report: The people of Saskatchewan know that tuberculosis is a bad weed. In the language of the farmer, it is a perennial which, if not uprooted, will shed its seeds from year to year. When these weeds or cases are sparse the best practice is to find them and remove them before the seeds are shed.

46

Dr Ferguson and Tuberculosis

To do this everyone must learn to identify tuberculosis in the seed, in the sprout, in the leaf, in the flower, or in the ripe shelling. That is why the educational campaign for the prevention of tuberculosis goes on in schools, Normal Schools, families, communities, and throughout the province generally. From past results our people have the faith, confidence and will to eradicate this disease. Come peace, come war, prosperity or depression, this life-saving campaign goes on, resulting in less infection, less new cases, and in the end less deaths.5 In the early years Ferguson made certain that both legislators and doctors were familiar with the sanatorium and its work. On 26 November 1920, he gave a tour of the sanatorium to thirty members of the legislative assembly, and in June 1922 the Saskatchewan Medical Association held its annual meeting at the Fort Qu’Appelle Sanatorium. After I published Ferguson’s biography, I learned of another method he used to ensure legislative awareness. As superintendent, based at Fort Qu’Appelle, he was required to pay a monthly visit to the other two sanatoria, in Saskatoon and Prince Albert. Depending on whether he felt the premier (J.G. Gardiner, 1926–29 and 1934–35) or the minister of health (Dr J.M. Uhrich of Rosthern, 1923–29 and 1934–44) most required some gentle prodding, Ferguson would have his secretary telephone that person’s secretary in Regina to learn when the dignitary was travelling north and on which train (there were four each day to Saskatoon). Ferguson would then be sure he was in Regina in time to catch the same train. This would give him three hours (four-and-a-half hours in the case of Health Minister Uhrich, if he was destined for his home constituency at Rosthern) to chat. Thus, those in authority, the decision-makers,

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36 Steps on the Road to Medicare

knew all about the problems and needs of all three sanatoria, the monthly field clinics in each major city and town, and so on. No person in a position such as Ferguson’s in our faster, busier age has the slightest hope for such close personal contact with those in authority. Ferguson was a rare person, superb in every aspect of his work. He had skills in teaching, clinical work, and research, and was also talented in administration and public relations. He knew exactly how to comfort the suffering, homesick, and lonesome. In his quiet way, by example and conviction, he taught everyone who came in contact with him and his work: doctors, nurses, medical students, patients and their families, and the general public. Ferguson was one of the first sanatorium administrators in Canada to give a high priority to continuing education for his medical staff. Even when the San was hopelessly in debt during years of drought and depression, even when short-handed during wartime, he sent his staff away to learn. In spite of the time and expense to get there, London, England, was one of the most popular destinations because of its renowned teachers and the wealth of clinical experience available. Members of the medical staff often took an entire year of postgraduate training at the sanatorium’s expense; each year at least one sanatorium physician went away for special studies. Training was sometimes rewarded by success in the Royal College of Physicians (mrcp) examination.6 Over the years, this education proved to be a good investment. Radiographers, nurses, and dietitians were regularly sent away for short courses and practical experience in another institution. There was no requirement of years of service to become eligible for further education. If the sanatorium needed someone trained in a new technique and a young staff member was

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Dr Ferguson and Tuberculosis

eager to learn, an educational opportunity was available after only one or two years of employment. Dr Harvey Boughton was the first to take educational leave; he spent two weeks in Winnipeg in 1920. Next, Ferguson went to Boston for two months in 1920; he spent one month studying heart disease with Dr Paul White, a world-renowned cardiologist, and three weeks taking a $100 course in internal medicine at Harvard University. Ferguson believed that the physician who is limited to treating one disease is “apt to develop a blind side, and to lose his true perspective in the interpretation of symptoms which are the common stock of widely different diseases.”7 To recognize early tuberculosis, one had to keep in touch with the whole field of internal medicine. In Boston, one of the first centres to provide courses for graduates in medicine, alongside a splendid medical library, a doctor’s medical experience and perspectives could be broadened. Later, Ferguson arranged for every student nurse in Saskatchewan to attend an eight-week affiliation course at a sanatorium. Between 1 June 1945 and May 1964, 3,774 student nurses had this practical experience at either the Fort Qu’Appelle or the Saskatoon sanatorium. Transportation and sickness expenses were paid by the sanatoria. The affiliate nursing course ended at Fort San in October 1962 and at the Saskatoon San in May 1964.

8. The first province to determine the prevalence of tuberculosis, 1921–22 After only four years as head of the tuberculosis program, Ferguson convinced the powers-that-be that little was known about the disease anywhere in North America. He persuaded the government to form the Saskatchewan Anti-tuberculosis Commission

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to determine the prevalence of tuberculosis in the Saskatchewan population and to plan future sanatorium beds on the basis of the findings. Not only was his wish granted, but he was made secretary of the commission when it was appointed by Orderin-Council on 22 July 1921, thereby gaining the staff and funds to research the extent of the tb problem in Saskatchewan. Thus, he was able to write his own ticket. The recommendations of the final report of the commission did not gather dust on a shelf, as do many government reports today, but instead formulated Ferguson’s lifelong objectives. Few medical men have had, early in their careers, an opportunity to document the extent of a target disease and in doing so, to plan for ways to combat it, setting the direction of their life work. Of the commission’s recommendations, published in October 1922, the first four were considered mandatory:8 1 Hospital and sanatorium accommodation must be increased to care for those who are spreaders of the disease. The Commission recommended the construction of two new sanatoria of at least one hundred beds each, to allow the average patient twelve months of treatment. 2 There must be provision for the care of children from homes where open tuberculosis is found. A preventorium should be established to prevent the newborn infant from contracting tuberculosis from its mother. Children should be separated from actively tuberculous parents. 3 The system of financing the cost of treatment must enable all those who need treatment to obtain it with the least delay. 4 Diagnostic facilities must be improved and extended to all parts of the province, along with a nursing service and follow-up of all ex-tuberculous patients.

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Dr Ferguson and Tuberculosis

As an additional bonus, when the commission disbanded, Ferguson co-opted its chairman, A.B. Cook, Regina’s sheriff, to become managing director of the Saskatchewan Anti-tuberculosis League and thus ensured its success.

9. The first representative cross-sectional school studies of tuberculosis, 1921 As part of the research necessary for the commission report, arrangements were made with school boards to examine about 200 children between the ages of six and fourteen in each of seven representative communities: Regina, Saskatoon, Moose Jaw, North Battleford, Cupar, Stoughton, and Heward. Each child received a physical examination by a chest specialist; an ear, nose, and throat specialist; and a dentist. Eighty of these children were selected, on the basis of physical findings, for a chest radiograph.9 Of the 1,184 children examined, ten had active tuberculosis; another fifteen were found to have tuberculosis on the followup chest radiograph. A positive tuberculin test in 56.6 per cent of children indicated they had been exposed to tuberculosis (44% by age six and 61% by age fourteen). Of an additional 162 First Nations children examined in residential schools, 93.1 per cent had a positive tuberculin test. Normal School students had a 75.6 per cent positive tuberculin test rate, and 0.9 per cent had active tuberculosis. They were followed up annually throughout Ferguson’s career; he watched with satisfaction the steady drop in the rate of positive tests. Of 185 dairy cows in the same communities, 18.5 per cent tested positive.

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36 Steps on the Road to Medicare

These baseline studies were, for their era, unusually sophisticated proportional samplings of representative communities. In his history of tuberculosis in Canada, Wherrett confirms that these studies were the first in Canada.10

10. The first traveling tuberculosis clinics, 1923 The Wherrett-Grzybowski report in May 1966 acknowledged that the credit for sponsoring Canada’s first traveling clinics was shared between Saskatchewan and Ontario.11 Clinics began in Regina in September 1923 and in Moose Jaw in May 1928, and for some years were held one day per week. Follow-up clinics were also offered in two Saskatoon hospitals and at Fort San. Once-a-month clinics, chiefly for patients referred by general practitioners for diagnosis of lung disease, were held in North Battleford and Swift Current (beginning in 1930), Yorkton and Canora (1933), Tisdale and Melfort (1934), and Wadena (1940).12

11. The first universal free diagnosis and treatment of tuberculosis, 1 January 1929 Ferguson worked systematically to gain grassroots support for free treatment of tuberculosis, advocated in the commission report in 1922. It took seven years. Few could afford to pay for a year or more of treatment in a sanatorium. But from 1917 until 1928 it was Saskatchewan’s policy that “all who were able to pay were required to pay.” In 1924, twenty-nine of 295 patients (9.8%) paid part of the costs for their treatment, even though some were bankrupted and returned home penniless. By 1928, only 2.5 per cent could pay for their treatment. The other 97.5 per cent required at least

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Dr Ferguson and Tuberculosis

partial financial help from their urban or rural municipal government. Saskatchewan’s Rural Municipal Act of 1920 required each rm to contribute $100 annually to the sanatorium. In 1921, the $30,100 from 301 rural municipalities was set aside as the nucleus of a pool to pay for the treatment of indigent rural patients. Rural municipalities in this way got a four-year head start on their urban counterparts, on the path towards “free treatment.” The Saskatchewan Association of Rural Municipalities (sarm), then the most influential organization in the province, complained at its annual meeting in March 1921 that the urban municipalities were exempt from this levy. In 1925, an urban pool was formed. Without both rural and urban municipal contributions, the sanatoria would have been insolvent. The first resolution to advocate totally free treatment for tuberculosis was introduced at the sarm annual meeting in 1925. Only six of the 600 representatives voted for it. Yet the seed had been planted and the idea grew. In 1926, there were twenty votes in favour. In 1927, a different motion, that the provincial government take over direct control of the sanatoria, carried by a small majority. The government, normally very responsive to resolutions from sarm, countered that they could not afford it. At the annual meeting of sarm in March 1928, a momentous resolution was moved by rm Weyburn #67 to petition Saskatchewan legislators “to amend the Sanatoria Act so that all classes of T.B. patients shall have free treatment available at the public expense … paid partly by the [provincial] government [and] partly by all rural and urban municipalities.”13 In the midst of the discussion, an ex-patient of Fort Qu’Appelle Sanatorium, now cured and employed as secretary of his

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municipality for nine years, stood up. There, before the eyes of all doubting Thomases, as was remarked later, stood a living example of what could be and was being done through efficient and timely treatment of tuberculosis. This time the motion passed unanimously. A similar resolution was later passed by the Saskatchewan Urban Municipal Association and by the United Farmers. Times were good just before the stock market crash and the depression. As soon as the legislature next met, early in December 1928, the Liberal government of James G. Gardiner presented the Saskatchewan Sanatoria and Hospitals Act. As a government bill, it passed readily. What was amazing was the speed of implementation. The new system of free treatment came into effect in less than a month, on 1 January 1929. The Honourable Sam J. Latta, minister of municipal affairs, characterized the new act as “a great social experiment – and a costly one at that.”14 Roughly half of the league’s operating funds came directly from the rural and urban municipalities, a greater participation than in any other province, “a distinctly Saskatchewan approach.”15 The municipal funding, of course, was not subject to competition from highways and welfare in annual government budgets. It was not unusual for a rural municipality in a given year to spend more money on one disease, tuberculosis, than on roads! There were immediate benefits. As Ferguson reported, “the effect of removing the financial barrier is earlier treatment, earlier isolation, and an [initial] increase in the number of days treatment and the gross cost, but the end result will be more cures and a shorter period of disability, lessened spread of the disease, a lower death rate, and eventually [fewer] new cases.”16 It was seven years before the next province, Alberta, offered free treatment in 1936. Manitoba followed in 1946.

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Dr Ferguson and Tuberculosis

Saskatchewan’s health minister, Allan Blakeney, said in 1964, “the introduction of diagnosis and treatment of tuberculosis at public expense was one of the early and essential steps in developing a program of health services available to all.”17 To have Saskatchewan lead all other jurisdictions in North America, the first to provide free treatment of tuberculosis, the most expensive disease that took longest to cure, was one of Ferguson’s greatest accomplishments. Saskatchewan’s success with universal availability of tuberculosis diagnosis and treatment became an important stepping stone toward universal hospitalization insurance and medicare.

12. The first epidemiologic study of susceptible First Nations people exposed to tuberculosis, 1928 Ferguson’s landmark study of the prevalence of tuberculosis as it reached “fertile ground,” a population with no previous history of exposure to the disease, is one of the best of a very few epidemiologic accounts of such a process anywhere in the world. A new infection, arriving for the first time, hits with great severity, affects almost any body organ at any age, and has a high mortality. Then, as the most susceptible die off and only the more resistant individuals survive, there is a natural and inevitable drop in the number of new cases of that disease. It is more humane and more efficient to prevent disease than to cure it. With his deep concern for First Nations people, Ferguson obtained annual research grants from Canada’s National Research Council (nrc), from 1926 until his retirement in 1948. These grants financed his studies of tb prevalence on adjacent Indian reserves, the first Bacille Calmette-Guérin (bcg) vaccination of First Nations infants, and the first in student nurses. The nrc had been formed on 29 November 1916, and

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its eleventh committee was formed in 1925 to study tuberculosis, initially in cattle. Ferguson graphed the rapid increase in deaths from tuberculosis among First Nations at the Qu’Appelle and File Hills agencies (figure 4.3) as they settled in small houses in close proximity to each other on reserves. Under the new conditions of stationary life, intermittent hunger, and cultural demoralization, the annual death rate from tuberculosis among First Nations was roughly 1,000 per 100,000 population in 1881. It quickly increased to reach the proportions of a serious epidemic by 1884, and became maximal in 1886 at 9,000 per 100,000 per year, about double the birth rate and accounting for two-thirds of all First Nations deaths. By 1895 the rate had dropped to 3,000, by 1901 to 2,000, and by 1907 was back to 1,000 per 100,000. Changes in living or sanitary conditions did not explain the drop. Ferguson recognized that this was the inevitable and natural course of a new epidemic on what researchers call “virgin soil” or a new population. Virtually all Indian children were “tuberculized”; by the age of eleven to fifteen, over 96 per cent had a positive tuberculin test.18 His field work began in 1926 with a thorough examination of children on the File Hills and Qu’Appelle reserves and those attending the Lebret and File Hills Indian schools. Such surveys became annual events. Ferguson recognized the need to determine the prevalence of tuberculosis in First Nations adults as well. How was he to get them together for chest radiographs in rural areas far from electrical sources? He had the brilliant inspiration to join the annual treaty party, when First Nations congregated to receive treaty money of $5 each. He persuaded the Victor X-ray Corporation of Winnipeg to supply a portable x-ray machine and the Delco Light Company of Regina to supply a portable generator. In the

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Dr Ferguson and Tuberculosis

second week of July 1927, all this equipment accompanied the treaty party to the File Hills Reserve, where full compliance was achieved and 130 adults were x-rayed. In 1928, Ferguson presented his landmark report at the prestigious meeting of the National Association for the Prevention of Tuberculosis in Great Britain: The moral and physical weakening of the Indian has to do with the introduction of the horse … firearms … liquor, the exchange of their fur tunics for the blanket, the exchange of the clothes necessary for warmth for alcohol, the extermination of the buffalo and the beaver, the concentrations upon reserves, the change of housing, the change of food, the exclusion of sun … by the clothing of the children; the compulsory concentration of children in

Figure 4.3 Graph of tuberculosis epidemic among First Nations (sla)

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schools, the change of occupation from hunting and warring to agricultural pursuits, and, on the mental side, the psychical depression of conquest by the whites, dependence on Government rations for food, visible ravages of white man’s diseases, desertion by, or incompetency of, their Michi-Manitou and triumph of Kitchi-Manitou, and failure of even the white man’s religion to protect them … The nudity of the Indian children in summer … was ended abruptly … The agents, in their zeal … instructed the parents to clothe their children. Thus for the first time in the history of the race the bountiful summer sun’s rays were largely excluded … a lowering of resistance to disease developed.19 Ferguson’s dedication to First Nations is exemplified by the four-week canoe trip he took in 1927, departing from the end of steel at Big River, to inspect those with tuberculosis at Ile-àla-Crosse and La Loche. Six years later, Dr Andrews from the Prince Albert Sanatorium made the first airplane flight to Ile-àla-Crosse. Ferguson treated First Nations patients as equals, as any compassionate doctor would. They in turn respected him. In 1935, they gave him what he considered the greatest honour of his life, a ceremony naming him as an honourary chief – MuskekeO-Kemacan (figure 4.4). First Nations people were not legally a responsibility of the Saskatchewan Anti-tuberculosis League, a provincial organization, but of the Government of Canada. In spite of this, one of Ferguson’s top priorities throughout his life was to reduce the ravages of the disease among that population. He engineered an agreement with the federal government in 1924 whereby forty beds were allocated for First Nations at the San as a means

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Dr Ferguson and Tuberculosis

of paying off some of the capital advanced by the province near the end of the First World War. Once the Prince Albert Sanatorium opened on 7 January 1930, there were adequate beds for Saskatchewan’s First Nations population, both adults and children. In striking contrast, Manitoba First Nations gained access to sanatorium treatment only in 1946 when the Clearwater Sanatorium opened in wartime United States Air Force buildings.

13. The first statistically controlled BCG vaccination among newborn First Nations infants, 1932–49 Between 1933 and 1943, Ferguson and his former University of Manitoba medical school classmate Dr Austin Simes, of the

Figure 4.4 Muskeke-O-Kemacan, Great White Physician (sla)

36 Steps on the Road to Medicare

Indian Health Unit, vaccinated 306 First Nations infants at birth. Another 303 infants served as controls. Their study was statistically sophisticated for its time – although through imperfect randomization by Dr Simes (tossing a coin for each subject would have been sufficient!), the bcg study lost the opportunity to be the world’s first fully randomized clinical trial.20 Ferguson and Simes’ joint paper showed that the incidence of tuberculosis was nearly five times greater in the unvaccinated, whose disease was more severe and more widespread than in the vaccinated group.21 The bcg studies were carried out in the face of frank hostility to bcg throughout the English-speaking world, apart from the strong support of the Canadian bcg pioneer, Armand Frappier in Montreal. Other North American doctors mistrusted live-bacteria vaccines in general and bcg in particular.

14. The first 1934–43

BCG

vaccination among student nurses,

Because 5 per cent of student nurses and nurses in western Canadian hospitals “broke down” (the term used in standard medical parlance) with tuberculosis, all tuberculin-negative student nurses in Saskatchewan hospitals and all tuberculin-negative sanatorium and mental hospital employees were given bcg vaccination. Ferguson reported in 1946 that this measure reduced the number of cases of manifest tuberculosis to less than a quarter of the previous rate for nurses, to one-fifth of the previous rate for sanatorium employees, and to one-fifth of the rate among student nurses in adjoining Manitoba.22 In subsequent years, this vaccination was extended to tuberculin-negative members of families in which tuberculosis had occurred.

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Dr Ferguson and Tuberculosis

15. The first provincewide photofluorographic surveys, 1942–47 Ferguson organized the first provincewide photofluorographic survey in North America, 1942–47. Since no machines were available commercially, he encouraged his radiographer, Robert Connell (figure 4.5), to develop a method of photographing a fluoroscopic screen with a 35-mm camera (figure 4.6). Connell was aided by Richard Tizley, a welder hired on the day the Second World War began. A second-hand van was purchased for $250 and trial mobile community surveys began in 1941. The aim was to achieve early diagnosis, when the disease would respond most readily to the simple measures then available – bed rest, fresh air, and good food. During the second Saskatoon survey in 1948, 41,082 of the 43,016 residents were radio graphed – the highest rate of participation ever reached (95.5%). About one new, active case of tuberculosis was found per thousand people.23 The survey was staffed by unpaid local volunteers in each village or town, all vying for a higher turnout than in the neighbouring town. Other expenses were met through funds raised by the act amateur hours on all Saskatchewan radio stations and by the annual Christmas Seal campaign. The survey of the entire province was completed in 1947; a second survey began immediately. In 1948, the Anti-tuberculosis League began to pay for a chest radiograph of every patient admitted to hospital. This program was fully operative in every one of 109 Saskatchewan hospitals by 1950. Since people admitted to hospital were more apt to be ill, this became one of the most effective means of detecting new cases of tuberculosis and, as a side effect, detected a roughly equal number of unsuspected lung cancers.

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Figure 4.5 Robert G. Connell (Mrs. G. Connell)

Figure 4.6 Photofluorograph machine used for mass tb surveys (sla)

Dr Ferguson and Tuberculosis

16. The first province with sufficient beds for tuberculosis patients, 1942 From 1921 through 1940, Saskatchewan had a lower tuberculosis mortality rate than any other province.24 Saskatchewan was the first province “to provide sufficient sanatorium beds to treat all tuberculous patients,” the aimed-for ratio being three beds for every tuberculosis death.25 The necessary facilities were disproportionate in size and cost considering the up-and-down finances of an agrarian province. High capital costs were combined with high costs of identifying patients with the disease. why was saskatchewan a leader?

The answer relates, in part, to the calibre of Ferguson, the strong support his own conviction generated, and the administration of the entire program by a “semi-official body, mainly lay and voluntary in its operation.”26 Where else could Ferguson have reached out to every farmer? Where else could he have garnered such solid grassroots support? Where else was such a highly developed social conscience and community co-operation the basis of everyday life? As Premier T.C. Douglas said at the fiftieth anniversary of the founding of the Anti-tuberculosis League, Saskatchewan people had developed “a special capacity to meet and solve problems that by far excels more fortunate places.” Douglas was right. The league had obtained “the support and co-operation of the public to a greater degree than [in] any other province.”27 This public- spirited group has continued its work in preventive medicine since 1981 as the Saskatchewan Lung Association, now the Lung Association of Saskatchewan.28

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lowest tuberculosis death rate in canada

Ferguson’s work bore fruit. He witnessed the decline of case rates from 98 per 100,000 population in 1925 to 51 per 100,000 in 1948. However, incidence and death rates also declined in regions that lacked sanatoria, representing the natural course of any epidemic. Then, with the advent of streptomycin and para-amino-salicyclic acid in 1948, tuberculosis death rates fell sharply. The Prince Albert Sanatorium was closed in 1961, Fort San in 1972, and the Saskatoon San in stages: it stopped taking inpatients in 1978 and outpatients in 1982, and its lab closed in 1986. Overall, though, Saskatchewan had the lowest tuberculosis death rates in Canada from 1921 through 1944 and again in 1954, 1957, 1958, and 1966.29 ferguson in later life

Ferguson was made a Member of the Order of the British Empire (mbe) on the king’s birthday in 1935. He received an honourary lld from the University of Saskatchewan in 1946. He retired on his sixty-fifth birthday, 12 September 1948. His next six years were spent in researching and writing his highly acclaimed book, Studies in Tuberculosis, published by the University of Toronto Press in 1955.30 He received the prestigious Charles Mickle Fellowship in 1961. His portrait, by artist Nicholas de Grandmaison, was commissioned by his friends in 1962. Ferguson died on 1 March 1964. some reasons for ferguson’s success

Ferguson was an unassuming, soft-spoken, compassionate doctor. His personal charm, vision, strength of purpose, and scientific methodology were to make him a leader in North America’s fight against tuberculosis. His quiet influence with the premier and the Department of Health and his compelling per-

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Dr Ferguson and Tuberculosis

suasiveness worked wonders. He had a lifelong knack for getting what he wanted from governments. Ferguson had the full support of the Anti-tuberculosis League’s dedicated board of directors. Peter McAra was mayor of Regina when he became the founding president of the league; McAra continued on the board of directors after he stepped down as first president, and he served again as president from 1930 to 1941. E.G. Hingley represented sarm for forty years and was president of the league from 1945 until his death in 1958. Dr F.W. Hart of Indian Head, an original trustee from 1911 to 1918, returned to the board as representative of the Saskatchewan Medical Association from 1932 to 1946. His son, Bob, married Ferguson’s daughter, Helen. Ferguson’s timing throughout the first thirteen years of his campaign was perfect. The return of veterans after the First World War caused the federal government to pour needed money into new buildings at Fort San; the higher federal per diem rate also helped augment the league’s bank balance. Free tuberculosis treatment passed the legislature in 1928, in part because the farm economy was buoyant in the late 1920s. The First World War had also changed public attitudes more than anyone realized; few other “charities” had as much appeal. All three Saskatchewan sanatoria took great care to maintain good relationships with all practising doctors. As Boughton said later of Ferguson, “One of his long suits was to play hand-inglove with the doctors who referred patients.” Ferguson consistently gained maximum government support, yet he kept a tight rein on management. There was no patronage and no featherbedding. The league provided a marvellous bargain to Saskatchewan in terms of service per patient day per dollar. Whether the Liberals or Conservatives were in power, Ferguson had immediate access to the premier and the minister

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of public health. (When the ccf gained power, Tommy Douglas confided to my father that the province’s recommendation to Ottawa that Ferguson be named Saskatchewan’s lieutenantgovernor had not been successful.) The league, followed by the Saskatchewan Lung Association, operated the sanatoria and clinics – the entire tuberculosis program – until 1987. Members of each successive government realized, sometimes contrary to dogma, that the arrangement was mutually beneficial. The various levels of government put up the money, and the league ran the incredibly cost-efficient organization, with a great deal of help from many volunteers and private organizations. At the same time the league attracted exceptionally dedicated people and provided a high standard of care. Ferguson’s other appointments and awards included: president of the Saskatchewan Medical Association (1922); fellow of the American College of Chest Physicians; member of the Senate of the University of Saskatchewan (1923–28); life member of the Royal Canadian Legion. R.G. Ferguson, mbe, ba, md, lld, 1883–1964, is remembered with respect and affection. His name is commemorated by the R.G. Ferguson professorship at the University of Saskatchewan, by the Dr George Ferguson School in Regina, and by one of Saskatchewan’s largest islands, Ferguson Island in Montreal Lake. “His resting place is in the valley he loved, but his shrine is in the hearts of the people of Saskatchewan.”31 George Ferguson! You should be here today. Saskatchewan needs you: she believes that tuberculosis Is controlled, That public health is no longer at risk,

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That the province’s wealth should be used to acquire luxury. Wake us up; show us again with your towering wisdom How to walk the common path of man; And perform the lowliest task with cheer.32 postscript

The number of new cases of tuberculosis among the non-First Nations population in Saskatchewan decreased from 931 in 1926 to 43 in 1990. In 1962 the mobile x-ray took chest radiographs of 3,462 Aboriginal people in northern Saskatchewan, those in the highest risk area, and found not one new case of tuberculosis. But the apparent defeat of the disease, especially in northern Saskatchewan, was short-lived. Sadly, the optimism so evident in 1964, the year Ferguson died, has since palled. Saskatchewan is no longer a leader. In 1987, its largest census area, the northern half of the province, had the highest rate of active new cases of tuberculosis (248.6 per 100,000) of any complete census region in Canada, and the Meadow Lake census division had the eighth-worst record in the country. Two reserves, Buffalo River and Portage la Loche, had rates of 1,000 per 100,000, 400 times that of Caucasians in southern Saskatchewan.33 In 1965, treaty Indians comprised 3 per cent of the Saskatchewan population, yet they had 75 new (not previously reported) cases of tuberculosis. These accounted for 34 per cent of the provincial total, a rate of 260 per thousand. In 1990, First Nations comprised 6 per cent of the population; their 156 new cases of tuberculosis accounted for 75 per cent of the total, at a rate of 267 per thousand.34 In 2012 the rates of new and relapsed cases of tuberculosis in Saskatchewan had dropped to 8.2 per 100,000. That year there were 55 new First Nations

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cases of tuberculosis, a rate of 49 per 100,000, and only 8 of those had primary tuberculosis, a marked improvement.35 Directly Observed Therapy (dot) was introduced into Saskatchewan in the autumn of 1989, to diminish the frequency of treatment failure and of very costly drug resistance. With another person identified to watch patients swallow their pills twice a week, selective breeding of resistant tb bacilli has greatly diminished. In the first four years with dot, compliance rose to over 85 per cent, drug resistance diminished from 13 per cent to 2 per cent, costs decreased to one-fifth the amount for self-administered treatment, and there were fewer hospital admissions.36

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CHAPTER 5

SIGERIST AND PENSIONERS’ CARE

Saskatchewan took a bold step toward medicare in 1944, not through health research or policy or management, but through politics. The province elected:

17. North America’s first social democratic government, 1944 “No person has had as profound an effect on the restructuring of health services in Canada as Tommy Douglas, that doughty little Scottish socialist fighter and orator”1 (figure 5.1). Douglas was “among the greatest political campaigners Canada has known.”2 His Co-operative Commonwealth Federation (ccf) party won a landslide victory, forty-three of the fifty-two seats, in the Saskatchewan election of 15 June 1944 and took office 10 July 1944. The ccf had a triumphant convention following this victory on 13 July 1944.3 Health was Tommy’s number one priority then and throughout his tenure as premier.4 To be certain that health matters were

Figure 5.1 Premier T.C. Douglas (sab r-a3421)

Sigerist and Pensioners’ Care

front and centre, Douglas assumed the health portfolio himself.5 For his first four-year term of office and into his second term, he carried this heavy burden in addition to his responsibilities as premier.

18. The Sigerist Commission, 1944: The first forward-looking provincewide survey to plan for future health needs One of Douglas’s very first priorities, the day after the election, was to contact Dr Henry Sigerist (figure 5.2), professor of the history of medicine at Johns Hopkins University,6 and author of a book that took a rosy view of Soviet medicine,7 to head a health study commission. Although Sigerist was a “physician of international reputation,” as Malcolm Taylor wrote, “there was a great deal of criticism later that a professor of the history of medicine … had been chosen rather than an expert in health services organization and administration.”8 Dr J. Lloyd Brown of Regina was the representative of the medical profession.9 The working group was known as the Saskatchewan Health Services Survey Commission (shssc). Sigerist and the other members began work on 6 September 1944. The commission visited various points across the province and conducted hearings to allow rural health advocates a place to present their initiatives. The files for the survey are held in the Saskatchewan Archives Board, and provide a snapshot of health ideas and concerns brewing in that moment. Several briefs stand out. sarm presented a ten-page brief that outlined various municipal hospital and salaried doctor schemes operating successfully in the province (see chapter 3).10 William J. Burak, reeve of the rm of Pittville, provided details of Pittville’s plan, which paid for hospitalization and doctor visits

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anywhere, for any length of time. His brief emphasized comprehensive coverage, freedom of choice, and local control.11 Matt Anderson, who spearheaded the “Matt Anderson Act” passed in 1939, emphasized the importance of free choice of doctor by the patient.12 Charles H. Chapin, secretary of rm McKillop, presented the full financial statements of what was known as Health Insurance District #1 (which was different from Swift Current Health Region #1; see chapter 6). Chapin pointed out that the health insurance scheme devised in his area of the province “relieved our residents of the financial worry of sickness and taught them to take early actions when any illness or symptoms appear.”13 Sigerist completed visits and hearings by 23 September, finished the report at five minutes after midnight on 1 October,14 and presented his formal report on 4 October 1944.15 As was the case with Lord Stephen Taylor, a medical doctor who gained the confidence of the profession and resolved the medicare dispute in 1962, Sigerist served without pay. His stay in Saskatchewan was too short, yet he accomplished a great deal. He recommended establishment of district health regions for preventive medicine, each centred on a district hospital equipped with an x-ray machine, a medical laboratory, and an ambulance. He advocated rural health centres with eight to ten maternity beds, staffed by a registered nurse and one or more municipal doctors. The municipal doctor plans, he wrote, should be “main tained and developed.”16 He noted that the public must be educated to seek medical advice at the centres, so that each doctor would no longer “spend a large part of his time driving around the country.” Patients were slowly becoming accustomed to seeking medical care in a centralized location. Recognizing that municipal doctors were overworked and underpaid, Sigerist suggested that they receive annual vacations

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Sigerist and Pensioners’ Care

Figure 5.2 Henry Sigerist at desk

with pay. Dr Elden Hitsman of Strasbourg in the rm of McKillop, which operated under the Matt Anderson plan, regularly took vacations while the health district paid a locum (replacement).17 Sigerist proposed “free hospitalization,” which he estimated would cost $3.60 per person per annum,18 and would require another 1,000 to 1,500 hospital beds in Saskatchewan,

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including a 500-bed university hospital attached to a new medical college in Saskatoon. He analyzed succinctly the thencurrent situation and offered solutions. It is easy, with hindsight, to realize that Sigerist’s crystal ball left much to be desired. His recommendation to build or improve many small village hospitals would have been appropriate in the 1930s but not as forward planning for the 1950s and 1960s. By following his report, Saskatchewan was saddled with too many small, one-doctor hospitals. Sigerist did not foresee that, farther down the road, the larger hospitals with better facilities and two or more doctors could, with improved highways, be reached more quickly in subsequent decades. Nor did he realize that doctors would desire relief from being on call twenty-four hours a day, seven days a week. Sigerist, a historian of medicine and not a futurist, also failed to foresee the rapidity of technological change that was already on the horizon. He overlooked the fact that larger farm machinery and highway improvement would contribute to rapid decline in the population of rural municipalities and villages and to increasing use by rural people of business and professional services in the cities. In the hospitals, rather than suggesting there be training of more x-ray technicians, or of combined laboratory and x-ray technologists appropriate for one-doctor hospitals, he recommended that “one nurse in every hospital be trained to handle the x-ray machine and the routine clinical laboratory work.”19 When he advocated consideration of sterilization for mental defectives, then popular in many jurisdictions, he failed to appreciate the ethical considerations involved. He demonstrated incredible naïveté when he prophesied that the complete eradication of venereal disease could be achieved in the near future.

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Sigerist and Pensioners’ Care

Professor Milton Roemer of the University of California, Los Angeles, nonetheless described the Sigerist report as “one of the most advanced health services reports of its time.”20 It provided the “blueprint” for medical care in Saskatchewan for half a century. Sigerist, in looking back on his life in 1950, admitted that he had rarely experienced “a warm feeling of having accomplished a job well,” but that one of these occasions was in 1944, on returning from Saskatchewan.21 douglas’s promises to doctors

At no time did Douglas make a salaried medical service a ccf platform plank.22 Indeed, his letter to J. Lloyd Brown dated 19 September 1945, published in the Saskatchewan Medical Quarterly that December, promised the medical profession that: (1) “a health insurance scheme shall be administered by a Commission which shall be free from political interference and influence”; (2) this commission “shall be representative of the public, those giving the service, and the Government”; (3) the commission “shall have sufficient power and jurisdiction to establish and to administer a plan”; (4) the chairman “shall be a physician”; (5) “no commissioner, representing a profession, shall be appointed except with the approval of the profession concerned”; and (6) “the professional committees shall have unrestricted jurisdiction over all scientific, technical, and professional matters.”23

19. The first comprehensive Social Assistance Plan for pensioners and widows, 1945 Douglas’s next urgent health priority was to provide comprehensive health care for those requiring social assistance, “old

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age and blind pensioners, widows on mother’s allowance, and their dependents.” There were 28,000 such people on the government rolls.24 On average, each doctor would have about fifty of these people as patients. Douglas met with the council of the College of Physicians and Surgeons of Saskatchewan on 23 August 1944 at Hotel Saskatchewan, two weeks before the arrival of Sigerist. The profession co-operated to the fullest. My father came home from the meeting bemused by the course of events. Douglas had asked the council for their estimate of what such a program would cost. The doctors did not know. They asked Douglas for his best guess. He didn’t know. Both sides recognized that these patients required an above-average amount of medical care. Nevertheless, they amicably agreed to use the figure suggested as the cost of medical care by the federal Heagerty Interdepartmental Advisory Committee on Health Insurance in December 1942 – $9.50 per person per year.25 At the annual meeting of the Saskatchewan Medical Association in September 1944, doctors agreed to monitor and police the plan for the agreed-upon fixed lump sum, on a one-year experimental basis. Final agreement was concluded on 1 October 1944, for implementation on 1 January 1945 of what was named the Saskatchewan Social Assistance Plan. By 1957 this plan had over 30,000 beneficiaries.26 This cordial agreement, reached “with extraordinary speed,”27 was welcome to everyone – what we would call today a win-win decision. The patients gained the right to health care without incurring a debt they had little hope of paying. Their families were relieved of responsibility. Municipalities were freed from any obligation to pay for indigents’ care. The doctors were paid for caring for individuals who had rarely been able to pay them in the past. The profession’s cornerstone method of payment – fee-for-service – had not been challenged.

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Sigerist and Pensioners’ Care

The key benefit for the government side, lost in all subsequent financing of health care, was that it could budget for an exact sum, the “ceiling principle,” without risk of over-expenditure. The doctors agreed to accept a fixed sum for any given year. Further, the government’s right to fund a major medical care program had been acknowledged with the new Saskatchewan Social Assistance Plan.28 Douglas had achieved his first health goal and his government had scored on the public opinion front. This scenario was as close to perfection as was ever possible in an imperfect world. The scheme was a success. The doctors themselves policed this scheme to ensure an equitable division of earnings. They could be much tougher on an over-billing member than any government agency. A doctor submitting an account was paid fifty cents on the dollar. The residual was divided proportionately at the end of the year, depending on the number of dollars unexpended in the fund. In 1945, the final payment brought that year’s earnings to 77.5 per cent of the fee schedule, and then in 1946, with increased utilization by patients, earnings dropped to 59 per cent. That year each doctor received a cheque at the end of the year for the final 9 per cent.29 In 1949, the profession negotiated a raise to $12 per capita,30 then to $15, and finally to $21 in 1958.31 Following the Sigerist report, the government moved to create the Health Services Planning Commission (hspc) in November 1944. Its mandate was to shepherd the report recommendations and other briefs and ideas relating to medical needs into policy. Dr Mindel Sheps acted as secretary, alongside Clarence Gibson (an experienced hospital administrator) and Tommy McLeod (Douglas’ financial wizard). The Sigerist report and the Social Assistance Plan were solid achievements in the first six months of North America’s first social-democratic government. The Sigerist report laid out a

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blueprint for change and created a forum for innovative discussion and ideas, and paved the way for Saskatchewan municipalities to band together to establish health districts. Douglas deserves full credit for giving health a higher priority than any political leader before or since. His dedication was coupled with charisma, a legendary sense of humour, and a remarkable adaptability which made the best of any situation. McLeod and McLeod note that Douglas had “brought to the political life of the country a civility that enriched the Canadian scene,” while carrying “a remarkably light load of ideological dogma.”32

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CHAPTER 6

S W I F T C U R R E N T H E A LT H R E G I O N

Joan Feather opens her two landmark articles on the history of the Swift Current Health Region with the following statement: Southwestern Saskatchewan seems an unlikely place for a major experiment in universal, prepaid health services. Rolling grassland, short, hardy crops struggling against drought and wind, vast expanses without signs of human dwelling – how can such a place give rise to a sophisticated service structure? The explanation is to be found in the unique combination of past experience, local leadership, and government policy, skillfully merged into an experiment with remarkable staying power.1 What was the “past experience and local leadership” that contributed to the creation and success of the Swift Current Health Region? Four rural municipalities within Saskatchewan’s southwest drybelt led the way (see map, figure 6.1). Anchoring

36 Steps on the Road to Medicare

Figure 6.1 Map of Health District #1 (Carol Beaulieu)

the old “Palliser Triangle” region of western Canada, these communities were particularly hard-hit by the dual whammy of dust and depression between 1914 and 1937.2 Residents were eager to think of new, collective solutions to reform the care system. In 1937, rm Pittville #169 at Hazlet paid Dr A.L. Caldwell of Cabri a municipal doctor salary of $2,700 per year even though Pittville constituted less than half of his practice area.3

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Swift Current Health Region

When Caldwell joined the army in November 1941, the ar rangement evolved so that residents paid a personal tax and carried an insurance card that paid any doctor, anywhere in Saskatchewan, 50 per cent of the fee schedule as payment in full, and paid any hospital $2.75 per day.4 Pittville residents thus were not restricted to the services of a single salaried doctor, as was the case with municipal doctor plans. This freedom of choice was popular. The plan, though, was contrary to the Rural Municipality Act and in fact, not legal – but legality did not stop the rm from continuing.5 In 1943, 1,200 Pittville residents were covered for a total cost of $13,031, or $10.91 per capita, a bargain for medical and hospital insurance combined.6 A similar renegade plan, which disregarded some of the conditions of the Rural Municipality Act controlling taxation and health, evolved in rm Miry Creek, directly north of rm Pittville. In 1937, the Abbey Cottage Hospital closed. In that same year, Miry Creek began a hospital plan. Funded through an additional land tax levy, Miry Creek residents could seek hospitalization in any hospital in Saskatchewan. They added a medical plan in July 1943, which paid for visits to any Saskatchewan doctor.7 Under guidance of its secretary-treasurer, Stewart Robertson, rm Webb #138, south and east of rm Pittville, operated its medical insurance scheme under the “Matt Anderson Plan” (see chapter 3). Fee-for-service payments were made to doctors visited by rm Webb patients both locally and in larger centres. It cost $7 per person or up to $50 per family.8 North of rm Webb, rm Riverside set out its plan in late 1944, modeled largely on the rm Pittville’s any-doctor, anywhere plan.9 Dr Mindel C. Sheps of the newly created Health Services Planning Commission in Regina presented a Memorandum on Organization of Health Regions to Premier Douglas on 20 April 1945. Any ten

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municipal councils could provide resolutions to form a health district, which would break open local health schemes to consider and provide for medical and hospital needs on a regional basis.10 The memorandum paved the way for what was to come. While the small rural municipalities in Saskatchewan’s southwest corner experimented with medical insurance plans, Swift Current, the pivot city of the region, needed a new hospital. In August 1945, Sheps arrived in Swift Current to discuss the possible formation of a union hospital district.11 She found a local advocate with a much larger agenda: Pittville’s secretary-treasurer, William J. Burak (figure 6.2). Burak was convinced that his Pittville plan should be extended throughout Saskatchewan’s southwest region. In January 1945, before the memorandum on health regions was formulated, Burak wrote to each municipality, proposing that they organize to form a health region to offer not just preventive medicine but a full health plan. The council of rm Pittville was the first to ask the government to establish a health region after the provincial government set out the regulations concerning the creation of health regions, published in the Saskatchewan Gazette on 31 July 1945.12 Rather than have separate meetings to discuss both a new hospital and a health region, Sheps suggested to Burak that “the question of organizing a health region could be discussed” when Sheps visited Swift Current on 18 August 1945.13 The ccf government, uncharacteristically, was dragging its feet. Douglas had given Sheps license to discuss public health, to steer the Swift Current region to set up a union hospital, which would become the central hospital in a district that would emphasize preventative medicine. Burak offered a complete health service plan instead. As a spinoff from that meeting, Burak was appointed a committee of one “to sound out the surrounding municipalities.”

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Swift Current Health Region

Figure 6.2 William J. Burak (Mrs Pola Burak)

A veritable whirlwind, a “mover and shaker,” as Lester Jorgenson called him,14 Burak lost no time. He sent a four-page single-spaced mimeographed letter on 23 August and a followup three-page letter on 30 August to thirty-one rural municipalities, thirty-six villages, six towns, and the City of Swift Current,15 offering his vision of a much larger enterprise, the formation of a region that would offer “complete medical, surgical and hospital services.” Burak also took his personal crusade to the regional weekly newspapers16 and attended regular council meetings of five rural municipalities to advance his proposals.17 He then called a meeting, which he chaired on 15 Sep tember 1945; forty-eight of the invited municipal governments sent delegates. The other two members of Burak’s organizing

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committee were Walter Melrose of rm Big Stick #141 at Golden Prairie and Carl Kjorven of rm Riverside #168 at Pennant.18 Premier Douglas had expressed doubt about the Swift Current priorities; he thought it prudent to have a slower evolution to full medical care. In a radio broadcast Douglas downplayed the necessity of a full regional plan.19 In an article in the Saskatchewan Medical Quarterly in December 1945, Douglas wrote that he wished to introduce a health program, “step by step.” He wrote of regional public health districts and hoped that “at least one public health district [would] be organized as soon as possible” – intending to begin with preventive services.20 Joan Feather confirms this; the government had planned an experimental health region “with a focus on public health services and diagnostic and specialized facilities. But … popular pressures forced a commitment to complete health services at public expense for the region.”21 Burak, who had given a lot of his time and spent his own money, never reimbursed, for “stamps, stationery, telephones, travelling and all other expenses,”22 won out with his grandiose plan.23 By 1 November 1945, the requisite petitions from ten municipalities had been collected, and a vote was held in these municipalities on 26 November 1945.24 The ballot read: “Do you want a comprehensive system of health insurance, hospital and medical care and preventative services?”25 By a 71 per cent vote (Shaunavon’s voters were barely in favour, 137 to 136),26 the residents of southwestern Saskatchewan voted to establish a health region. The Douglas ccf government, to its credit, responded promptly to regional wishes. It passed an Order-in-Council on 11 December 1945 authorizing formation of Swift Current Health Region No. 1.27 On 17 January 1946, the organizational meeting at Gull Lake,28 attended by sixty of the eligible eighty delegates, passed

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Swift Current Health Region

Figure 6.3 Carl Kjorven (Lester Jorgenson)

Figure 6.4 Stewart Robertson (Leah Robertson Koldingnes)

a simple resolution: “That the Regional Board of Health be instructed to provide hospital, medical, and limited dental care as soon as possible and that the funds required be raised by 25 per cent from a land tax and 75 per cent from a personal tax.”29 Carl Kjorven from rm Riverside was selected as chair (figure 6.3), and Stewart Robertson from rm Webb as secretary-treasurer (figure 6.4), bringing their experience to the table.30 The representatives from the district medical society31 met with the executive of the regional board on 3 May 1946. They accepted payment at 75 per cent of the Saskatchewan medical fee schedule, and agreed to have a meeting once a year between themselves and the board. Each side trusted the other. The meeting lasted only fifteen minutes.

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20. The first comprehensive regional health care and the first comprehensive hospital plan in North America, 1946; first region in Canada to combine public health with medical care, 1946 Dr Arthur F.W. Peart, the district medical health officer, arrived in January 1946 and the full-blown preventive program began on 1 May. The Swift Current Sun boldly announced the story as winds of change.32 The new board established an office in Swift Current 7 May 1946. Peart moved on after only nine months and was replaced by Dr Lloyd Davey.33 Universal medical and hospital care came into force throughout Health Region No. 1 on 1 July 1946, two years ahead of Great Britain’s National Health Insurance Plan, which began on 1 July 1948.34 Dr Vincent L. Matthews (Figure 6.5), the third medical health officer, from 1 July 1948 through February 1957,35 provided seamless integration of preventive work with medical care36 and acted as accounts assessor and statistician for the regional board. A man of integrity, Matthews quietly earned the respect of both the medical profession in the area and the general public.37 The drought-stricken Swift Current Health Region comprised an area of 13,932 square miles and a 1946 population of 53,597.38 From the time the region was opened for homestead settlement in 1908, only one year in approximately seven had provided a sound financial return to farmers.39 When the scheme began, only nineteen medical doctors resided in the region, including four specialists in Swift Current.40 With assured payment and, as doctors returned from service in the armed forces, increased availability, the number of doctors jumped to thirty-four in 1947 and thirty-six in 1948. As Lloyd Brown reported: “a fine spirit of co-operation between the doctors and laymen on the Board was evident … and a very evi-

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Swift Current Health Region

Figure 6.5 Dr Vince Matthews (Pat Matthews)

dent desire … to run their own affairs with a minimum of interference or control from the outside.”41 The region’s staff, all paid by the Saskatchewan government, consisted of the medical health officer, seven public health nurses, a health educator, and three sanitary inspectors. Stewart Robertson, functioning as a chief executive officer, held this position until he retired at the end of 1966. Robertson was a frugal Scot who had left Scotland in 1920 at age twenty. Not only did he obtain full value for each dollar spent, but his own office was small, with second-hand furniture, bare wood floors, and no drapes. His first secretary, Pat Ditner, describes him as “caring, kind, sensitive, even-tempered, compassionate, patient … hard working and willing.”42 Nothing flustered him. Each rural municipality and the City of Swift Current had an elected representative; all were laymen. Dr Orville Hjertaas of the Department of Health, assigned to organize health regions,

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remembered the “outstanding board of bright and caring people … basically farmers.”43 The board contained “staunch Liberals and Conservatives and hard line C.C.F.ers, but they all left their politics on the doorstep.”44 The regional health scheme was financed by a personal tax – $15 for one person, $24 for two, $30 for three, and $35 for a family of four or more – and a property tax, calculated to raise 25 per cent of the total, set at 2.2 mills. The provincial government contributed twenty-five cents per capita and paid one-half the cost of x-ray, children’s dental, and out-patient services. The provincial contribution to the Swift Current plan in 1948 came to $63,691.45 For the first six months of the scheme, hospitalization costs were 42 per cent of total expenditures, having been underestimated by about $75,000.46 Fortunately, the advent of provincewide universal hospitalization on 1 January 1947 removed hospital expenses from the six-month-old region’s budget and thus saved the Swift Current plan from bankruptcy. Other measures which brought the budget under better control included: reducing specialist fees from 75 per cent to 50 per cent of the provincial rates in 1948; introducing utilization fees, which controlled “double doctoring” and “shopping around” for medical services, as well as overuse for minor ailments; and the “ceiling principle,” which introduced a budget ceiling in the expectation that the health region as a group had to adhere to strict guidelines.47 Expenditure for medical services within the region, on a feefor-service basis, was $410,453 in 1947 and $453,925 in 1948. In 1948, doctors received an average gross revenue of $12,880 – a net income averaging $8,114, since the overhead for a doctor in the area was estimated at 37 per cent.48 Referrals to specialists outside the region, mainly Regina, came to $58,547 in

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Swift Current Health Region

1947 and $67,909 in 1948. The per capita cost for medical service in 1947 was only $9.83 and in 1948, $10.23.49 For the first time, as Dr J. Lloyd Brown pointed out, statisticians had access to reliable figures concerning the cost of medical care, a valuable side benefit from the operation of the Swift Current plan. The region’s doctors were aware that specialists in Regina and Saskatoon looked askance at this experiment in “socialized medicine.” Dr J.A. Matheson of Gull Lake said, “there have been times when we in the Swift Current area felt like black sheep … We have been trying out some ideas that have not been approved.” He went on to tell of the benefits of the scheme: “security and stability … better incomes … The patients are getting a better service … partly due to an increase in the number of physicians.”50 Payment was in cash from the provincial government, no longer in chickens or sides of beef. Dr Gordon Howden, a family practitioner in Maple Creek before he left to specialize in ophthalmology, gave a well-reasoned account of his experience. He found the scheme did not affect the doctor-patient relationship, but the doctor’s work increased considerably and “many have acquired a taste for xrays … because of the good feeling and spirit of co-operation between ourselves and the Regional Board, we have had an excellent opportunity to present our case under favourable circumstances.”51 One measure of success: the infant mortality rate is reputed to have fallen from a high level (before 1946) to the lowest rate in Saskatchewan in 1965 – 14.4 per thousand live births.52 Dr Arthur D. Kelly, deputy secretary of the Canadian Medical Association, visited the area in 1946. He found that the regional board enjoyed “a large measure of local autonomy.”

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He characterized the region as “a successful experiment in the large-scale provision of medical care, courageously applied, efficiently managed and remarkably free from attempts to make the facts fit preconceived ideas, financial or otherwise.”53

21. The first regional hospital board in Canada, 1951 Vince Matthews’ reminiscences include the information that the Swift Current Regional Hospital Council, formed in 1951, was the first regional hospital organization in Canada, an early precursor of a system that came into vogue, for better or for worse, in most Canadian provinces only in the 1980s and 1990s.54 As Maureen Matthews55 said on her superlative cbc Ideas program with Lister Sinclair, 5 December 1990, “The basic idea was that every citizen deserved equal access to adequate medical care.”56 The following comments excerpted from that cbc program, provide the inside experience of two doctors in the scheme. dr gordon howden: The one thing that doctors and the municipal people felt … that it was our plan. It was a local plan, we could change things, we could communicate, there wasn’t a political overtone at all. It was purely for the benefit of the people in the plan … the fact that it was on a small scale, the fact that it was a give-and-take situation with the municipalities and the doctors, both willing to learn, and being able to change the plans … the doctors did feel that they had input. dr cas wolan: the Health Region trusted the doctors and the doctors trusted the Health Region … after one of these meetings with Stewart Robertson for a few hours, we decided that for the balance of the year we’d go on fifty-one percent of our

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Swift Current Health Region

usual payments … it was kind of a hard deal to take but I agreed to this thing, Stewart agreed to it, and I went back to the physicians and told them why and they accepted it.57 The secret of the success of the Swift Current Health Region was the integrity, pragmatism, and openness of all concerned. Dr Vince Matthews, Stewart Robertson, and Dr Cas Wolan, the doctors’ representative for financial matters, would have coffee together most mornings at the Venice Café in Swift Current. It was, Matthews recorded, “the best buzz group in which I have ever been involved.”58 If a doctor new to the area was overservicing his patients or wanting to install an x-ray machine as a money-maker in his private office, the three would reach an amicable agreement to resolve the problem. Carl Kjorven, a farmer from near Cabri, was a skillful chairman. When Robertson retired on 31 December 1966 after twenty-one years of service, the Regina Leader Post argued that he had achieved greater “closeness of the operating between the doctors and the health region board, and between the patients and the health region board.”59 Before the withdrawal of services of most Saskatchewan physicians in the still-remembered “doctors’ strike” between 1 and 23 July 1962, the Swift Current Health Region “asked to remain autonomous and carry on with their own successful plan.”60 But events became so emotional and so polarized that on 1 July the doctors within the region closed their office doors in concert with those elsewhere in Saskatchewan. After Lord Stephen Taylor’s negotiated compromise on 23 July 1962, many doctors returned to work throughout Saskatch ewan. The Swift Current area continued to operate separately from the provincial health plan, offering advantages over the

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rest of the province: no extra billing and no hospital privilege problems.61 An extra fee of $14 was added to pay for a children’s dental plan. Collection of taxes and doctors’ billings remained separate from the provincial plan.62 In 1953, short of revenue, the Swift Current board added deterrent fees ($1 for an office visit and $2 for a house call).63 By 1972, as part of a new federal-provincial agreement, the province assumed direct responsibility for medical services to those over 65, relieving the board of responsibility for this age group. By 1974, the region ceased levying its own personal taxes. Until 1980, regional cards continued to be issued annually by each rm and town office, but in 1981 the province moved the region medical accounts into Regina.64 Only in 1988 was the region fully merged into the Saskatchewan Medical Care Insurance Commission, and the Swift Current office closed. The last regional information meeting was held on 3 June 1993, the final vestige of local involvement.65 The Swift Current Health Region was unique. It was a success. It was thoroughly tested. It was made to work. As Taylor says, “It had attracted a higher ratio of doctors-to-population than any other rural part of Saskatchewan.”66 The public, the doctors, and the inordinately small administrative staff felt a sense of ownership, of empowerment.67 Swift Current became a major stepping stone on the road to medicare.68 Lester Jorgenson of rm Miry Creek #229 emphasizes that this was a local, grassroots phenomenon. Although supported by the province, “the widely held concept that the Swift Current plan was a provincially directed pilot project does not fit the recorded facts.”69

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CHAPTER 7

MEDICAL COLLEGE AND UNIVERSITY HOSPITAL

The success of any future medicare program in Saskatchewan required a first-rate medical school. Although a two-year medical course had been offered at the University of Saskatchewan since 1926, Saskatchewan medical students had to move to other provinces for their clinical training. Sigerist’s report in 1944 recommended construction of a full, five-year medical school and a 500-bed university hospital in Saskatoon. Sigerist predicted the building and equipping of the hospital and medical school would cost $2 million,1 with annual operating costs of $150,000. university of saskatchewan college of medicine, 1955

Even before the 1944 election, T.C. Douglas was planning for a five-year medical college if and when he took power. In thinking of possible candidates for a dean of medicine, he took advice from Dr W.C. Gibson, then serving at the Royal Canadian Air Force Clinical Investigation unit in Regina.2 Gibson suggested

36 Steps on the Road to Medicare

his former teacher at McGill University, Dr J. Wendell Macleod.3 However, it was not until July 1951 that the provincial budget and Macleod’s personal circumstances allowed him to accept the position. Macleod was a man of vision; he spent a year studying medical education and recruiting department heads before settling in Saskatoon.4 Meanwhile, in the spring of 1945, the legislature voted $100,000 to begin construction of the medical college; the cornerstone was laid by T.C. Douglas on 26 August 1946. The official opening took place on 8 May 1950.5 The first medical class was admitted in the fall of 1953 and graduated in 1958. There are benefits from a small class size. In spite of usually inadequate funding for the medical college, Saskatchewan medical graduates have done well. The history of the medical college has been chronicled through 1976 by Dr Douglas J. Buchan,6 and from 1976 through 1998 by Dr Louis Horlick.7 university hospital

Premier Douglas established the Board of Governors for the university hospital in September 1946. In December 1946, he agreed to an expenditure of $7 million for a 550-bed hospital, to be connected to the medical building.8 The legislature passed the University Hospital Act in 1947. Construction of three wings of the hospital began in 1948, but due to worrisome delays for financial reasons, the cornerstone was not laid by Premier Douglas until 19 September 1952. In his address, he wisely said, “we wanted no medical school at all unless we could have the best possible.”9 The hospital opening ceremony took place on 14 May 1955. Delays and inflation caused the price of the university hospital to rise far above the “ballpark estimate” of $1,500,000 given

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Medical College and University Hospital

by Dr W.S. Lindsay, dean of the two-year basic science course in medicine, and adopted by Sigerist in his report. The final cost of the hospital was seven times higher – $10,589,703.10 The university hospital brought top-notch specialists and subspecialists and greatly raised the standards of medical care in Saskatchewan, as recorded by Louis Horlick.11 The medical college and university hospital were necessary ingredients in the preparation for medicare.

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CHAPTER 8

PROVINCEWIDE H O S P I TA L I Z AT I O N

Hospital services are costly. They require support from municipal and provincial governments to provide funding and sound policies. Above all, the primary concern should be for the patient. With momentum gained from experience with cottage and union hospitals and the Swift Current Health Region No. 1, Saskatchewan moved toward provincewide hospitalization.

22. The first province to provide capital grants for widespread hospital construction, 1945 Saskatchewan took Sigerist’s advice to heart in becoming the first province to provide funds for capital construction of hospitals, a major step on the road to medicare.1 Between 16 March 1945 and 1 March 1949, the government provided $653,714 in outright construction grants and $173,500 in loans.2 The National Health Grants Programme in 1948 added substantial federal funds to support hospital construction; Saskatchewan,

Provincewide Hospitalization

sadly, having been too quick off the mark, was ineligible for matching federal funds for new construction since most of its hospitals had already been built. The province was in double jeopardy because some of the operational health programs had also been launched in anticipation of federal support; it was learned only too late that, because they were already underway, they were disqualified from receiving federal assistance.3 Nonetheless, the Saskatchewan program moved hospital construction costs out of tight municipal budgets, allowing larger, better equipped hospitals to be built. Larger centralized hospitals could incorporate modern conveniences and technologies, from plumbing and heating infrastructure to power, which led to specialized laboratory and x-ray rooms. Twenty-one new hospitals were established over four years, and forty-one union hospital districts formed.4

23. The first universal hospitalization insurance program in North America, 1 January 1947 Introduction of the first provincewide, compulsory hospitalization insurance program in North America was achieved in Saskatchewan with remarkable speed and efficiency. Hospitalization was expected to cost even more than physician services and thus be the more expensive “half” of the medicare equation. Sigerist estimated that universal, provincewide hospitalization insurance would cost $3.60 per person (about $3.5 million)5 per year and would require another 1,000 to 1,500 hospital beds in Saskatchewan,6 including a university hospital of at least 500 beds.7 The first steps toward provincewide hospitalization insurance included: the Saskatchewan Social Assistance Plan (1 January 1945; see chapter 5), which paid for both medical and hospital services for the province’s most

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needy; free hospitalization and treatment for cancer patients; and full coverage for hospitalization and treatment for mental illness.8 The move to provincewide hospitalization insurance would spread the cost of hospital care across all citizens and ease financial pressure on smaller municipalities. It would also be least likely to disrupt the balance between the doctors’ professional considerations and provincial or regional purse strings.9 The doctors in Saskatchewan enthusiastically and almost unanimously supported the introduction of provincewide hospitalization insurance on 1 January 1947. Doctors could now admit patients to hospital whenever necessary, without concern for cost. Patients could be treated in whichever hospital was best for their care, for the time needed to recover, whether that was a few days or many months. Small hospitals rejoiced, for a time. The Red Cross Outpost Hospital at Paddockwood, for example, no longer needed to rely on intermittent and sporadic local upkeep or payment – hospital costs were covered by the new plan. Still, consolidation and construction in larger centres with provincial support led to rural hospital closures.10 dr mott and the saskatchewan hospital services plan (shsp), 1 january 1947

Dr Fred D. Mott (figure 8.1), a graduate of the McGill Medical School and a senior officer with the United States Public Health Service, became chairman of the Saskatchewan Health Services Planning Commission on 1 September 1946. Tommy Douglas deserves credit for making such a wise choice. Mott’s appointment was welcomed by the medical profession.11 Mott, a man of integrity and a good listener, as well as a man of action, moved the plans for the Saskatchewan Hospital Services Plan (shsp) “into high gear.”12

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Figure 8.1 Dr Fred D. Mott (sab r-a7994)

The provincial hospital plan broke new ground. The administrative machinery had to be invented “from scratch,” and became the model for all subsequent plans. Malcolm Taylor, an interested graduate student of health administration from the University of California, passing through Regina, describes the unprecedented pioneering effort as follows: The new uniform hospital accounting system was finalized under G.W. Myers; the point system was completed,13 the tax collection procedures agreed upon with the municipalities; and the organization of shsp decided upon; scores of clerical, secretarial, and tabulating personnel were appointed and trained, and a massive publicity program was mounted to encourage early registration and tax payment.

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It was a period of feverish activity, reminiscent of mobilization in 1939. The only office space available was in an ancient, vacated store building; clerical desks were long rows of plywood-on-trestles, with clerks sitting elbow-toelbow, processing the registration and tax collection payments.14 The annual hospital premium was $5 for each adult and child, with a maximum of $30 per family. Each municipality received a 5 per cent commission for collecting the premium. The plan provided “complete hospital benefits to all residents of the province. It included public ward care, X-ray and laboratory services, common drugs, and other hospital services. It also provided for the payment of a flat per diem amount toward the cost of out-of-province hospitalization for any Saskatchewan resident.”15 Each resident received a hospitalization card with a number. The shsp was administratively separate from the Department of Health but was not the “independent, nonpolitical commission” the doctors had desired. The deputy minister of health sat on the commission, which oversaw both the shsp and the Medical Services Division, which administered the Social Assistance Medical Care program (see chapter 5). Sigerist’s financial projections were wildly short of reality. The hospitalization costs for the first year were almost exactly twice his forecast – $7,560,763, a per capita cost of roughly $9.69. In subsequent years that $7.5 million seemed a bargain. Per capita costs of hospitalization rose rapidly, to $11.42 in 1948 and $13.59 in 1949. The most economical component in the early years was administration, which consumed only about 5 per cent of total expenditures.16 The $5 per person hospital tax initially covered 60 per cent of the cost of provincewide hospitalization.17 As Taylor says, “The tax collection system was

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successful to a degree unexpected for a regressive ‘poll’ tax.” He adds, “In Saskatchewan, the plan became popular before it was expensive; in B.C., it was expensive before it was popular … a main issue defeating the [British Columbia] government in 1952.”18 Historian James McAllister noted that until 1944, health spending comprised only 1.4 per cent of the Saskatchewan provincial budget. Within four years of implementing the hospitalization plan, health’s portion of the provincial budget rose to 13.1 per cent.19 poliomyelitis treatment

The hospital plan was put to an early test in its first year: 277 polio cases were reported in Saskatchewan, with twelve deaths. Poliomyelitis “was one of the most feared diseases” of the twentieth century.20 The polio clinic in Saskatoon was augmented by the addition of polio clinics in Regina and Moose Jaw. Unlimited free hospital, medical, and nursing services were financed through shsp. In 1952, Saskatchewan was the epicentre of the Canadian polio epidemic. The government took the threat seriously. By the end of 1960, 99 per cent of Saskatchewan children had been immunized.21 Polio joined tuberculosis, cancer, and mental illness as special diseases requiring full provincial medical support. saskatchewan air ambulance

The move toward health regions and centralized hospitals gave support to an innovative initiative. On 3 February 1946, an air ambulance service was put in place. The service speeded up the transfer of residents from remote or rural areas for treatment at the larger regional centres and offset rural hospital closures.22 New hospital construction, universal hospitalization insurance, and a vigorous response to special diseases broadened

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health care in Saskatchewan. By 1958, “the volume of hospital service received by Saskatchewan residents (2,100 days per 1,000 persons per year) was “the highest in North America … their needs are being met.”23 the saskatchewan health survey, 1949–51

On 28 July 1948, the government of Canada announced that it would make funds available for each province to survey “present health services and facilities.”24 Saskatchewan was allotted $43,506 for the provincial survey. A committee of twelve had one representative each from registered nurses, dentists, urban municipalities, rural municipalities, labour, the hospital association, the farmers’ union, the Swift Current Health Region (Carl Kjorven), and two from the medical association (C.J. Houston and G.G. Ferguson, registrar of the Saskatchewan College of Physicians and Surgeons). Dr Mott was chair and Malcolm G. Taylor (figure 8.2) was research director and secretary. In the middle of the health survey, on 14 November 1949, Douglas turned over the Ministry of Health to T.J. Bentley, the member from Gull Lake. It was probably more than simple coincidence that Bentley, a farmer, and later on the field staff of the Saskatchewan Wheat Pool, represented a riding within the Swift Current Health Region. The diverse group met amicably.25 Mott listened to each viewpoint and then asked for overall consensus. As each question came up, it was hammered out to the point of agreement. No minority report was submitted, nor were interim reports supplied to the organizations that each member represented. After more than two years’ work and twenty-five meetings, the twovolume report contained a full catalogue of Saskatchewan’s health resources and an estimate of needs in future.26 Ken McTaggart, in The First Decade, wrote that the Saskatchewan

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Provincewide Hospitalization

Figure 8.2 Malcolm G. Taylor (sab rws-a11567, by permission of Michael West)

Health Survey report surpassed that for any other province; he described it as “the classic of such projects.”27 In addition, as C.J. Houston reported to the College of Physicians and Surgeons, the Saskatchewan committee “established a precedent in working out health matters. It has proved that a widely representative type of Commission can work.”28 Of 115 recommendations, the first was that “a comprehensive health insurance program should be undertaken at the earliest possible date.”29 hospitalization universal throughout canada, 1961

British Columbia’s hospitalization plan, the second in Canada, followed in 1949 but, lacking Saskatchewan’s superb organization, was an administrative nightmare that suffered horrendous problems. Federal funding for hospitalization, on a cost-sharing

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basis of 45 per cent, started 1 July 1958.30 On 1 January 1959, Ontario’s plan went into effect. By 1961, all provinces were participating, with Quebec the last to join. Each province, watching the Saskatchewan example, sent administrators to Regina to learn how to do it right. Federal funds through the cost-sharing agreement to support the hospital plan eased Saskatchewan’s purse strings. The money provided the Saskatchewan government with the funds it needed to undertake its long-sought goal of universal medicare, covering both hospital and medical services.

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CHAPTER 9

I N N O VAT I O N S I N P S Y C H I AT RY

When Saskatchewan became a province in 1905, psychiatry and mental hospitals across Canada were in a backwater compared to the rest of medicine. The first opportunity to show leadership was scuttled by unfortunate advice from Ontario. a missed opportunity to pioneer small, humane psychiatric cottage hospitals, 1908

Dr David Low of Regina, the provincial health officer (figure 9.1), was sent in 1907 to visit mental hospitals in eastern Canada and the United States. He was asked to consult widely and to make recommendations for construction of a mental hospital in the new province. He visited two up-to-date mental hospitals in New York State, at Ogdensburg and Ward Island, and the Protestant Hospital for the Insane at Verdun, Quebec. At these three hospitals, “instead of measures of restraint such as padded cells and straight-jackets,” there was sufficient staff and patients were allowed their freedom and even were allowed to use the libraries that were provided.1

36 Steps on the Road to Medicare

Figure 9.1 Dr David Low (sab r-a3569)

Low recommended “a cottage system.” However, Dr C.K. Clarke, superintendent of the Toronto Asylum, was asked to be a consultant to the Toronto architectural firm of Darling and Pearson, who were concerned about “scattered plumbing and heating lines” if a cottage plan were chosen. Clarke admitted that the cottage system is “ideal for the patients themselves, and provides means for breaking up the patients into smaller distinct groups,” yet he advised against it on economic and climatic grounds.2 With the devastating winter of 1906–07 firmly in the rear-view mirror in Saskatchewan, it is perhaps not sur-

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prising that heating issues at public institutions carried weight. With coal and wood prices factored into maintenance costs, the Canadian climate would indeed have an impact.3 It is nonetheless a pity that the government chose to follow “expert advice” from Toronto and ignored Dr Low’s recommendations. In retrospect, a series of cottages with closed-in connections between them, suitable for a cold climate, would have made Saskatchewan a leader, giving mentally ill patients more humane treatment. Sadly, the government opted for a pavilion-style institution at North Battleford,4 which opened on 4 February 1914 with 314 patients. The patient population increased to 853 in 1920 and 985 in 1930. A second pavilion institution opened in Weyburn in 1921; it had 1,058 patients in 1930 and about 1,500 in 1963.5 By 1948, including those in the “training school for mental defectives,” 4,500 mental patients were institutionalized in Saskatchewan, “the highest institutionalized rate per capita” in Canada, with “not more than ten Registered Nurses in the three institutions.”6 Weyburn’s hospital has been cited as the last asylum-styled psychiatric care facility, and the largest in the British Commonwealth. Large mental hospitals were inherently counterproductive. “Patients came from long distances, tended to stay a long time and fairly often were not discharged. Deaths were high.”7 “The huge corridors and indefinite spaces would clearly be extremely damaging to people whose perceptual apparatus was already out of gear … the large overcrowded institution not only did not help patients, it hurt them.”8 Yet, the Saskatchewan mental hospitals and their managers deserve credit for some unusually fine care. J.W. MacNeill, first medical superintendent at the Saskatchewan Hospital North Battleford, abolished restraints, removed bars from windows, and changed the use of the term “asylum” to “hospital.” Farm

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and irrigation projects, including extensive gardens, supported the value of beautiful surroundings and meaningful work in helping patients live more fully. Those at the hospital were not inmates but patients, humans with illnesses in need of care.9

24. The first province to provide free psychiatric treatment, 1 January 1946 Medical historian Erika Dyck noted that Douglas “deplored the tradition of placing people with mental illnesses in custodial institutions.”10 Instead, he advocated community care as much as possible, with an emphasis on intervention and preventative medicine. By 1945, Douglas was publicly advocating early diagnosis and treatment, as well as an aggressive public awareness campaign in an attempt to remove the stigma of mental illness: “to get the public to know that there is no more disgrace for one member of the family to get mentally ill than there is for any other member of the family to [get] pneumonia.”11 The Sigerist Commission, as well as Douglas’s own thoughts on mental health and his position as health minister, no doubt combined to push forward the move, in the throne speech of 1945, to full hospitalization and treatment coverage for mental health patients.12 As a result, the government considered the patients and took steps to differentiate those who had mental or physical handicaps from others who experienced mental illnesses or drug and alcohol addictions. Treatment paths diverged.13 Mental health reforms, as well as a new emphasis on treatment, research, and care, placed Saskatchewan at the forefront in the postwar period. Dyck contends that the “delicate and complicated set of historical and psychological factors gave

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rise to a new vision” of mental health innovation.14 Medical historian Colin Smith went further, declaring that the Douglas government initiated a “halcyon period” of mental health services.15

25. The first free outpatient service for mental health patients in Canada, beginning 1947–51 On 1 November 1946, Dr D.G. (Griff) McKerracher became Commissioner of Psychiatric Services for Saskatchewan. Described as a “man of immense charm,” McKerracher was enthusiastic about his role and sympathetic to both the needs of mental health and the innovations required to change how things had been done.16 He “strongly urged a reconceptualization of mental health as an area indistinguishable from general medicine, meaning that its treatment would take place in a general hospital.”17 He moved quickly, establishing an outpatient clinic, the Munroe Wing, of the Regina General Hospital in 1947. Part-time or full-time clinics were operating in Weyburn, North Battleford, Saskatoon, Moose Jaw, Assiniboia, Swift Current, Yorkton, and Prince Albert by 1951.18 Saskatche wan’s per capita expenditures on mental health patients were the highest in Canada.19

26. The first 500-hour psychiatric nurse training program in Canada, 1947 Psychiatric nurses had traditionally trained “on the job.” In 1930, a more formalized “ward attendant” training program began in Saskatchewan.20 Dr F.S. (Sam) Lawson, director of the Saskatchewan Hospital, Weyburn (figure 9.2) wished to upgrade

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Figure 9.2 Dr F.S. Lawson (sdcmh)

the training of attendants to support more expert and humane care for the patients. Supported by McKerracher (and following recommendations in the Sigerist report), Lawson in 1947 devised a three-year (500-hour) program, one or two hours of lectures each day from October to June, to upgrade the training and status of the caregivers.21 Those who completed the course successfully earned a Registered Psychiatric Nurse (rpn) diploma.22 The graduates from this program eventually formed “about 90% of the psychiatric nursing staff” in the two large mental hospitals and tended to be “the most stable members of the community psychiatric team,” remaining for longer periods. Registered Psychiatric Nurses throughout the province provided continuity of patient care, made regular home visits, demon-

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strated a genuine concern, and fulfilled “the traditional helping role.”23 Dyck recorded instances of women coming to Weyburn to take the course, drawn by both the expanded role of women as psychiatric nurses and the provincial system of loans and bursaries to support the training.24

27. The first Psychiatric Nurses Act in North America, 25 March 1948; first Psychiatric Nurses Association in North America, 1948 On the heels of the move to formalize psychiatric nurse training, Saskatchewan enjoyed two more firsts: it shepherded the creation of the Psychiatric Nurses Act, a North American first, in 1948, which led to the first Psychiatric Nurses Association, which registered psychiatric nurses.25

28. The first provincial government to emphasize and fund psychiatric research, 1950s The change toward improving psychiatric care and mental health led to Saskatchewan’s revised Mental Health Act, passed in 1950. It classed mental health as a medical function,26 giving doctors a supportive base for medical intervention. The 1950s spawned a new era of experimentation and research, with Saskatchewan in the lead. Medical historian Dr John Mills asserted that Saskatchewan was the first jurisdiction to commit to a fully funded, provincewide program of psychiatric research, which was comprehensive in humane treatment of mental illness.27 Dyck notes that the 1950s were a period of “unbounded optimism” toward psychiatric research, where McKerracher “nurtured novel perspectives in mental health.”28

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the first province to explore psychedelic therapy, 1953–63

Two of the most innovative researchers facing the challenge of treating mental illness on an equal basis with other medical concerns were Dr Abram Hoffer and Dr Humphry Osmond. Hoffer, a native of Saskatchewan, came to medicine by way of agriculture, through biochemistry. He became the director of the provincial psychiatric research program.29 Hoffer, “an outstanding physician and researcher,” supported “adventurous, questioning, experimental, and optimistic attitudes at a time when they had been lacking.”30 Osmond, a Brit, was baptized as a physician during the Second World War. The war taught him that mental illness could be just as damaging, and sometimes more so, than physical stressors. He began, with his colleague John Smythies, to research mescaline, a chemical substance derived from the peyote cactus plant. The two of them also began working with d-lysergic acid diethylamide (lsd) to induce hallucinations not unlike those suffered by schizophrenic psychotic patients. Osmond came to Weyburn, Saskatchewan, in 1951, first as clinical director and then as medical superintendent at the Saskatchewan Hospital. He pursued his research studies in the bold Saskatchewan medical environment.31 By explaining mental illness as a metabolic dysfunction,32 Osmond and Hoffer were among an elite group of psychiatric researchers intent on researching drug therapies to alleviate psychotic symptoms. But the Saskatchewan experiments underscored more than a simple biochemical connection: mental illness and mental health involved both biological and social considerations. The lsd experiments fused the two.33 The “psychedelic” experience as therapy, as it became known, was

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Figure 9.3 Dr D. Griffith McKerracher (McKerracher Centre, Saskatoon Health Region)

a Saskatchewan first, but has failed to achieve acceptance by psychiatrists.34 29. The first open psychiatric ward that included psychotic patients in a general teaching hospital in Canada, 1955 On 1 July 1955, Dr McKerracher took the post of Head of the Department of Psychiatry, University of Saskatchewan and Dr Lawson took over as Director of the Psychiatric Services Branch of Saskatchewan.35 When the university hospital opened its doors in 1955 in Saskatoon, psychiatric patients were treated almost exactly as were those on medical and surgical wards, being free to visit the cafeteria and obtain passes to visit outside the hospital. Windows were not barred. No one was re strained. From 660 admissions, psychiatric patients left the

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ward without permission on seventy-seven occasions; forty-four returned of their own accord, fifteen were returned by relatives, eight by police, and six by hospital staff.36 McKerracher (figure 9.3), admitted ninety unselected patients who had been committed to the Saskatchewan Hospital at North Battleford and concluded that almost all mentally ill patients could be treated in a general hospital.37 Family practitioners could visit their patients and some could take part in their care. The average length of stay was twenty-one days,38 much shorter than the average stay (18.2 years, often until death!) at North Battleford.39

30. The Saskatchewan Plan, a first in Canada, 1956 Despite advances, the situation at the Saskatchewan Hospital, Weyburn, was appalling. Overcrowded and unclean, it was symbolic of the old institution-style incarceration methods. To address these conditions and find new solutions, in 1956, Dr Sam Lawson and Regina architect Kiyoshi Izumi boldly presented their theoretical and unproven plan, named “The Saskatchewan Plan.” The Saskatchewan Plan hoped to keep patients closer to their families through building eight or more small regional cottage hospitals designed by Izumi. Sam Lawson wrote in 1958: “The older concept of the mental hospital as an asylum where the mentally ill could be stored out of harm’s way is no longer acceptable.”40 Lawson and Izumi presented their plan to a meeting of the American Psychiatric Association Mental Hospital Institute in Denver, Colorado.41 Dr John Mills believes that Sam Lawson, Griffith McKerracher, and Humphry Osmond (figure 9.4), the three senior psychiatrists at Weyburn, developed the plan through study and many long discussions,

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Figure 9.4 Dr Humphry Osmond (sdcmh)

during the year or two before McKerracher accepted the headship of psychiatry at the new medical college in Saskatoon. Lawson expected that construction of the first regional cottage hospital, a radical departure in function and architecture and designed to “give the patients living conditions that are as near those of domestic living as possible,”42 would begin in Swift Current in 1957, but it was delayed by four years and was then built in Yorkton instead.43 At the Yorkton facility, Lawson explained, “all patients from one district are seen by the same team,” thus providing “continuity of care.”44 The cottagestyle Yorkton unit with 148 beds proved to be larger than required. It was the only one of the planned eight hospitals that was built; although the second was authorized for Prince Albert in 1965, that promise was never kept.45 In many ways, the Saskatchewan Plan hoped to reverse the missed opportunity

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to develop humane regional cottage hospitals first proposed by Dr Low in 1908. In striking contrast to the jail-like treatment in North American mental hospitals with large wards, where some patients were naked and others were kept in restraint, cottage hospital operation would be governed by the following six principles: 1 No human being should be incarcerated in an institution when any better solution can be found. 2 The mentally ill should have an equal standard of care to that given to the physically ill. 3 The continuity of care which is provided to the physically ill should also be provided to the mentally ill. 4 There should be integration of psychiatric care with general medical and surgical care. 5 Comprehensive care in the patient’s home area should be made available. 6 In-patient facilities should be designed in such a way that they assist the patient’s recovery.46 The key to the Saskatchewan Plan, as enunciated by McKerracher, was “community service, especially follow-up … through a home-care program.”47 the first psychiatric ward to invite a general practitioner to treat mentally ill patients, 1957

Dr Abe Voth was the first (1957) and Dr Wilf McCorkell (1958 through 1 July 1961) the second family practitioner allotted two beds on the psychiatric ward of the new university hospital in Saskatoon.48 Each had an interest in mental illness, attended psychiatric teaching rounds, and was asked by other family prac titioners to see their patients. McKerracher said that McCorkell

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“participates in teaching with unusual success.”49 McCorkell published his experiences in treating sixty-four psychiatric patients.50 His patients were discharged in an average of twenty-one days, although twenty-one of the sixty-four returned for further treatment.51 Both Voth and McCorkell, from their contact and training, became more confident in dealing with mental patients in subsequent office practice.52 The innovative advances in psychiatric care and clinical research in Saskatchewan had dramatic results. The numbers of in-patients at both Saskatchewan Hospitals declined. Between 1963 and 1966, psychiatric residents at Weyburn declined from 1,519 to 421, a 72 per cent reduction. Dr John Mills contends that it was “the highest rate of de-institutionalization ever recorded in any mental institution anywhere in the world.” Many of the discharged patients were initially “placed in approved homes under the overall supervision of psychiatric nurses.”53 Such de-institutionalization is the hallmark of contemporary psychiatric care.

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CHAPTER 10

H I G H - V O LTA G E C A N C E R T R E AT M E N T

Saskatchewan was slow off the mark in using radiation to treat cancer but, once up to speed, it led the world. As with the initial provision of radium in 1932, high-voltage treatment could be available only with government support. In 1922, Dr Ellice McDonald,1 a Saskatchewan man who had been raised at Fort Qu’Appelle2 and later specialized in cancer research at the University of Pennsylvania, visited University of Saskatchewan president Dr Walter Murray. McDonald informed Murray that the province of Quebec had just purchased a gram of radium for $75,000 and suggested that Saskatchewan should take similar action. In response, Murray wrote to Saskatchewan Premier Charles A. Dunning on 6 October 1922 to offer the services of university physicists if the province should decide to follow Quebec’s example and offer cancer treatment to its citizens.3 Dunning replied that the province’s higher health priority was tuberculosis.4

High-voltage Cancer Treatment

31. The first cancer control agency in Canada, 1930, with government-sponsored cancer clinics, 1931 In 1929, the Saskatchewan Medical Association formed a Cancer Committee. This committee proposed the establishment of a voluntary lay-medical Canadian Society for the Control of Cancer, which gradually developed into today’s Canadian Cancer Society.5 The Saskatchewan Cancer Committee enlisted Dr E.L. Harrington (figure 10.1), professor of physics at the University of Saskatchewan, as their only non-medical member.6 Harrington’s advice led to the drafting of the Saskatchewan Cancer Commission Act, passed by the Conservative government of J.T.M. Anderson in 1930.7 This act established the first cancer control agency in Canada and probably the first in North America. North America’s first government-sponsored, part-time (two mornings a week) consultative, diagnostic, and treatment clinics were staffed by radiologists: Dr Earle E. Shepley (figure 10.2) at the Saskatoon City Hospital (beginning in 1931),8 and Dr Clarence M. Henry at the Regina General Hospital (1932).9 Patients were treated with what were then called “high-voltage” machines, operating at 400 kilovolts peak.10 Treatment and hospitalization were the financial responsibility of the patient,11 but the government funded the equipment.

32. The first cancer registry system in Canada, 1932 In 1931, Dr Shepley visited the leading cancer centres, particularly the Cancer Institute in Philadelphia, operated by Ellice McDonald, and the New York Memorial Hospital, under Dr James Ewing. On his return, Shepley submitted to the Sask atchewan Cancer Commission a thoughtful document, “The

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Figure 10.1 Dr Ertle L. Harrington (University of Saskatchewan Archives)

Figure 10.2 Dr Earle E. Shepley (A. Becker)

Essentials of an Ideal Cancer Policy.” In the following year, the Saskatchewan Tumour Registry began, requiring compulsory reporting of all new cancer cases. It was the first cancer registry system in Canada.12 The Saskatchewan government allocated $115,000 for the purchase of radium in 1931, an extraordinary measure given

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Figure 10.3 Dr Allan W. Blair (sab r-b11015)

the fiscal constraints of the Great Depression.13 From the university, Dr Harrington distributed radon to each of the cancer clinics in small gold tubes or “seeds” which had a 3.8-day halflife. Harrington was a proficient and enthusiastic glass-blower who built and operated the radon plant from 1931 until 1962, extracting the radioactive gas emitted by radium in solution.14 The average number of patients referred per year to the two clinics increased, from 575 to 735 to 1,065, in the first four three-year periods until the end of 1943. In 1939, Dr Allan W. Blair (figure 10.3), a Regina boy, a graduate of McGill University, and a radiotherapist at the Toronto General Hospital, took over as director of the Regina cancer clinic.15 On 1 April 1944, the outgoing Liberal government of W.J. Pat terson, under pressure from Dr George Dragan, who had been a backbench Liberal member from Kelvington in the eighth legislature, proposed a bare-bones cancer bill, An Act Respecting the Control and Treatment of Cancer. The bill died on the floor as the ninth legislature prorogued, leading to an election.

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33. The first Cancer Control Act in North America, 1944 Following the landslide victory of the ccf on 15 June 1944, T.C. Douglas lost no time. Dr Blair was promoted to director of cancer services for the province. The first session of the legislature began on 19 October and ended on 10 November 1944. High on the Douglas agenda was the Cancer Control Act, which passed in October. Any person who had resided in the province for three months was now eligible for all services necessary for the diagnosis and treatment of cancer, without charge.16 The program was paid entirely from government revenues and took effect 1 January 1945, at the same time as the new Social Assistance Care plan (see chapter 5). With free treatment, between 1944 and 1946 the number of patients jumped twofold to reach 2,626 in 1946.17

34. Canada’s first full-time cancer physicist, Harold Johns, 1945 Blair was extremely foresighted in his recognition that the radiation treatment program would benefit from a full-time radiation physicist. Blair’s first letter, dated 12 December 1944, to Dr Harrington at the university, suggested that a full-time physicist be hired jointly by the Saskatchewan Cancer Commission and the university. Six days later, Harrington replied, offering full co-operation. On 25 March 1945, Harrington hired Dr Harold E. Johns (figure 10.4) for this joint position, with the rank of assistant professor, at $3,600 per annum. Johns was a thirty-year-old instructor at the Radar School at the University of Alberta, working for Canada’s war effort. He had received his bachelor’s degree in physics from McMaster University in 1936, his master’s from the University of Toronto in 1937, and

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Figure 10.4 Dr Harold E. Johns (sca)

his PhD from Toronto in 1939.18 In his previous work at Edmonton, Johns had used a radium source to obtain industrial photographs of steel propeller shafts to search for metal fatigue, a very early example of industrial radiography. In Saskatchewan, he was to give “half his time to supervision of the radium and x-ray therapy equipment of the two cancer clinics.” Johns later told Lauriston Taylor19 that he thus became Canada’s first full-time cancer physicist.20 In May 1946, Johns was given a travelling scholarship of $800,21 which allowed him to visit, by train, the leading radiation physics centres in Canada and the United States. While in Toronto, he attended a series of lectures given by Professor M.V. Mayneord, a senior medical physicist from the Royal Cancer Hospital in London, England. Mayneord, probably the first to do so, mentioned the possibility of using cobalt-60 as a radiation source. Harrington picked up on the idea; the next year

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in his presidential address to the Chemical, Mathematical and Physical Sciences Division of the Royal Society of Canada, he predicted that cobalt-60 “may become a more suitable source than radium itself in the treatment of cancer.”22 Meanwhile, Johns returned home in 1946 with the conviction that another type of high-energy radiation source under development, the betatron, offered immediate promise. After a quick visit to Premier and Health Minister Douglas in Regina (see introduction), Johns and Blair asked for a betatron of perhaps 35 MeV. The first 2.3-MeV betatron had been built in 1940 by Dr D.W. Kerst at the University of Illinois in Urbana and a 20-MeV prototype had then been built in 1942, based on the preliminary work of Dr Lester Skaggs. University of Saskatchewan President James S. Thomson wrote to Blair on 18 November 1946: “I called last week upon Dr C.J. Mackenzie, President of the National Research Council, to discuss with him the use of a betatron in connection with the cancer treatment in this province. Dr MacKenzie … expressed some doubts as to whether research was fully advanced to make such a project practicable … Matters affecting the use of atomic energy are really under the control of the Atomic Energy Commission of which General A.G.L. McNaughton is the chairman.” It did not hurt the cause that McNaughton was a native of Moosomin, Saskatchewan.23 Blair’s reassuring letter to Mackenzie on 11 December 1946 was the cornerstone of all future developmental research in radiation therapy: “It is not planned to use it for any actual treatment until the physical measurements have been completed to everyone’s satisfaction.” This time-consuming attention to fine detail by Saskatoon physicists allowed those in another province, without such scruples, to, five years later, be the first to treat a patient with cobalt-60.

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Meanwhile, other centres viewed the progress in Saskatchewan with suspicion. Harrington indicated their concerns in a letter to University of Saskatchewan President James S. Thomson on 20 February 1947: In the earliest part of the discussion regarding the betatron, it appeared that a certain member of the Atomic Energy Commission, to which this matter must be referred for decision, had expressed the belief that if the reason for the betatron was mainly medical it would be in the interest of the country as a whole to locate it in a large medical centre, say, in Toronto. In the mind of Dean Mackenzie, the chance of obtaining a favourable action on our request for this equipment would be better if any possible uses in medicine of the betatron were given but little emphasis.24 The price tag for the betatron was high – $80,000. The Atomic Energy Control Board provided $30,000. Johns was disturbed because this amount was insufficient, but Blair was jubilant. “Spend that money, Johns,” he said, “When it is gone more will be found.”25

35. The first concerted clinical use of the betatron in the world, 1949 On 3 May 1948, Johns, accompanied by Drs R.N.H. Haslam and L. Katz of the physics department, arrived in Milwaukee to examine “their” betatron. Where else could an agricultural province have found a manufacturer of heavy-duty machines more suitable than an agricultural equipment company, in this case, Allis-Chalmers in Milwaukee, Wisconsin? Johns wrote back to Blair on 12 May 1948:

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The betatron is finished but has not been tested. The machine which we are getting is the one ordered by the University of Pennsylvania, but they have no building finished to house it and have allowed us to have it … Professor Kerst has been more than cooperative. First he introduced us to all his men and gave us full access to all blueprints, all reprints, keys to the building … Kerst then presented us with two donuts [sic] for nothing and one electron donut for a nominal sum … Kerst is amazed at the rapidity with which we have pursued our program and in the fact we are getting the first betatron to be installed in any university or hospital … The University of Illinois medical school gets the third betatron (second to the University of Pennsylvania) and I heard yesterday that the University of California is getting one, at Berkeley.26 The 24-MeV betatron was installed in the physics department at the University of Saskatchewan that summer (figure 10.5). In keeping with the earlier promise, about seven months were spent in meticulous calibration of this machine for its first use, and dose distribution measurements were ongoing.27 The first patient was treated on 29 March 1949.28 Sadly, Dr Blair (Saskatchewan’s director of cancer services) did not live to see this historic day: he suffered a sudden and untimely death from a heart attack on 9 November 1948. As Milford D. Schultz said of this Saskatoon machine in his historical review in 1975, “Thus started the really first concerted clinical investigation of the usefulness of multimegavoltage as a radiotherapeutic tool.”29 The location of the betatron, in the physics department on the university campus, meant that patients were brought across the river from Saskatoon City Hospital and then across the campus. Even after University Hospital was completed on campus

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in 1955, there were still difficulties in transporting patients outdoors for a distance equivalent to several city blocks. The operating costs of the betatron were also exorbitant. Dr T.A. Watson (figure 10.6), head of radiation oncology at the University of Saskatchewan, reported on 10 November 1949 to Dr O.H. Warwick of the National Cancer Institute that each betatron tube or “doughnut” cost $3,800 (figure 10.7). Although “guaranteed” to last for 150 hours, “No doughnut which has so far been used has lasted nearly as long as this … [T]he cost of the doughnut alone is $25.70 an hour … eleven patients were treated at an average cost of $224 per patient.” In seventeen years, only 301 patients were treated with the betatron.30

Figure 10.5 Betatron (sca)

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Figure 10.6 Dr T.A. Watson (sca)

Figure 10.7 High-energy tube or “doughnut” (sca)

High-voltage Cancer Treatment

Nevertheless, as with any high energy source, the betatron offered “a method of delivering easily a high dose to tumours at a depth, without appreciably affecting the overlying skin … Radiation sickness and blood changes are much less likely.”31

36. The first use of calibrated cobalt-60 in the world, 1951 In June 1949, Johns, keen to develop cobalt-60 as a more economical source of high-energy radiation, visited the Chalk River reactor in Ontario, the only installation in the world then capable of producing large quantities of radioactive cobalt. There he visited with Drs A.J. Cipriani and W.B. Lewis of the Atomic Energy Project. On 15 July 1949 Johns wrote to University of Saskatchewan President W.P. Thompson, asking for an effective source of 1,000 curies of cobalt-60, about 100 times the activity of any radium unit. Johns asked for “between $2500 and $7000 to cover the total cost of construction.” Johns, Cipriani, and Lewis agreed that this project would receive greater priority if it were considered as a research project, not a cancer treatment project. Saskatchewan’s simple two-page, three-copy application for the isotope was sent to the National Research Council at Chalk River on 13 August 1949.32 It was a timely application. Three radioactive cobalt sources were placed in the Chalk River pile to “cook” in the fall of 1949.33 Saskatchewan received Chalk River’s first cobalt source on 30 July 1951 and the University of Western Ontario received its source on 16 October of that year. These dates are of crucial importance, as will become evident. The third source was released for use in the United States in 1952. Each cobalt source was 2.5 cm in diameter and 1.25 cm thick. Sybil Johns, Harold’s wife, later described these as “a little half-

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inch stack of these cobalt discs about the size of a quarter.”34 As Johns had forecast, the approximate strength was 1,000 curies, or 37 GBq. The Saskatoon unit was designed by Johns and Lloyd Bates, a graduate student, and was built by Johnny MacKay, the proprietor of Acme Machine and Electric in Saskatoon. It was installed in Room 167 in the newly constructed cancer wing of University Hospital, adjacent to the medical college, on 17 August 1951. The room was hardly ready for use: the walls were still being plastered and the concrete floor had not yet been poured. Rigorous depth-dose measurements, using phantoms, soon began.35 The unit, weighing approximately 0.9 tonnes, consisted of a steel-encased cylinder suspended from an overhead carriage. A rotating, circular platform, flush with the floor, permitted rotation therapy (figure 10.8). A variety of treatment fields could be obtained by using interchangeable lead plugs, developed and manufactured by MacKay. In order to turn the machine on and off, Johns and MacKay in essence reinvented the wheel (figure 10.9). The radioactive cobalt source was mounted on the circumference of a wheel near the centre of the head. By rotating the wheel, the source could be moved 180 degrees from its shielded resting position until it was opposite an opening through which the radiation emerged.36 The Saskatoon Star-Phoenix on 18 August 1951 printed a photograph of the installation (figure 10.10). The Saskatoon unit was officially commissioned on 23 October, but even more rigorous measurements were continued until 8 November, when the first patient was treated by Watson. Watson modestly but sincerely downplayed attempts to publicize the importance or the priority of Saskatoon’s achievement, saying this was “merely a device that might provide more efficient and economical cancer treatment.”37 Steadfast to scientific integrity, being first

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Figure 10.8 Cobalt-60 unit with Sylvia O. Fedoruk (sca)

36 Steps on the Road to Medicare

Figure 10.9 Diagram of Cobalt-60 (sca) Figure 10.10 Installation of Cobalt-60 (sca and Saskatoon Star-Phoenix)

was not important to any of the Saskatoon players, whereas London seems to have viewed it as a race to be won at almost any cost. Eldorado Mining and Refining had completed the second unit for installation at Victoria Hospital in London, Ontario, on 23 October. Their unit, using a somewhat different design, consisted of a head pivoted between the arms of the horizontal “Y”

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that could be raised and lowered. The beam was turned on and off when a pool of mercury was introduced between the source and a conical opening in the head. The field size was varied by means of four lead blocks at right angles to each other. This was the prototype of the Atomic Energy of Canada Limited (aecl) cobalt unit.38 Dr Ivan H. Smith quickly treated the first patient in London, Ontario, on 27 October, four days after installation. The first cobalt treatment at London was widely publicized in the Canadian press. The Saskatoon Star-Phoenix commented on the “cobalt race” in an editorial on 7 November 1951: We hope Messrs Truman, Stalin, Peron, et al won’t think someone is trying to steal their thunder, but we think they ought to know theirs is not the only atomic race going on in the world. Another has been declared by The London Free Press which claims, editorially, “the world’s first cobalt bomb” for … the Ontario city. With all due respect to the preservation of national peace and goodwill, that is a boast which this newspaper cannot allow to go unchallenged – especially since the Free Press reports that “one is also being installed at Saskatoon, Sask.” One is indeed. Or, to be more accurate, one has been installed. Historians can assess the relative merits of the two claims. Suffice it to say that the first patient at London was treated with a machine that had not been calibrated. The patient had no hope of cure and died soon afterwards. The first patient at Saskatoon had advanced carcinoma of the cervix at age forty, unlikely to be cured by any treatment regimen then known. She received a precise dose to an exact area, with the radiation depth dose carefully plotted at each level. Not only was she cured of her

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cancer, but she lived to the advanced age of ninety years in Victoria, British Columbia. She died on 26 October 1998.39 London was first in the public relations competition, but would its methodology have passed an ethics committee? In retrospect, one might question the ethics of “treating” a patient with an approximate dose of radiation to an approximate area of her body, with an uncalibrated machine, and with little hope for palliation, much less cure. The Saskatoon group may have come out second in boasting to the public, but they were first in achievement and in promulgation of their results to the scientific world. The first formal publication giving details of cobalt therapy was from Saskatoon, not London. It was brief and to the point, much as Wilhelm Carl von Röntgen’s first published description of x-rays had been fifty-four years earlier.40 The authors of the report from Saskatoon, sometimes referred to privately and affectionately as the “Saskatchewan mafia,” were H.E. Johns, L.M. Bates, E.R. Epp, D.V. Cormack, and S.O. Fedoruk, all from Saskatchewan, and three University of Saskatchewan physics graduates (A. Morrison, W.R. Dixon, and C. Garrett), working at the radiology laboratory in the physics division of the National Research Council in Ottawa. Their paper was fasttracked and appeared in print in London, England the very next month, December 1951. The paper describes both Canadian cobalt units and concludes, “The cobalt units are flexible, simple to operate, and should require little servicing. They may prove to be very convenient sources of high-energy radiation.”41 A second paper by the same authors appeared in Science in March 1952.42 More detailed papers on depth doses and use of the two units and the Saskatchewan betatron filled an entire issue of the Journal of the Canadian Association of Radiologists

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in March 1952. The Saskatchewan cobalt-60 depth-dose data43 were included in a regular issue and a special supplement to the British Journal of Radiology in 1951 and 1952. Additional Saskatoon contributions to dosimetry appeared in other American, British, and Swedish radiology journals. Sylvia’s July 1951 Master’s thesis (ma rather than MSc in those years) was titled simply “Depth Dose.” The Saskatchewan-based depthdose charts were on the walls of active radiotherapy departments throughout the world.44 Johnny MacKay of Acme Machine and Electric turned his attention to designing a new collimator system, whereby a large number of interleaved diaphragms replaced the lead plugs, to direct the rays precisely (figure 10.11). MacKay’s small engineering firm in Saskatoon produced these collimators for over

Figure 10.11 Collimation apparatus for Cobalt-60 (sca)

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100 Picker Cobalt units that were distributed around the world. The original Saskatoon cobalt-60 unit treated 6,728 patients over twenty-one years until finally it was replaced by a commercial aecl cobalt-60 machine in 1972. Since the cobalt-60 unit was compact and economical to purchase and maintain, it became the “workhorse” for high-voltage radiotherapy for thirty years. By 1984, there were about 2,500 cobalt-60 units in routine use in the free world, 1,500 of which had been built in Canada by aecl.45 These machines remain the only affordable radiotherapy option in some third-world countries. liver and whole body photoscanning

Sylvia Fedoruk was a pioneer in nuclear imaging. She modified a Reed Curtis scanner to image the size and shape of the liver in 250 patients, the first images of isotope liver scanning published in the world’s most prestigious medical journal, the New England Journal of Medicine46 in 1960. Sylvia Fedoruk47 and Doug Cormack supervised Trevor Cradduck for his MSc thesis in 1962, for which he constructed a whole-body rectilinear scanner.48 That scanner was soon joined by the first gamma camera in Canada, designed by Sylvia Fedoruk and Trevor Cradduck in collaboration with Nuclear Enterprises of Winnipeg, and installed in the Saskatoon Cancer Clinic in 1964.49 Fedoruk also served on an International Commission on Radiation Units that recommended, in the late 1960s, use of modulation transfer function (mtf) as the most appropriate means of measuring collimator resolution for both rectilinear scanners and gamma cameras. mtf was regarded as the standard into the 1970s.50 Although Fedoruk’s nuclear medicine research tended to be forgotten, in October 2012, the year-old, 47-million-dollar

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Figure 10.12 Photoscan of normal liver (Sylvia Fedoruk collection)

Canadian Centre for Nuclear Innovation at the University of Saskatchewan was posthumously named in her honour. As Sylvia Fedoruk and I wrote in our chapter in the book produced to celebrate the 100th anniversary of Röntgen’s discovery of the x-ray: “Though born of war-time nuclear research, the cobalt bomb was in practice a ploughshare rather than a sword, and a largely Canadian contribution to medical care. With its flair for trend-setting performance in medicine, Saskatchewan had led the way.”51 Yes, indeed, Saskatchewan had led the entire world!

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EPILOGUE

The ccf government, from its election in 1944, had a clear goal: to build on Saskatchewan’s unique fifteen years of free diagnosis and treatment of the most expensive disease, tuberculosis, by adding health care for pensioners and widows, for those with cancer and mental diseases, and then provincewide hospitalization. These represented step-wise progressions from innovative policy formation, a view of community-based health and wellness, direct attacks on insidious diseases, to psychedelic experimentation – always within the annual provincial budget. Success in provincewide hospitalization as well as the example of the Swift Current Health Region became models upon which to build the gift for which both Saskatchewan and ccf Premier Tommy Douglas are now famous: universal medicare. The introduction of medicare became one of Saskatchewan’s defining moments.

Epilogue

the first universal medicare in north america, 1962

Medicare became law in Saskatchewan on 1 July 1962. It was a tumultuous time. Inadequate communication and bad timing between the physicians and the government bred misunderstanding and confrontation, which led to an action not contemplated by the government: withdrawal of services by the great majority of doctors. Each side, government and medical profession, “was convinced of the legitimacy of its role, the rightness of its goals, and of its power to achieve them.”1 My father, Dr C.J. Houston, believed that the impasse resulted first from the misguided attempt by the medical profession to use advertising to influence the 1960 provincial election. The doctors hired a public relations firm from central Canada, possibly more experienced in selling soft drinks or motor cars, who had no understanding of the Saskatchewan psyche, or the inappropriateness of such an intervention from a professional group. Dr Noel Doig’s recent book, Setting the Record Straight: A Doctor’s Memoir of the 1962 Medicare Crisis, refers repeatedly to the harmful effects of political intervention by a profession.2 Tommy Douglas had been minister of health from 1944 to 1949, but gave up the health portfolio on 14 November 1949. T.J. Bentley, who succeeded Douglas as minister, changed tack. He wished the health scheme to be under the direct control of the Department of Health, not an independent commission. Relations had been changing, hardening between the doctors and the department. Douglas and his ministers, when they put forward the medicare plan, “believed – indeed, were confident – that a consensus could be achieved”3 between the College of Physicians and Surgeons and the government over the details of the plan. But Douglas, by 1961 had resigned to lead the federal ndp and was succeeded as premier by Woodrow Lloyd. My father felt that Douglas, had he remained premier, would have

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permitted a commission rather than allow the doctors to carry out their threat to strike. Given his previous experience during the give-and-take setting up the Social Assistance Plan, Dad was sure that, if an arm’s length commission with representatives from both sides had been established, the doctors might have agreed to certain payment schedules, including a cap on fee-forservice or a prorated schedule of fees per year. During the dispute, Douglas’s previous unequivocal support for the commission model no longer seemed an option for Woodrow Lloyd. The withdrawal of medical services, the so-called doctors’ strike in July 1962, brought tension even to those outside the doctor-government divide. Mary Kirychuk and Sargent Mc Gowan of Paddockwood had a wedding date of 28 July 1962. Sargent later recalled: “This was the year of the doctors’ strike regarding the imposition of Medicare and there was concern about whether prospective couples could get blood tests which are essential prior to marriage. In this, as in so many others, the public ‘hue and cry’ was much greater than the actual threat and to my knowledge little real difficulty was experienced by people who were either physically ill or merely in love.”4 Under the distinguished arbitration of Lord Stephen Taylor, a socialist and a medical doctor, who shuttled back and forth between the government and representatives of the Saskatchewan College of Physicians and Surgeons, and earned the trust of both sides, the Saskatoon Agreement was signed on 23 July.5 One objective account of this trying time is provided in chapter 5 of Malcolm Taylor’s 1978 book.6 Although a public poll in 1965 still preferred a voluntary health plan, rather than a compulsory one,7 the doctors saw an immediate benefit: in 1963, Saskatchewan physicians’ incomes had quickly become the highest in Canada.8 Greg Marchildon and Klaartje Schrijvers

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noted that “the government was generally perceived to have won the strike.” But the truth supports a deeper victory for the doctors: “organized medicine was able to improve the economic position of its members even while it preserved the contractual system of remuneration and private practice, protected the role of physicians at the centre of the healthcare system, and prevented major changes to primary healthcare.”9 medicare in other provinces

The national initiative of Prime Minister John G. Diefenbaker, the Member of Parliament from Prince Albert, Saskatchewan, prepared the way for medicare in the rest of Canada. Diefenbaker appointed Mr Justice Emmett M. Hall, chief justice of Saskatchewan, to chair a commission. The other six members were not appointed until July 1961.10 The commission’s report was released on 19 June 1964. It recommended that “as a nation, we now take the necessary … decisions to make all the fruits of the health sciences available to all our residents without hindrance of any kind.”11 The medicare bill was not passed by the federal government until 16 December 1966. Federal medical care insurance program funding did not become available until 1 July 1968, the date on which the second province, British Columbia, joined. Manitoba, Newfoundland, and Nova Scotia joined in on 1 April 1969; Alberta on 1 July 1969; Ontario on 1 October 1969; Quebec, 1 November 1970; Prince Edward Island, 1 December 1970; New Brunswick, 1 January 1971; and the North West Territories and Yukon on 1 April 1972.12 Thus, it took almost nine years for medicare to reach all of Canada. Saskatchewan had led, not only in many steps on the road to medicare, but in the implementation of medicare itself.

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Epilogue

why did saskatchewan take the lead?

Medicare got its start in Saskatchewan because, as in the biblical parable, the seeds fell on fertile ground. In 1941, despite the scourge of the Depression, Saskatchewan still had the third highest population in Canada. Although stable, its status relative to the rest of Canada quickly declined: other provinces surged, and by 1961 Saskatchewan had fallen to fifth place.13 Despite (or perhaps because of) the “Great Divide” of the Depression, where people faced terrible choices due to extreme poverty,14 Saskatchewan consistently led all of Canada in public health innovations and legislation, including the many Canadian, North American, and world “firsts” recounted in this book. Even more remarkable were the two instances in which Saskatchewan led the entire world: the first provincewide hospital plan (1947) and the first provincewide medicare plan (1962). But why Saskatchewan? In a province without a large city, there were few rich people or powerful corporations. Rarely did people have surplus cash, but there was an abundance of good will, of trust in one another, of a willingness to help each other, and of a sense that lives could be improved through communal effort. Mutual co-operation among pioneer settlers was more the rule than the exception; it was better to do things together than separately. If a family had to build a barn, neighbours came to help raise the rafters. The entire community would turn out to build a curling rink. Throughout the twentieth century, community co-operation manifested itself in public ways; not only in health concerns, but also in the development of the farmer-owned and -operated Saskatchewan Wheat Pool, and politically through the creation and election of the social-democratic ccf party. Saskatchewan residents had a strong sense of justice and fairness. Honesty was the rule. Municipal politicians were forward-

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thinking and innovative, using and changing the municipal structure to full advantage to meet the needs of local residents. A high priority was given to health matters by the public, especially women. Church women set up hospitals, while farm women, through the Homemakers, the women’s section of the Grain Growers Association, the Red Cross societies, the iode, and the many union hospital auxiliaries (among others) underscored the connection between gender and health. Saskatoon provided an outstanding example when, in 1914, to combat the spread of bovine tuberculosis through milk, it became the first city in the British Empire to forbid the sale of raw milk. We suggest that the co-operative spirit of the predominantly rural Saskatchewan people, most of them immigrants from Europe, had been developed to a higher and more practical degree than in any other jurisdiction in North America. That community spirit was reforged in the fires of the Great Depression. In the face of immense economic, environmental, and social adversity, the world shifted. As the drought receded, war and postwar affluence brought a reordering of priorities. There was a willingness to try new social experiments, to pool the collective economic might for the social stability of all. The advances made in Saskatchewan required two ingredients: the co-operative spirit, as described above, and the individuals whose passion and direction became the catalyst. It is our thesis that without the unique community spirit, coupled with “the right person in the right place at the right time,” some or most of the events recounted here would not have come to pass. These leaders possessed unusual wisdom and prudence. Survivors of the Depression, severe drought, and dust storms (“the Dirty Thirties”), these men and women were more frugal than any group since and not in the least litigious. Much effort went unpaid. Every dollar went a long way. The people of

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Saskatchewan were, to use today’s term, proactive. Whether bureaucrat, politician, or scientist, each leader saw a need, gathered the evidence necessary for an informed decision, and then acted expeditiously. Nearly immediate response by government was then more the rule than the exception. Each visionary’s effort added to the foundation built by a predecessor. These were simple times, without red tape. The time was right. From a historical perspective, we can look back over the Saskatchewan events chronicled in this book and at least dream about returning to our roots. At the local level, think of the grass roots empowerment felt by the pioneers whose municipal taxes paid for innovative municipal doctors and hospital plans and contributed directly to tuberculosis control and the Swift Current Health Plan! Centralized control proved to have some down-sides. The loss of local control was brought home to me on 5 July 2002 when I was the guest speaker at the 100th anniversary of the Yorkton hospital. This hospital had a superb nursing training program from 1903 until 1969;15 the near-overflow crowd at the banquet was composed mainly of nurses who had trained in Yorkton and had gathered from across Canada to demonstrate their undiminished loyalty and esprit-de-corps.16 They still resent the closure of this successful program by centralists. Canada’s present nursing shortage (and the doctor shortage in rural areas!) were the predictable result of bad decisions and poor planning that were not evidence-based. Nurses have always been the backbone of the health care system. Provincially, consider the assumption by both Sigerist and Douglas that the medical school should be the linchpin of the health care system; the unstated corollary would be that it requires commensurate funding. As my father warned T.C. Douglas

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in 1946, medical schools are extremely expensive and a secondrate medical school would be worse than no medical school.17 Federally, funding of medicare would be less of a problem if the federal contribution were restored to the 50 per cent provided to each province in the early years, rather than the current figure, said to be about 14 per cent. Moving medicare forward may ask of us all, at each level, to learn from our history. Can we emulate the co-operative spirit, altruism, and ingenuity shown by Saskatchewan pioneers?

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NOTES

in t roduc tion 1 Louis Horlick, “Medicare and Canadian Federalism.” In A.M. Herzberg and I. Krupka, eds., Statistics, Science and Public Policy. The Two Cultures? Proceedings of the Fourth Conference on Statistics, Science and Public Policy, Hailsham, UK, 1999 (Kingston: Queen’s University 1999), 153–8. 2 Lewis H. Thomas, The Making of a Socialist: Recollections of T.C. Douglas (Edmonton: University of Alberta Press, 1982), 372–3. 3 Eleanor McKinnon. “Open Door Policy,” in Ed and Pemrose Whelan, Touched by Tommy (Regina: Whelan Publications, 1990), 25. 4 A slightly different version of the story can be found in C.S. Houston and S. Fedoruk, “Radiation Therapy in Saskatchewan,” in J. Aldrich and B. Lentle, eds., A New Kind of Ray: The Radiological Sciences in Canada (Canadian Association of Radiologists, 1995), 153–4; and C.L. Greenstock, “From Szechuan to Saskatchewan,” 247–51.

Notes to pages 4–6

1

2

3

4

5

6 7 8

9 10

c ha pter one E.E. Rich, ed., The Publications of the Hudson’s Bay Record Society: Cumberland and Hudson House Journals 1775–82, Second Series, 1779–82 (London: The Hudson’s Bay Record Society, 1952), 228; 232–3. John W.R. McIntyre and C. Stuart Houston, “Smallpox and Its Control in Canada.” Canadian Medical Association Journal 161, 12 (14 Dec. 1999): 1543–7; C. Stuart Houston and Stan Houston, “The First Smallpox Epidemic on the Canadian Plains: In the Fur-Trader’s Words,” Canadian Journal of Infectious Diseases 11, 2 (March/April 2000): 112–15. Sally Clubb, Our Story: 75 Years of Caring (Saskatoon: St Paul’s Hospital, 1982), 2; Marguerite E. Robinson, The First Fifty Years (Regina: Saskatchewan Registered Nurses Association, 1967), 8. John Murray Gibbon and Mary S. Mathewson, Three Centuries of Canadian Nursing (Toronto: Macmillan, 1947), 214. Not until 1927 was a two-storey brick building, St Joseph’s Hospital, built at Ile-à-la-Crosse with government support. H.C. Jamieson, Early Medicine in Alberta (Edmonton: Douglas, 1947), 21; see also Marcel M.C. Dirk, A Healthy Outlook: The Centennial History of the Medicine Hat Regional Hospital (Medicine Hat: Holmes Printing, 1989). R.B. Deane, “Augustus L. Jukes, a Pioneer Surgeon,” Calgary Associate Clinic Historical Bulletin 2, 4 (1938): 1–4. Robinson, First Fifty Years, 8. Joyce Morgan and Barb Straker, “Medical History of Saltcoats,” in Saltcoats Roots and Branches (Saltcoats: Saltcoats and District Historical Society, 1982), 217–23. Robert Lampard, “Medicare: An Alberta Legacy,” Legacy May–July 1998: 34. Lewis Thomas, “Early Territorial Hospitals,” Saskatchewan

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Notes to pages 6–18

11 12 13

14 15 16 17 18 19 20 21

History 2, 2 (1949): 16–20. In the 1891 census the entire Medicine Hat district had a population of only 1,316. The Calgary hospital opened later in 1890 and the Lethbridge hospital in 1894. Gibbon and Mathewson, Three Centuries, 208. In 1901 there were 91,279 people in the area that was to become Saskatchewan in 1905. Personal copies of this large book, owned by each midwifery student in most English-speaking countries, were affectionately named “Maggie.” Robinson, First Fifty Years, 32, 39. Saskatchewan Department of Agriculture, Annual Report 1906 (Regina), 156–8. A. Becker, “The Lake Geneva Mission, Wakaw, Saskatchewan,” Saskatchewan History 29 (1976): 51–64. Clubb, Our Story, 6. Saskatoon City Hospital Golden Anniversary, 1909–1959 (Saskatoon: City Hospital, 1959), 18. Joan Feather and Vincent L. Matthews, “Early Medical Care in Saskatchewan,” Saskatchewan History 37 (1984): 41–54. Sister Yvonne Bezaire, Our Roots: A Promise (Saskatoon: Catholic Health Association of Saskatchewan, 1993), 4. C.S. Houston, “Early Saskatchewan Hospitals,” Annals of the Royal College of Physicians and Surgeons of Canada 23 (1990): 265–70.

c ha pter two 1 C.S. Houston, “Maurice MacDonald Seymour: A Leader in Public Health,” Annals of the Royal College of Physicians and Surgeons of Canada 31 (1998): 41–3, by permission. 2 Evelyn Eager, Saskatchewan Government: Politics and Pragmatism (Saskatoon: Western Producer Prairie Books, 1980), 147.

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Notes to pages 18–22

3 Seymour eventually became the Commissioner of Public Health, among other distinctions. See Statutes of Saskatchewan 1909 C. 8, Sec. 33; see also Robert I. McLaren, The Saskatchewan Practice of Public Administration in Historical Perspective, Studies of Health and Human Services, Canadian Studies Volume 19 (Lewiston, ny: The Edwin Mellen Press, 1998): 12–13. 4 M.M. Seymour, “Public Health Work in Saskatchewan,” Canadian Medical Association Journal 15 (1925): 276. 5 Brief from Society of Obstetricians and Gynecologists via College of Physicians and Surgeons to the Thompson Committee, in the files of C.J. Houston, Saskatchewan Archives Board (sab). 6 Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan, 1944–1964” (Master’s thesis, University of Regina, 1990), 6. 7 Seymour, “Public Health,” 274. 8 Ibid., 275. 9 Ibid., 277. 10 M.M. Seymour, “A Study of Milk Problems in Canada,” [Canadian] Public Health Journal 17 (1926a): 241–4, 295–301, 353–8, 394–404. 11 Ibid., 300. 12 M.M. Seymour, “The Seymour Plan,” [Canadian] Public Health Journal 17 (1926b): 593–6. 13 Seymour, “Public Health,” 275, 277. The Saskatchewan Department of Health Annual Report (1929: 95) again made the claim that Saskatchewan was acknowledged as still having the “lowest death rate in the Dominion and in the Empire.” Presumably the relative youth of newcomers was the main explanation.

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Notes to pages 23–8

14 Lillian Chase, “Maurice MacDonald Seymour,” Canadian Medical Association Journal 30 (1929): 212–13. 15 McLaren, Saskatchewan Practice of Public Administration, 12–13. c h a pter three 1 Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan, 1944–1964” (Master’s thesis, University of Regina, 1990), 16. 2 Holdfast History and Heritage Committee, Holdfast, History and Heritage (Author: 1980), 39. 3 Doris Hungle, “Medical Services.” In Holdfast, History and Heritage, 83–5. Dilke was the nearest village on the Regina side of Holdfast. 4 A vacancy was pending at Craik, population 427, about twenty miles west; the doctor there was about to enlist, and hoped that Schmitt could replace him (Mrs J.A. Dunn, “Our First Municipal Doctor,” Western Producer, 1 March 1962). 5 In the 1916 census, the population of Holdfast was 167, Chamberlain 138, Dilke 93, and Penzance 60. Initially, none of the inhabitants of the four villages was covered by the doctor plan. The rural population in rm Sarnia numbered 2,090; payment of taxes earned medical care from Dr Schmitt. 6 C.S. Houston, “Saskatchewan’s Municipal Doctors: A Forerunner of the Medicare System that Developed 50 Years Later,” Canadian Medical Association Journal 151 (1994): 1642–4, by permission. 7 Holdfast, History and Heritage, 83. 8 Arthur E. Childe was the municipal doctor for rm Victory #226 at Beechy. Present for only two years, he was nevertheless

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Notes to pages 28–33

9

10 11

12 13 14 15 16 17 18 19 20 21 22 23

24

remembered fondly thirty years later. He became Winnipeg’s foremost scientific radiologist, with special skills in pediatric radiology (my field) and neuro-radiology. D.S. Johnstone, “Report of the Committee re Municipal Physicians,” Canadian Medical Association Journal 17 (1927): xii–xiv. C. Rufus Rorem, The “Municipal Doctor” System in Rural Saskatchewan (Chicago: University of Chicago Press, 1931). Ibid., 13. Rorem came to Saskatchewan because of information that Alberta had only two municipal doctors and Manitoba, three. They operated under the provincial Rural Municipality Act of 1929, Secs. 168 and 169. Rorem, “Municipal Doctor,” 12, 16. Gordon Ferguson, “Income Tax and the Municipal Physician,” Saskatchewan Medical Quarterly 14, 2 (1950): 407–10. Rorem, “Municipal Doctor,” 61. Ibid., 62–3. Ibid., 61. Ibid., 74. W.W. Wheeler, “Where Doctors Send No Bills,” Reader’s Digest, July 1935: 75–7. Rorem, “Municipal Doctor,” 83–4. G.E. Britnell, “Saskatchewan,” Encyclopedia Canadiana 9 (1958): 205–28. Mombourquette, “A Government and Health Care,” 28–30. Gordon Lawson, “The Co-operative Commonwealth Federation, Health Care Reform, and Physician Remuneration in the Province of Saskatchewan, 1915–1949” (Master’s thesis, University of Regina, 1998), 38. R.G. Ferguson, “Report of [the] Committee on Economics,” Saskatchewan Medical Quarterly 2, 4 (1938): 12–18.

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Notes to pages 33–6

25 Ibid., 15. 26 J.J. Collins, “Report of the Municipal Doctors’ Questionnaire,” Saskatchewan Medical Quarterly 5, 4 (1941): 11–24. 27 Health Services Board, Saskatchewan Medical Association, “Model Municipal Contract,” Saskatchewan Medical Quarterly 6, 2 (1942): 17–25. 28 Lawson, “Co-operative Commonwealth,” 131, 145; Advisory Planning Committee Special Document 2A, footnote 138 in Gordon Lawson, “The Road Not Taken: The Health Services Planning Commission Proposals and Physician Remuneration in Saskatchewan,” Canadian Bulletin of Medical History 26, 2 (2009): 426. 29 Joan Feather and Vincent L. Matthews, “Early Medical Care in Saskatchewan,” Saskatchewan History 37 (1984): 41–54. 30 Ibid., 47. The ten uhds were at Davidson, Edam, Eston, Kerrobert, Kindersley, Lloydminster, Lampman, Rosetown, Shaunavon, and Wadena. 31 Statutes of Saskatchewan, 1916, C.12; 1917, C.9; Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 71. 32 A.G. MacKay, Municipal Hospitals 1919 (Edmonton: Municipal Hospital Branch, 1919). 33 Arthur K. Whiston, Municipal Hospitals (Edmonton: Hospitals Branch, Department of Public Health, 1922). 34 Later, in 1948, hospital construction was further supported by federal funds from the National Health Grants Programme, the first federal initiative in health care. See chapter 8. 35 F.D. Mott, “Hospital Services in Saskatchewan,” American Journal of Public Health 37 (1947): 1539–44. 36 Feather and Matthews, “Early Medical Care,” 47. 37 Statutes of Saskatchewan: 1918–19, C.100, Sec. 2. The two rural municipalities named in the Saskatchewan legislation, of

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Notes to pages 36–41

38

39

40 41

42 43

44

45 46

47

course, are both within Saskatchewan; Malcolm G. Taylor, “The Saskatchewan Hospital Services Plan” (PhD dissertation, University of California, Berkeley, 1949, mimeographed), 72. David Tuckwell wrote “Helping to Solve a Prairie Problem” about the Lloydminster experience in 1917, published in the Canadian Medical Association Journal 7: 800–3. Statutes of Saskatchewan: 1927, C.67, The Union Hospital Act, Sec. 2; 1936, C.37, The Village Act, Sec. 236; 1936, C.36, The Town Act, Sec. 8. Statutes of Saskatchewan: 1934–35, C.30, Sec. 245. C. Stuart Houston and Merle Massie, “Four Precursors of Medicare in Saskatchewan,” Canadian Bulletin of Medical History 26 (2009): 379–93. Taylor, Health Insurance, 72. sab files, sarm brief to Sigerist 25 September 1944; Stuart Houston, “Matt Anderson’s 1939 Health Plan: How Effective and How Economical?” Saskatchewan History 57, 2 (2005): 4–14; see also Houston and Massie, “Four Precursors of Medicare.” Merle Massie, “Red Cross Outpost Hospitals,” Encyclopedia of Saskatchewan (Regina: Canadian Plains Research Centre, 2005): 742; Merle Massie, “Ruth Dulmage Shewchuk: A Saskatchewan Red Cross Outpost Nurse,” Saskatchewan History 56, 2 (2004): 35–44. Taylor, Health Insurance, 72. Robin F. Badgley and Samuel Wolfe, Doctors’ Strike: Medical Care and Conflict in Saskatchewan (Toronto: Macmillan, 1967), 24. Taylor, Health Insurance, 72.

c ha pter four 1 C.S. Houston, R.G. Ferguson, Crusader against Tuberculosis

154

Notes to pages 43–53

2

3 4 5 6 7 8 9

10

11

12

13

(Toronto: Hannah Institute and Dundurn Press, 1991), by permission Associated Medical Services Inc. through its Hannah Institute for the History of Medicine Program. A.B. Cook, R.G. Ferguson, J.F. Cairns, and R.H. Brighton, Report of the Saskatchewan Anti-tuberculosis Commission (Regina: J.W. Reid, King’s Printer, 1922). Helen Ferguson, “That a child might live,” Valley Echo 40, 12 (1959): 4–6. H. Boughton, “A.C.T. million dollar story,” Valley Echo 45, 3 (1964): 19–20. Saskatchewan Anti-tuberculosis League. Annual Report, 1942. Conveying formal membership in the prestigious Royal College of Physicians, thus allowing use of the initials mrcp. Houston, R.G. Ferguson, 58. Cook et al., Report … Anti-tuberculosis Commission. R.G. Ferguson, “A Tuberculosis Survey of 1,346 School Children in Saskatchewan,” Canadian Medical Association Journal 12 (1922): 381–3. G.J. Wherrett, The Miracle of the Empty Beds: A History of Tuberculosis in Canada (Toronto: University of Toronto Press, 1977), 35, 187. In 1922, the Canadian Red Cross provided funds for the Canadian Tuberculosis Association to undertake similar representative school surveys in the other provinces. G.J. Wherrett and S. Grzybowski, Report and Recommendations on Tuberculosis Control in Saskatchewan (Ottawa: Department of National Health and Welfare, 1966), 8. Jean B.D. Larmour, A Matter of Life and Breath: The 75-year History of the Saskatchewan Anti-tuberculosis League and the Saskatchewan Lung Association (Saskatoon: Saskatchewan Lung Association, 1987), 18, augmented by Dr Dudley G. Barnett, personal communication, May 2002. Houston, R.G. Ferguson, 81–2.

155

Notes to pages 54–63

14 15 16 17 18

19

20 21 22

23

24

25

26

27

Ibid., 83. Wherrett & Grzybowski, “Report and Recommendations,” 5, 6. Houston, R.G. Ferguson, 83. Ibid., 84. For an important recent look at tuberculosis, First Nations, and Saskatchewan, see Maureen Lux, “Perfect Subjects: Race, Tuberculosis, and the Qu’Appelle bcg Vaccine Trial,” Canadian Bulletin of Medical History 15 (1998): 277–95. R.G. Ferguson, “Tuberculosis Among the Indians of the Great Canadian Plains,” Transactions of the National Association for the Prevention of Tuberculosis 14 (1928): 625–45. C.S. Houston, “Ferguson’s bcg Research: Canada’s First Randomized Clinical Trial?” Investigative Medicine 16 (1983): 89–91. R.G. Ferguson and A.B. Simes, “bcg Vaccination of Indian Infants in Saskatchewan,” Tubercle 30 (1949): 5–11. R.G. Ferguson, “bcg Vaccination in Hospitals and Sanatoria of Saskatchewan,” Canadian Journal of Public Health 37 (1946): 435–51. G.D. Barnett, “Results of Mass Surveys in the Province of Saskatchewan, 1942–1947,” Canadian Tuberculosis Association Annual Papers 50 (1950): 33–6. Wherrett, Miracle, 255. Later, from 1941 through 1955, Ontario had the lowest tb death rate, except for 1944 and 1954, when Saskatchewan briefly regained the lead. Anonymous, Canadian Tuberculosis Association Bulletin 22, 2 (1943): 4; Wherrett and Grzybowski, Report and Recommendations, 7–8. Wherrett and Grzybowski, Report and Recommendations, 4. In Canada, only the Manitoba Sanatorium Board was similarly constituted. Ibid., 10.

156

Notes to pages 63–9

28 Larmour, A Matter of Life, 101–15. 29 Wherret, Miracle, 255. 30 R.G. Ferguson, Studies in Tuberculosis (Toronto: University of Toronto Press, 1955). 31 C. Smith, “Saskatchewan’s ‘Health Hero’ Enshrined in Hearts of People,” Saskatchewan Health Newsletter 15, 3 (1964): 2, 15. 32 V.H. Hoeppner, Life and Breath 1, 3 (August 1989): 4. 33 Houston, R.G. Ferguson, 134–6. 34 V.H. Hoeppner “Tuberculosis in Saskatchewan Treaty Indians,” Prairie Medical Journal 65 (1995): 18–20. 35 Dr Assaad Al-Azem, TB Control Saskatchewan, Public Health Services. 36 Hoeppner “Tuberculosis,” 19–20.

1

2

3

4

c h a pter five E.W. Barootes, “The Role of Saskatchewan in GovernmentSponsored Health Care: A Retrospective Review,” Annals of the Royal College of Physicians and Surgeons of Canada 24, 2 (1991): 117–19. Thomas H. McLeod and Ian McLeod, Tommy Douglas: The Road to Jerusalem (Edmonton: Hurtig, 1987), 112. This is a superb biography of Douglas. Jacalyn Duffin, “The Guru and the Godfather: Henry Sigerist, Hugh Maclean, and the Politics of Health Care Reform in 1940s Canada,” Canadian Bulletin of Medical History 9, 2 (1992): 191–218. During its final fifteen months in office, W.J. Patterson’s Liberal government had appointed two committees to study the possibility of health insurance. The bipartisan Select Special Committee of twenty-five Liberal and ccf mlas, chaired by Bamm Hogarth, a Liberal mla from Regina, had been appointed on

157

Notes to pages 71–3

5

6

7 8 9

10

11

2 March 1943; they gave an interim report on 12 April 1943 and a final report on 31 March 1944. The Saskatchewan Reconstruction Council, established on 20 October 1943, did not give its final report until August 1944, after the election. Sigerist made “extensive use” of the briefs presented to both groups (Gordon S. Lawson, “The Co-operative Commonwealth Federation, Health Reform and Physician Remuneration in the Province of Saskatchewan, 1915–1949” [Master’s thesis, University of Regina, 1998], 50–4). Dr Hugh MacLean, a Regina surgeon from 1913 to 1938, and ccf candidate in the 1935 federal election, advised Douglas to take the health portfolio (Duffin, “The Guru and the Godfather,” 191–218). Douglas phoned Sigerist first on 16 June. (Nora Sigerist Beeson, ed. & trans., Henry E. Sigerist: Autobiographical Writings [Montreal: McGill University Press, 1966], 187). Henry E. Sigerist, Socialized Medicine in the Soviet Union (New York: W.W. Norton, 1937). Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 88, 434. Also assisting Sigerist were Dr Mindel Cherniak Sheps, a family practitioner and Manitoba ccf executive member from Winnipeg, as secretary; Ann Heffel, a nurse; C.C. Gibson, a hospital administrator; and Dr J.L. Connell, a dentist. (Duane John Mombourquette, “A Government and Health Care: the Cooperative Commonwealth Federation in Saskatchewan, 1944–64” [Master’s thesis, University of Regina, 1990], 54.) Stuart Houston, “Matt Anderson’s 1939 Health Plan: How Effective and How Economical?” Saskatchewan History, Fall 2005: 4–14. C. Stuart Houston and Merle Massie, “Four Precursors of Medicare in Saskatchewan,” Canadian Bulletin of Medical History 26, 2 (2009): 379–93.

158

Notes to pages 72–7

12 13 14 15 16 17 18

19 20 21 22

23 24 25

26

27 28

Houston, “Matt Anderson’s 1939 Health Plan,” 10. Chapin, Report to shssc, 6 (sab R251 file 2 no. 21). Beeson, Henry E. Sigerist, 190. H.E. Sigerist, Report of the Commissioner (Regina: Health Services Survey Commission, 1944). Ibid., 5; also cited by Lawson, “Co-operative Commonwealth Federation,” 62. Houston, “Matt Anderson’s 1939 Health Plan,” n62. This figure was unrealistic, given that the average cost of hospitalization per capita in Saskatchewan had that year already reached $5.20, having risen from $1.93 in 1934 (Malcolm G. Taylor, “The Saskatchewan Hospital Services Plan” [PhD dissertation, University of California, Berkeley, 1949, mimeographed], 140.) Sigerist, Report of the Commissioner, 5. Cited by Taylor, Health Insurance, 434. Beeson, Henry E. Sigerist, 231. Lawson’s 1998 thesis explains how fee-for-service payment became entrenched, and why the ccf government chose not to follow the Health Services Planning Commission’s recommendation that doctors be placed on salary. T.C. Douglas to Dr J.L. Brown, letter reprinted in Saskatchewan Medical Quarterly 9, 3 (1945): 31–4. Taylor, Health Insurance, 87. Advisory Committee on Health Insurance, Report (Ottawa: 1942–43). This 558-page report was presented by Chairman J.J. Heagerty to the House of Commons in December 1942. F.B. Roth and R.B. DeFries, “The Saskatchewan Department of Public Health,” Canadian Journal of Public Health 49, 7 (1958): 276–85. Taylor, Health Insurance, 252. See chapter 8, n8. Ibid, 244.

159

Notes to pages 77–81

29 The Social Assistance Plan was administered by the Medical Services Division of the Saskatchewan Department of Public Health (ibid., 252). 30 Ibid., 252. 31 Mombourquette, “A Government and Health Care,” 119. 32 McLeod and McLeod, Tommy Douglas, 312. Thomas H. McLeod was a trusted economic advisor to T.C. Douglas. See A.W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961 (Toronto: University of Toronto Press, 2004), 61. c h apter six 1 Joan Feather, “From Concept to Reality: Formation of the Swift Current Health Region,” Prairie Forum 16 (1991a): 59. 2 Curtis McManus, Happyland: A History of the “Dirty Thirties” in Saskatchewan, 1914–1937 (Calgary: University of Calgary Press, 2011). 3 Hazlet Historical Society, Hazlet and Its Heritage (Hazlet, 1987), 1, 3. 4 Somewhat similar plans that, unlike the municipal doctor plans, allowed free choice of doctor, had begun in Alberta at Cardston in 1932 (Beryl Shaw, “Medicare in Cardston,” in Chief Mountain Country: A History of Cardston and District. [Cardston: Cardston and District Historical Society, 1987], 72–4), and at Lamont in 1933 where, for the first two years, “services exceeded payment five-fold” (Robert Lampard, “Medicare: An Alberta Legacy,” Legacy, May–July 1998: 34–5). The Cardston plan ran until 1968; Shaw failed to claim this as “the longest continuous, voluntary, prepaid medical insurance program in Canada for thirty-seven years” (Robert Lampard, Alberta’s Medical History: “Young and Lusty, and Full of Life” [Red Deer, ab, Published by Robert Lampard; printed by Friesens, 2008], 631–6).

160

Notes to pages 81–4

5 6 7 8 9 10 11 12

13 14

15

16

17

18 19 20 21 22

Houston and Massie, “Four Precursors,” 383. Feather, “From Concept to Reality,” 70. Houston and Massie, “Four Precursors,” 383–5. Webb History Book Committee, Prairie Memories (Webb, 1982), 62. Houston and Massie, “Four Precursors,” 385. Ibid., 386. Swift Current Sun, 25 August 1945. Syd Munt, “How Swift Current Region Was Organized.” (Mimeographed, 3 pages, 1946). As postmaster at Hazlet (Oct. 1943–Sept. 1950: Hazlet and Its Heritage, 61), Munt’s father, John, had handled the voluminous mail sent out by Burak the previous year. Munt, “How Swift Current Region,” 1. Lester Jorgenson, “Rural Municipality of Miry Creek No. 229 and Health Region No. 1,” in Bridging the Centuries (Abbey, sk: Miry Creek Area History Book Committee, 2000), 52–8. F.D. Mott, “Prepaid Medical Care under Governmental Auspices in Saskatchewan,” Canadian Journal of Public Health 41 (1950): 403–10. Munt, “How Swift Current Region,” 1. Burak met in person with Dave Belbeck of the Swift Current Sun, S.H. Gamble of the Gull Lake Advance, and W. Sharpe of the Shaunavon Standard. Burak attended council meetings at rm Grassy Creek #78 at Shaunavon, rm Arlington #79 at Dollard, rm Bone Creek #108 at Instow, rm Carmichael #109, and rm Gull Lake #139. Feather, “From Concept to Reality,” 72–3. Ibid., 74. T.C. Douglas, “The Doctor in Saskatchewan’s Health Plans,” Saskatchewan Medical Quarterly 9, 1 (1945): 24–31. Feather, “From Concept to Reality,” 74. Munt, “How Swift Current Region,” 2.

161

Notes to pages 84–6

23 Burak suffered a crushing personal disappointment when Stewart Robertson was appointed to the job that he had coveted. Burak moved out of the area permanently to become secretarytreasurer in other municipalities at Hafford, Ogema, and lastly rm Aberdeen #373. He died in Saskatoon on 8 June 1976. 24 Feather, “From Concept to Reality,” 74. 25 Pat Cammer, “Some Memories of the Beginnings of Health Region #1” (Typescript of speech given at the final Swift Current Health Region information meeting, Swift Current, 3 June 1993). 26 Feather, “From Concept to Reality,” 75. 27 Sadly, on 5 December 2001, a Ministry of Health bureaucrat in Regina, lacking any sense of history or justice, renumbered Saskatchewan’s health regions, from east to west. Swift Current was stripped of its historical right to continue a hallowed tradition as “Number One” – not only in Saskatchewan, but in all of North America. 28 Gull Lake was at first hesitant to join a health region and opposed the plan. It sought discussion and confirmation regarding financing. Letter, 25 September 1945, Town of Gull Lake to Ministry of Health. Files in Gull Lake town office. 29 Stewart Robertson, “New Horizons for Better Health.” In Winds of Change (Swift Current: Swift Current Health Region, 1966), 23–6. From the beginning the plan provided a dental program for children, although it was not fully implemented during the first two years. 30 The vice-president was Ken Rutherford, a school principal who was also mayor of Swift Current. In 1960, Ken was an unsuccessful ccf candidate in the 1960 provincial election in British Columbia. 31 Drs O.M. Irwin and R.R. Stirrett of Swift Current, Dr J.A. Matheson of Gull Lake, and Dr F.B. Dawson of Maple Creek. 32 Swift Current Sun 30 April 1946.

162

Notes to pages 86–8

33 Dr Lloyd Davey lasted seventeen months, resigning 30 June 1948. Pay was inadequate. Later, Peart was general secretary of the Canadian Medical Association, based in Toronto in 1966. 34 Dr Alan Gregg of the Rockefeller Foundation, when touring western Canada to examine medical services, visited the Health Services Planning Commission in Regina. In answer to the question, “In which countries are health services supplied to residents … under a plan sponsored by the State,” he answered: 1. Russia. 2. Peking [Beijing] China, for 200,000 people. 3. Swift Current Health Region No. 1. This story was related to the first annual meeting of Health Region No. 1 on 25 September 1947 by Carl Kjorven. 35 Apart from one leave, during which he still served part-time. 36 Fred D. Mott, “Prepaid Medical Care,” 403–10. Mott called this unique arrangement a “dual and yet co-ordinated program of community and personal health services.” 37 Vince Matthews was director, Medical and Hospital Services Branch, 1957–62; acting deputy minister, 1962–63; and associate deputy minister, 1963–64, Saskatchewan Department of Health. Thereafter he was professor and head, Department of Social and Preventive Medicine at the University of Saskatchewan. He retired and became professor emeritus in 1987 and died suddenly on 7 October 1988. 38 Swift Current Health Region, Winds of Change, 8. 39 McManus, Happyland. 40 Two surgeons, an obstetrician, and an anaesthetist. 41 J. Lloyd Brown, “Swift Current Health Insurance Scheme,” Saskatchewan Medical Quarterly 14, 2 (1949): 353–67. 42 Cammer, “Some Memories.” In April 1947, when she married Ross Cammer, a farmer west of Webb, Patricia Ditner left her position as Stewart Robertson’s secretary. 43 Dr Orville Hjertaas, interview by Maureen Matthews, “The

163

Notes to pages 88–92

44 45 46

47

48 49 50 51 52 53 54 55 56 57 58 59 60 61

Origins of Medicare,” Ideas, Canadian Broadcasting Corporation, 5 December 1990, transcript, 2. Cammer, “Some Memories.” Brown, “Swift Current Health Insurance,” 357. J.A. Matheson, O.M. Irwin, F.B. Dawson, and G.G. Ferguson, “Report of the Swift Current Health Region No. 1,” Saskatchewan Medical Quarterly 11 (1947): 21–5. E.A. Tollefson, Bitter Medicine: The Saskatchewan Medicare Feud (Saskatoon: Modern Press, 1964); Gordon Lawson, “The Road Not Taken: The 1945 Health Services Planning Commission Proposals and Physician Remuneration in Saskatchewan,” Canadian Bulletin of Medical History 26, 2 (2009): 395–427. Matheson et al., “Report of Health Region No. 1,” 24. Brown, “Swift Current Health Insurance,” 358. J.A. Matheson, “Swift Current Health Service,” Saskatchewan Medical Quarterly 14 (1950): 368–70. Gordon Howden, “General Practice in Health Region No. 1,” Saskatchewan Medical Quarterly 13 (1949): 335–9. Swift Current Health Region, Winds of Change, 55. A.D. Kelly, “The Swift Current Experiment,” Canadian Medical Association Journal 58 (1946): 506–11. V.L. Matthews, “Patterns for Progress Emerge.” In Swift Current Health Region, Winds of Change, 18–21. Maureen Matthews is the daughter of the late Dr Vincent L. Matthews. Maureen Matthews, “The Origins of Medicare,” Ideas, Canadian Broadcasting Corporation, 5 December 1990, transcript, 10. Ibid., 5, 8. V.L. Matthews, Winds of Change, p. 19 Regina Leader Post 19 January 1967. Jorgenson, “Rural Municipality of Miry Creek,” 56. Ibid., 56.

164

Notes to pages 92–4

62 Joan Feather, “Impact of the Swift Current Health Region: Experiment or Model?” Prairie Forum 16 (1991b): 225–48. 63 Swift Current Health Region, “The Swift Current Medical – Dental Program, 1946 to 1962.” (Mimeographed, n.d.). 64 Feather, “Impact,” 243. 65 Jorgenson, “Rural Municipality of Miry Creek,” 57. 66 Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 266. 67 Vince Matthews (Address to annual meeting, Swift Current Health Region Board, 5 June 1985). 68 I was shocked to realize that Saskatchewan lagged behind other provinces in establishing rural health regions. The Swift Current Health Region No. 1 was the only fully functioning health region in Saskatchewan – in one respect a beacon in a land of darkness; by 1943, all other provinces except Saskatchewan had a system of rural public health units for preventive medicine (Feather, “From Concept to Reality,” 66). 69 Jorgenson, “Rural Municipality of Miry Creek,” 55. c ha pter seven 1 Henry E. Sigerist, Report of the Commissioner (Regina: Health Services Survey Commission, 1944), 11. 2 Gibson went on to become professor of neurological research and of the history of medicine at the University of British Columbia. 3 Douglas J. Buchan, Greenhouse to Medical Centre: Saskatchewan’s Medical School 1926–1978 (Saskatoon: University of Saskatchewan, 1983), 39. 4 On a personal note, my medical class at the University of Manitoba elected Wendell Macleod as our honorary president. As a result, he gave the address, “The Gold-headed Cane” at our graduating banquet in Winnipeg in 1951.

165

Notes to pages 94–7

5 Buchan, Greenhouse, 21–2. 6 Ibid. 7 Louis Horlick, Medical College to Community Resource: Saskatchewan’s Medical School, 1978–1998 (Saskatoon: University of Saskatchewan, 1999). 8 Louis Horlick, They Built Better Than They Knew: Saskatchewan’s Royal University Hospital. A History, 1955–1992 (Saskatoon: Royal University Hospital Foundation, 2001), 16. 9 Ibid., 19. 10 Buchan, Greenhouse, 36. 11 Horlick, They Built Better.

1 2

3 4

5 6

7

c h apter eight W. Douglas Piercey, “Hospitals,” Encyclopedia Canadiana 5 (1958): 161–4. Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan” (Master’s thesis, University of Regina, 1990), 68. Ibid., 103–4. A.W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan 1944–1961 (University of Toronto Press, 2004), 145. H.E. Sigerist, Report of the Commissioner (Regina: Health Services Survey Commission, 1944), 7. Aided by “provincial hospital construction grants … the ratio of hospital beds to population increased from 4.8 per 1,000 in 1946 to 6.5 per 1,000 in 1951.” Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGillQueen’s University Press, 1978), 103–4. Louis Horlick, They Built Better Than They Knew: Saskatchewan’s Royal University Hospital. A History, 1995–1992 (Saskatoon: Royal University Hospital Foundation, 2001), 10.

166

Notes to pages 98–101

8 Johnson, Dream No Little Dreams, 80. See chapter 5, nn26–8. 9 Harley D. Dickinson and Renée Torgerson, “Medicare: Saskatchewan’s Gift to the Nation?” in Jene M. Porter, ed., Perspectives of Saskatchewan (University of Manitoba Press, 2009): 175–96. 10 By 1949, the Paddockwood hospital closed its doors. Merle Massie, “Ruth Dulmage Shewchuk: A Saskatchewan Red Cross Outpost Nurse,” Saskatchewan History 56, 2 (Fall 2004): 35–43. 11 Most doctors were also accepting of Thomas H. McLeod, the brilliant economist seconded to the Health Services Planning Commission, but they were suspicious of Dr Cecil Sheps, Mott’s predecessor, and especially of Cecil’s wife, Mindel, who had served for a longer time as secretary of the hspc. Most physicians thought this couple had too much power, and sensed that they wished to impose their version of socialist ideology on the province. 12 Taylor, Health Insurance, 102–3. 13 Hospitals were graded and paid a per diem rate that varied with the facilities and services provided (ibid., 102). 14 Ibid., 103. 15 Johnson, Dream No Little Dreams, 145. 16 F.D. Mott, “Prepaid Medical Care under Government Auspices in Saskatchewan,” Canadian Journal of Public Health 41 (1950): 407. 17 F.D. Mott, “Hospital Services in Saskatchewan,” American Journal of Public Health 37 (1947): 1542. 18 Taylor, Health Insurance, 104; 167, 435n84. 19 James A. McAllister, The Government of Edward Schreyer (Montreal: McGill-Queen’s University Press, 1984), 43. 20 Christopher J. Rutty, “The Middle–Class Plague: Epidemic Polio and the Canadian State, 1936–1937,” in Canadian Bulletin of Medical History 13, 2 (1996): 277–314; 277.

167

Notes to pages 101–5

21 Janet MacKenzie, “The Saskatchewan Response to Poliomyelitis,” Report for the Saskatchewan Western Development Museum, 2002. 22 Johnson, Dream No Little Dreams, 145. 23 Milton I. Roemer, “‘Socialized’ Health Services in Saskatchewan,” Social Research 25 (1958): 87–101. 24 Privy Council (Canada) 3408. This was followed by Saskatchewan Order-in-Council 74/49 on 11 January 1949. 25 By chance, two other members in addition to my father, Dr C.J. Houston, were from Yorkton, population 5,000. City clerk Howard Jackson represented the Saskatchewan Urban Municipalities Association and newspaper publisher S.N. Wynn represented the Saskatchewan Hospital Association. 26 C.S. Houston, “The Early Years of the Saskatchewan Medical Quarterly,” Canadian Medical Association Journal 118 (1978): 118–19, by permission. 27 Ken McTaggart, The First Decade (Ottawa: Canadian Medical Association, 1973), 43. 28 C.J. Houston, “Report,” Saskatchewan Medical Quarterly 15, 4 (1951), 626. 29 Health Survey Committee, Saskatchewan Health Survey Report (Regina: Government of Saskatchewan, 1951), 225. During these meetings, Malcolm Taylor and C.J. Houston became lifelong friends. Taylor later was in charge of research for the federal Royal Commission on Health Services chaired by Saskatchewan Chief Justice Emmett Hall, 1961–64. 30 Taylor, Health Insurance, 167, 233. c h apter nine 1 Fannie H. Kahan, Brains and Bricks: The History of the Yorkton Psychiatric Centre (Regina: White Cross Publications, 1965), 13–15.

168

Notes to pages 106–9

2 Ibid., 16. 3 Joe Cherwinski, “The Rise and Incomplete Fall of a Contemporary Legend: Frozen Englishmen in the Canadian Prairies during the Winter of 1906-1907,” Canadian Ethnic Studies/Etudes ethniques au Canada 30, 3 (1999): 20–43. 4 Harley Dickinson, The Two Psychiatries: The Transformation of Psychiatric Work in Saskatchewan, 1905–1984 (Regina: Canadian Plains Research Centre, 1989), 21. 5 Colin M. Smith, “Mental Health Services in Saskatchewan, 1914–1978” (Typescript of talk given to psychiatry rounds, University Hospital, 17 February 1984). 6 D.G. McKerracher, “A New Program in the Training and Employment of Ward Personnel.” American Journal of Psychiatry 106 (1949): 259–64. 7 Colin M. Smith, “A Decade of Psychiatry in Saskatchewan,” Saskatchewan Medical Quarterly 38, 3 (1974): 31–3. 8 Humphry Osmond, “Function as the Basis of Psychiatric Ward Design,” Mental Hospitals 8, 4 (April 1957): 23–9; also paraphrased in Kahan, Brains and Bricks, 25, 83. 9 Colin Smith, “Mental Health Services,” Encyclopedia of Saskatchewan (Canadian Plains Research Centre, 2005): 599–600. 10 Erika Dyck, Psychedelic Psychiatry: LSD from Clinic to Campus (John Hopkins University Press, 2008), 22. 11 Saskatchewan Legislative Records, Legislative Journal, sess. 1945, vol. 44, p. 14; cited in Dyck, Psychedelic Psychiatry, 23, 149. 12 Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961 (University of Toronto Press, 2004), 80 13 Smith, “Mental Health Services,” 600. 14 Dyck, Psychedelic Psychiatry, 23. 15 Smith, “Mental Health Services,” 600.

169

Notes to pages 109–12

16 John Mills, “Lessons from the Periphery: Psychiatry in Saskatchewan, Canada 1944–1968.” History of Psychiatry 18, 2 (2007): 179–201. Mills, a retired psychology professor from the University of Saskatchewan, died 14 March 2012 in Comox, bc. 17 Dyck, Psychedelic Psychiatry, 25. 18 Mills, “Lessons from the Periphery,” 182. 19 Ibid., 181. 20 Angela Martin, “Psychiatric Nursing,” Encyclopedia of Saskatchewan, 729. 21 M.C. Schreder and Colin M. Smith, “La formation des infirmiers psychiatriques,” Information Psychiatrique 50 (1974): 489–94. 22 Instruction for untrained ward attendants had begun in 1930, but they received only sixty hours of lectures over two years. 23 Mills, “Lessons from the Periphery,”195, citing a 1985 presentation by M. Schreder. 24 Dyck, Psychedelic Psychiatry, 24, 149n35. 25 Martin, “Psychiatric Nursing,” 729. See also Chris Dooley, “‘The older staff, myself included, we were pretty institutionalized ourselves’: Authority and Insight in Practitioner Narratives of Psychiatric Deinstitutionalization in Prairie Canada,” Canadian Bulletin of Medical History 29 (2012): 101–23. 26 Smith, “Mental Health Services,” 600. 27 Mills, “Lessons from the Periphery,”182. 28 Dyck, Psychedelic Psychiatry, 26. 29 Ibid., 26; Smith, “Mental Health Services,” 600. 30 Smith, “Mental Health Services,”600. 31 Dyck, Psychedelic Psychiatry, 13, 17–19; Smith, “Mental Health Services,”600. 32 Dyck, Psychedelic Psychiatry, 27.

170

Notes to pages 112–15

33 34 35 36

37

38 39

40 41

42 43

44 45

Ibid., 31. See, e.g., Dyck, Psychedelic Psychiatry, 74. Mills, “Lessons from the Periphery,”184. C.M. Smith and L.L. McKay, “The Open Psychiatric Ward and Its Vicissitudes,” American Journal of Psychiatry 121 (1965): 763–7. C.M. Smith and D.G. McKerracher, “The Comprehensive Psychiatric Unit in the General Hospital,” American Journal of Psychiatry 121 (1964): 52–7. D.G. McKerracher, “Psychiatry in General Practice,” Canadian Medical Association Journal 88 (1963): 1014–16. W.A. Cassell, C.M. Smith, F. Grunberg, J.A. Boan, and R.F. Thomas, “Comparing Costs of Hospital and Community Care,” Hospital and Community Psychiatry 23 (1972): 197–200. F.S. Lawson, “Mental Hospitals: Their Size and Function,” Canadian Journal of Public Health 49 (1958): 186–95. F.S. Lawson and K. Izumi, “The Saskatchewan Plan,” Mental Hospitals 8 (1957): 27–31. Dr Ian McDonald informs me that McKerracher was also at the Denver meeting in 1956, but was watching television – a World Series baseball game famous that day for a no-hitter – while Lawson delivered the paper on the Saskatchewan Plan. Kahan, Brains and Bricks, 27. Saskatchewan’s first and only cottage mental hospital, adjacent to the new 200-bed regional hospital, opened in Yorkton in October 1963, with five cottages of thirty beds each. F.S. Lawson, “Saskatchewan’s First Regional Mental Health Facility,” Mental Hospitals 16 (2) February 1965: 85–6. F.S. Lawson, “The Saskatchewan Plan,” Canadian Nurse 63, 6 (June 1967): 27–9.

171

Notes to pages 116–19

46 Smith, “A Decade of Psychiatry,” 31. 47 D.G. McKerracher, “Psychiatric Care in Transition,” Mental Hygiene 45 (1961): 3–9. 48 D.G. McKerracher, Department of Psychiatry, Annual Report, 1963. University of Saskatchewan Archives. 49 Ibid. 50 W.J. McCorkell and D.G. McKerracher, “The Family Doctor and the Psychiatric Ward,” Mental Hospitals 13 (1962): 300–2. 51 The rural equivalent was at Central Butte, where the three family practitioners received regular twice-monthly support from a visiting psychiatrist for two years. (L.W. Christ, E. Christ, and G.W. Mainprize, “Observations on the Psychiatric Project at Central Butte, Saskatchewan,” Canadian Family Physician 13 [1967]: 35–41). 52 D.G. McKerracher, C.M. Smith, F.E. Coburn, and I.M. McDonald, “General-Practice Psychiatry: Two Canadian Experiments, Lancet 2 (1965): 1005–7. 53 Mills, “Lessons from the Periphery,” 185. c ha pter ten 1 Ellice had been named for his birthplace, Fort Ellice, the Hudson’s Bay Company (hbc) post on the Manitoba-Saskatchewan boundary. 2 The son of Archibald McDonald, an hbc fur trader, Ellice had graduated in medicine from McGill University with his MB and BCh in 1901. 3 Murray to Dunning, 6 October 1922. Premier Dunning papers Y–16–0, pages 25, 918–19 (unpublished letters), Saskatchewan Archives Board (SAB), M6. 4 Dunning to Murray, 11 October 1922, SAB, M6. 5 R.A. Macbeth, “The Origin of the Canadian Cancer Society,” Canadian Bulletin of Medical History 22: 155–73.

172

Notes to pages 119–22

6 B.W. Currie, “Ertle Leslie Harrington, 1887–1956,” Proceedings and Transactions of the Royal Society of Canada 50 (1956): 91. 7 R.O. Davison, “Saskatchewan’s Programme for Cancer Control,” Canadian Public Health Journal 24 (1933): 566–71. 8 A. Becker, “A Sketch of Radiology at St Paul’s Hospital,” Saskatchewan Medical Quarterly 34 (1970): 34–6. 9 J. Hawkes, The Story of Saskatchewan and Its People (Regina: S.J. Clarke, 1924), 1720–1; “Obituary: Dr Clarence Henry,” Canadian Medical Association Journal 70 (1954): 701. 10 Anonymous, “400 K.V. X-ray Therapy Unit Now Available in This Province,” Saskatchewan Medical Quarterly 2 (1938): 22. 11 For a “nominal” fee of $10, an appreciable amount in those times. Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan, 1944–1964” (Master’s thesis, University of Regina, 1990), 25. 12 Charles R. Hayter, “Compromising on Cancer: The Saskatchewan Cancer Commission and the Medical Profession, 1930–1940,” Saskatchewan History 54 (2002): 5–17. 13 Mombourquette, “A Government and Health Care,” 25. 14 D.V. Cormack, “The Saskatchewan Radon Plant, 1931–1962,” Physics in Canada 41 (1985): 3–5. 15 Blair had trained as a surgeon in Winnipeg. Following concentrated cancer training at centres in Great Britain, France, Germany, Belgium and Sweden, he was employed as a cancer specialist at New York Memorial Hospital, the University of Alabama, and then the University of Toronto. 16 Contrary to popular belief in Saskatchewan, Alberta offered free cancer treatment in Calgary and Edmonton, beginning in 1941. Saskatchewan was not first in this regard. 17 M.S. Acker and T.A. Watson, “Saskatchewan’s Experience with

173

Notes to pages 123–6

18 19

20

21

22 23

24

25 26

a Comprehensive Public Cancer Program,” American Journal of Public Health 50 (1960): 65–73. Anonymous, “Portraits in Radiology: Harold Elford Johns, PhD,” Applied Radiology 1978: 25. Lauriston S. Taylor was the founder and chair of the U.S. National Council on Radiation Protection and Measurements (ncrp), 1929–77. He was the guru of radiation protection throughout my radiology career, until he died at age 102 in 1994. He was the leading biographer of other radiation physicists world-wide. Harold Johns, Transcript of interview by Lauriston S. Taylor, Rockville, Maryland, 17 October 1979, cited in C.S. Houston and S.O. Fedoruk, “Radiation Therapy in Saskatchewan,” in J.E. Aldrich and B.C. Lentle, eds., A New Kind of Ray (Vancouver: University of British Columbia, 1995), 141–54. Six years later, in November 1952, the Saskatchewan Division of the Canadian Cancer Society gave Sylvia Fedoruk a $1,000 travelling fellowship to cover a two-month visit to cancer treatment sites in Chicago, Cincinnati, Detroit, New York, Oak Ridge and San Francisco; her expenses came to $996. Houston and Fedoruk, “Radiation Therapy,” 147. McNaughton had been born to a pioneer family at Moosomin, 25 February 1887. Trained as an engineer at McGill University, he was president of the Atomic Energy Control Board of Canada, 1946–48. C.S. Houston and S.O. Fedoruk, “Saskatchewan’s Role in Radiotherapy Research,” Canadian Medical Association Journal 132 (1985): 854–64, by permission. H.E. Johns, “aapm Coolidge Award,” Medical Physics 3 (1976): 375. Houston and Fedoruk, “Saskatchewan’s Role,” 858. The betatron was financed by a joint grant of over $120,000 from

174

Notes to pages 126–9

27

28

29 30 31

32 33

Atomic Energy Control Board and the ccf government, with additional help from the National Cancer Institute Sask Division of the Canadian Cancer Society. Saskatchewan’s application was chosen over several other Canadian universities. Muriel Snider, “Twenty–five Million Volts of Hope.” Saturday Night 18 October 1949. E.L. Harrington, R.N.H. Haslam, H.E. Johns, and L. Katz, “The Betatron Building and Installation at the University of Saskatchewan,” Science 110 (1949): 283–5; H.E. Johns, E.K. Darby, R.N.H. Haslam, L. Katz, and E.L. Harrington, “Depth Dose Data and Isodose Distributions for Radiation from a 22 Mev Betatron,” American Journal of Roentgenology 62 (1949): 257–68; H.E. Johns, E.K. Darby, and R.O. Kornelson, “The Physical Aspects of Treatment of Cancer by 22 Mev X-rays,” British Journal of Radiology 24 (1951): 355–64; S.O. Fedoruk, H.E. Johns, and T.A. Watson, “Isodose Distributions for a 1100 Curie Cobalt 60 unit,” Radiology 60 (1953): 348–54. (Sixteen additional papers concerning radiation dose measurements are cited in Houston and Fedoruk, “Radiation Therapy,” 426). At this time, Dr H. Quastler, with the help of physicist D.W. Kerst, had treated a single patient with a betatron. H. Quastler and G.D. Adams, “Techniques for Application of the Betatron to Medical therapy with Report of One Case,” American Journal of Roentgenology and Radium Therapy 61 (1949): 591–625. M.D. Schulz, “The Supervoltage Story,” American Journal of Roentgenology 124 (1975): 541–59. Houston and Fedoruk, “Radiation Therapy,” 147. Johns, letter to the president, Saskatchewan Division of the Canadian Cancer Society, cited in Houston and Fedoruk, “Saskatchewan’s Role,” 858. Houston and Fedoruk, “Radiation Therapy,” 149. Houston and Fedoruk, “Saskatchewan’s Role,” 859.

175

Notes to pages 130–6

34 Sybil Johns, “At Home with the Atom,” Mayfair Magazine 30 (July 1955): 30–1 and 53–8. 35 Houston and Fedoruk, “Radiation Therapy,” 149. 36 Ibid., 149–50. 37 Ibid., 150. 38 Ibid., 151. 39 Date of death obtained from Medical Records, Saskatoon Cancer Agency. An article by historian Paul Litt, “Photon Finish: The Race to Build the Bomb,” Beaver 82, 2 (April–May 2002): 28–31, fails to mention the drastic difference in the survival of the first two patients treated, nor does it mention that only one of the cobalt-60 machines had been carefully calibrated. 40 W.C. von Röntgen, “Ueber eine neue Art von Strahlen [On a New Kind of Ray],” Sitzungsberichten der Würzburger Physikmedic. Gesellschaft [Proceedings of the Physical-Medical Society of Würzburg], 28 December 1895; second communication in Nature, 1896. Röntgen could have become a very wealthy man, but he deliberately refrained from taking a patent on his invention; he wished to share it with the world. 41 H.E. Johns, L.M. Bates, E.R. Epp, D.V. Cormack, and S.O. Fedoruk, “1,000-Curie Cobalt-60 Units for Radiation Therapy,” Nature 168 (1951): 1035–8. 42 A. Morrison, W.R. Dixon, C. Garrett, H.E. Johns, L.M. Bates, E.R. Epp, D.V. Cormack, and S.O. Fedoruk, “Multicurie Cobalt 60 Units for Radiation Therapy,” Science 115 (1952): 310–12. 43 As isodose curves. 44 S.O. Fedoruk, H.E. Johns and T.A. Watson, “Isodose Distributions for a 1,100-Curie Cobalt60 unit,” Radiology 60 (1960): 348–54. 45 D. Cassels, “Brave New Worlds for Nuclear Medicine,” Ascent 1 (1979): 8–10.

176

Notes to pages 136–9

46 D.A. Fee and S.O. Fedoruk, “Clinical Value of Liver Photoscanning,” New England Journal of Medicine 262 (1960), 123–5. 47 A more complete biography of Sylvia Fedoruk can be found in Stuart Houston and Bill Waiser, Tommy’s Team: The People behind the Douglas Years (Calgary: Fifth House, 2010), 42–8. 48 T.D. Cradduck, “The Design of a Detection and Display System for a Radio-isotope Scanner” (MSc thesis, University of Saskatchewan Department of Physics, 1962). T.D. Cradduck and S.O. Fedoruk, “A Study of Collimators for Use in Radioisotope Scanning Techniques,” Journal of the Canadian Association of Radiologists 13 (1962): 9–13. 49 T. Cradduck, “Flashback, Saskatoon, 1961,” in A New Kind of Ray, edited by J.E. Aldrich and B.C. Lentle (Vancouver, ubc Press, 1995), 386–7. Cradduck’s PhD dissertation in 1965 resulted in two more joint papers with Fedoruk: T.D. Cradduck, S.O. Fedoruk and J.A. MacKay, “A ‘Large Crystal’ Scintillation Scanner,” Journal of Nuclear Medicine 5 (1964): 27–39; T.D. Cradduck and S.O. Fedoruk, “An Experimental Determination of the Overall Spatial Resolution of a Scintillation Camera,” Physics in Medicine and Biology 10 (1965): 67–76. 50 S.J. MacIntyre. S.O. Fedoruk, C.C. Harris, D.E. Kuhl, and J.R. Mallard, “Sensitivity and Resolution in Radioisotope Scanning: A Report to the International Commission on Radiation Units and Measurements,” in Medical Isotope Scintigraphy, vol. 1 (Vienna: International Atomic Energy Agency, 1969): 391–433. 51 Houston and Fedoruk, “Radiation Therapy,” 154. e pi logue 1 Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 239–330.

177

Notes to pages 139–41

2 Noel Doig, Setting the Record Straight: A Doctor’s Memoir of the 1962 Medicare Crisis (Saskatoon: Indie Ink Publishing, 2012). 3 A.W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961 (Toronto: University of Toronto Press, 2004), 251. 4 Sargent E. and Mary McGowan, Cordwood and Courage (Paddockwood and District History Committee: Friesen Printers, 1982): 357–9. 5 Five days before the McGowans’ wedding date. They got their blood tests finished in time, and the wedding went forward 28 July 1962. 6 Taylor, Health Insurance, 239–330; E.A. Tollefson, Bitter Medicine: The Saskatchewan Medicare Feud (Saskatoon, Modern Press, 1964) provides a legal viewpoint. Robin F. Badgley and Samuel Wolfe, Doctors’ Strike: Medical Care and Conflict in Saskatchewan (Toronto: Macmillan, 1967) is a third recommended source. A recent example is Noel Doig, Setting the Record Straight. See also Gregory P. Marchildon and Klaartje Schrijvers, “Physician Resistance and the Forging of Public Healthcare: A Comparative Analysis of the Doctors’ Strikes in Canada and Belgium in the 1960s,” Medical History 55, 2 (April 2011): 203–22. 7 Taylor, Health Insurance, 367. 8 Taylor, Health Insurance and Canadian Public Policy, revised edition 2009, 502. 9 Marchildon and Schrijvers, “Physician Resistance,” 222. 10 Two medical doctors, David M. Baltzan of Saskatoon and Arthur van Wart of Fredericton, New Brunswick; Dean Alice Gerard of the University of Montreal School of Nursing; Dr Leslie Strachan, a dentist from London, Ontario; Wallace McCutcheon, an industrialist from Ontario, and Dr O.J.

178

Notes to pages 141–5

11 12 13 14 15

16

17

Firestone, an economist. Dr Malcolm G. Taylor was research consultant and Professor Bernard Blishen was research director. Taylor, Health Insurance, 342. Ibid., 375. Greg Marchildon, ed., The Heavy Hand of History (Regina: Canadian Plains Research Center, 2005): 61. Ibid., 51. As a family practitioner in Yorkton, 1951–60, my assigned role was to teach the student nurses about dermatology and sexually transmitted diseases. Fourteen of the twenty-one members of the nursing class of 1962 returned; that evening they sang two songs as part of the entertainment. When the new medical school was about to open in Newfoundland in 1967, and Lord Stephen Taylor was president of Memorial University, I was offered the headship of diagnostic radiology. I have since admired from afar the funding and stability of that department. Free from the intervening level of bureaucracy of a city-wide health board, which in Saskatoon has yet to develop appreciable priorities for either teaching or research, impoverished Newfoundland, it appears to me, regards its medical school as a provincial resource and treasure.

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INDEX

Abbey, 37, 81. See also Miry Creek Aberdeen, Scotland, 7 Acme Machine and Electric, 130, 135 Act Respecting the Control and Treatment of Cancer (proposed, 1944), 121 Agnes, Sister, 4 Agriculture, Minister of, 27 air ambulance, 101–2 Alberta, 3; free cancer treatment, 173n16; joined medicare, 141; tuberculosis treatment, 54; Venereal Disease Act (1918), 19; union hospitals, 35–7. Alexander, A.B., 43 Allis-Chalmers Company, 125 American College of Chest Physicians, 66

American Psychiatric Association Mental Hospital Institute, 114 American Public Health Association, 22 Anderson, J.T.M., 119 Anderson, Matt, 38. See also Matt Anderson Plan; McKillop (rm); Municipal Medical and Hospital Services Act; Strasbourg Andrews, C.H., 58 Anglican Sisterhood of St John the Divine, 5 Anna Turnbull Memorial Hospital, 11 Associated Canadian Travelers (act), 46, 61 Assumption College, 18 Atomic Energy Commission, 124–5

Index

Atomic Energy Control Board of Canada, 125 Atomic Energy of Canada Limited (aecl), 133 Atomic Energy Project, 129 Bacille Calmette-Guérin (bcg) vaccination, 55, 59–60 Barnett, G.D., 43 Bassano, ab: municipal union hospital, 35 Bates, L.M. (Lloyd), 130, 134. See also “Saskatchewan mafia” Battleford: hospital, 11; nwmp hospital, 4; population, 11; tuberculosis treatment, 19. See also North Battleford Beechy (municipal doctor), 28 Bell, James, 5 Bentley, T.J., 102, 139 betatron, 124–9, 134 Bethune (municipal doctor), 28 Biggins, nurse, 5 Big River, 58 Big Stick (rm), 84 Birsay (municipal doctor), 28 Blair, Allan, xviii–xix, 121–6 Blakeney, Allan, 55 Boston, ma, 49 Boucher, Sister, 4 Boughton, Harvey, 43, 49, 65 Brandon, mb, 6, 7 Brandon College, xx Britannia (rm), 36

182

British Columbia, 101, 134; hospitalization plan, 103; joined medicare, 141 British Journal of Radiology, 135 Brock (municipal doctor), 28 Brown, J. Lloyd, 71, 75, 86, 89. See also Saskatchewan Health Services Planning Commission Buchan, Douglas J., 94 Buffalo River First Nation reserve, 67 Bureau of Public Health, 18 Cabri, 80, 91 Caldwell, A.L., 80–1 Canadian Cancer Society, 119 Canadian Centre for Nuclear Innovation, 137 Canadian Medical Association, 28, 89 Canadian Pacific Railway, 18 Canadian Public Health Association, 22 Canadian Society for the Control of Cancer, 119 cancer, 22, 43, 61, 98, 118–37 Cancer Control Act, 122 Canora: hospital, 13, 15; tb clinics, 52 Cardston, ab: municipal union hospital, 35 cbc (Canadian Broadcasting Corporation): xxi, 90 “ceiling principle,” 77, 88 Chalk River, on, 129

Index

Chamberlain (municipal doctor), 28 Chapin, Charles H., 72. See also McKillop (rm) Chapman, Roy, 26. See also Dilke charge nurse, 39–40 Charles Mickle Fellowship, 64 Chase, Lillian, 23 Christmas Seal campaign, 46, 61 Churchill River, 4 Cipriani, A.J., 129 Clarke, C.K., 106 Clearwater Sanatorium, 59 cobalt-60, 123–4, 129–37 Collins, John J., 33. See also Ituna Committee on Municipal Physicians, 28. See also D.S. Johnstone Conference of State and Provincial Health Authorities, 22–3. See also Seymour Plan Connell, Robert, 61–2 continuing education, 48–9 Cook, A.B., 51 Coombs, Mother Hannah Grier, 4–5 co-operation (particularly community), 63, 86, 89, 142 Co-operative Commonwealth Federation (ccf), xviii, 66, 69, 75, 82, 84, 88, 122, 138, 142, 157n4, 158n5, 158n9, 159n22, 162n30, 174n26

183

Cormack, D.V., 134, 136. See also “Saskatchewan mafia” cottage hospital, 5, 6, 10, 39, 81, 96; psychiatric cottage hospitals, 105–7, 114–16, 171n43 Craik, 27; municipal doctor, 28; population 151n4 Cumberland House, 3 Cupar: school tb survey, 51 Darling and Pearson (architectural firm), 106 Davey, Lloyd, 86, 163n33 death rate, 22, 54, 56, 64 de Grandmaison, Nicholas, 64 Delco Light Company, 56 Denver, Colo., 114 depth dose, 130, 133–5 Diefenbaker, John G., 141 Dilke, 26, 151n3. See also Chapman, Roy diphtheria, 22, 31, 41 Directly Observed Therapy (dot), 68 Ditner, Pat, 87, 163n42 Dixon, W.R., 134 d-lysergic acid diethylamide (lsd), 112–13. See also psychedelic therapy “doctors’ strike,” xix, 91, 139–41 Doig, Noel, 139 Dominion Health of Animals Branch, 22 “doughnut” or high-energy

Index

betatron tube, 126–8. See also betatron Douglas, Shirley, xxi Douglas, T.C., 63, 66, 69–71; on approving the betatron, xix–xxi; on cancer treatment, 122, 124; as cbc’s “Greatest Canadian,” xxi; promises nonpolitical commission, 75; health policy as Minister of Health, 75–8; on health regions, 81, 84; and medical college and university hospital, 93–5; on mental health, 108–9; on resigning as Minister of Health, 102; role in medicare, 139–40; and Saskatchewan Health Services Planning Commission, 98; epilogue 138–41 Dragan, George, 121 Dr George Ferguson School, 66. See also Regina drought, 32–3, 48, 79, 86, 143 Drumheller, ab: municipal union hospital, 35 Dunning, Charles A., 118 Dyck, Erika, 108–11 dysentery, 20 Echo Lake, 20 Eldorado Mining and Refining, 132 Elkin, Nurse, 5 empowerment, 92, 144

184

Epp, E.R., 34. See also “Saskatchewan mafia” Ewing, James, 119 Feather, Joan, 79, 84 Fedoruk, Sylvia, 134–7. See also Foreword; “Saskatchewan mafia” fee-for-service, xix, 28, 76, 81, 140, 159n22 Ferguson, G. Gordon, 102 Ferguson, Helen, 65 Ferguson Island, 66 Ferguson, Robert George (R.G.), 20, 33, 41–67 File Hills Indian Agency, 56–7 Fines, Clarence, xx First Nations, 3–4, 43, 51, 55–60, 67–8, 156n18 Fort Ellice, 172n1 Fort Qu’Appelle, 43, 118 Fort Qu’Appelle Sanatorium (Fort San), 43, 45, 47, 49, 52, 64–5; nursing course, 49; post office, 43 Fort Walsh: nwmp hospital (and pharmacist), 4 Frappier, Armand, 60 Fraser (Myles), Margaret, 7 Freemont (municipal doctor), 28 Gardiner, James G., 47, 54 Garrett, C., 134 Gibson, Clarence, 77 Gibson, W.C., 93, 165n2

Index

Goderich, on, 19 Golden Prairie, 84 gonorrhea, 19 Grain Growers’ Assocation (women’s section), 143 Grandin, Bishop, 4 Grand Rapids, mb, 5 grassroots, 23, 44, 52, 63, 92 Grey Nuns (Sisters of Charity), 4, 11, 13 Gull Lake, 84, 89, 102 Hall, Emmett M., 141, 168n29 Hanna, ab: municipal union hospital, 35 Harrington, Ertle L., 119–25 Hart, Bob, 65 Hart, F.W., 65 Harvard University, 49 Haslam, R.N.H., 125 Hazlet, 80 Heagerty, J.J., 159n25 Heagerty Interdepartmental Advisory Committee on Health Insurance, 76 Health Insurance District #1, 72. See also McKillop (rm), Chapin, Charles H. Health Services Board, 32–3 Health Services Planning Commission, 77, 81, 98, 159n22 Health Services Survey Commission (Saskatchewan) (shssc), 71

185

Henry, Clarence M., 119 Heward: school tb survey, 51 High River, ab: municipal union hospital, 35 Hingley, E.G., 65 Hitsman, Elden, 73 Hjertaas, Orville, 87 Hoffer, Abram, 112 Hogarth, Bamm, 157n4 Holdfast, 25, 27 Holdfast (municipal doctor), 25–8, 32 Homemakers’ Clubs, 23, 45, 143 Horlick, Louis, 94–5 Houston, C.J. (father of C. Stuart Houston), 102–3; Introduction and Epilogue Howden, Gordon, 89–90 Hudson’s Bay Company (hbc), 3–4; 172n1 Hugh Waddell Memorial Hospital, 15. See also Canora Humboldt: hospital, 16 Ile-à-la-Crosse, 58; first hospital in Saskatchewan, 4 Imperial Order Daughters of the Empire (iode), 46, 143 Indian Head, 19, 65; hospital, 10; nursing training, 10; population, 11 infant mortality rate, 89 Irwin, O.M., 162n31 Islay, ab: municipal union hospital, 35

Index

Ituna, 33 Izumi, Kiyoshi, 114. See also Saskatchewan Plan Johns Hopkins University, 71 Johns, Alfred Edward, xx Johns, Harold, xvii–xx, 122–5, 129–30, 134. See also “Saskatchewan mafia” Johns, Sybil, 129 Johnson, A.W., 160n32 Johnstone, D.S., 28. See also Committee on Municipal Physicians Joliette, nd, 41 Jorgenson, Lester, 83, 85, 92 Journal of the Canadian Association of Radiologists, 134 Jukes, Augustus L., 4 Katz, L., 125 Kelly, Arthur D., 89. See also Canadian Medical Association Kelvington, 121 Kerst, D.W., 124, 126, 175n28 King Edward tuberculosis hospital, 43. See also Winnipeg King George infectious disease hospital, 43. See also Winnipeg Kirkby, R.W., 43 Kirychuk, Mary, 140 Kitchi-Manitou, 58 Kjorven, Carl, 84, 85, 91, 102, 163n34

186

Lady Minto Hospital, 13. See also Melfort La Loche, 58, 67 Langley, George, 27. See also Minister of Agriculture Lashburn: hospital, 15 Latta, S.J., 54 Lawson, F.S. (Sam), 109–10, 113–15. See also Saskatchewan Plan Leader Post, 91 League of Nations, 22–3 Lebret Indian School, 56 Leroy (municipal doctor), 28 Lewis, W.B., 129. See also Atomic Energy Project Lindsay, W.S., 95 Lintlaw (municipal doctor), 28 Lloyd, Woodrow, 139–40 Lloydminster, 36; hospital, 11, 35, 36, 37 Lloydminster Times, 36 London, England, 48, 123, 134 London, on, 132–4 London Free Press, 133 Lorne, Marquis of (governor general), 6 Low, David, 105–7 lsd. See d-lysergic acid diethylamide MacDonald, Maria, 18 MacKay, John, 130, 135–6. See also Acme Machine and Electric

Index

Mackenzie, C.J., 124–5. See also National Research Council MacLean, Hugh, 158n5 Macleod, J. Wendell, 94, 165n4 MacNeill, J.W., 107 Manitoba, 3, 20, 42, 152n11, 158n9; joined medicare, 141; tuberculosis treatment, 54, 59–60, 156n26 Maple Creek, 89, 162n31; hospital and nurse training school, 10; nwmp hospital, 4; population, 11 Marchildon, Gregory, 140 Mary E. Truesdell Nursing Home, 6 maternity grant, 19, 39 Matheson, J.A., 89, 162n31 Matthews, Maureen, 90, 164n65 Matthews, Vincent L., 86–7, 90–1, 163n37 Mayneord, M.V., 123. See Royal Cancer Hospital Matt Anderson Plan, 38–40; 72–3, 81 McAllister, James, 101 McAra, Peter, 65 McCorkell, Wilf, 116–17 McDonald, Ellice, 118–19 McGill University, 19, 94, 121, 174n23, 192n2; medical school, 98 McGowan, Sargent, 140, 178n5 McKerracher, D.G. (Griffith),

187

109–11, 113–16 McKillop (rm), 38, 72–3 McKinnon, Eleanor, ix–xix McLaren, Robert, 23 McLean, C.S., 32 McLeod, Ian, 78 McLeod, Thomas H. (Tommy), 77 McMaster University, 122 McNaughton, A.G.L., 124, 174n23 McTaggart, Ken, 102 Meadow Lake, 67 medical college, 74, 92–3, 130 Medicine Hat, ab: hospital, 6; population, 149n10 medicine men and women, 3–4 Melfort: hospital 13; tb clinics, 52. See also Lady Minto; Victorian Order of Nurses Melrose, Walter, 84 Memorandum on Organization of Health Regions, 81 Mental Health Act, 111 mescaline, 112 milk, 20–1, 44, 143; pasteurization, 22. See also tuberculosis Millar, (nurse), 5 Mills, John, 111, 114, 117, 170n16 Minister of Agriculture, 27 Minto, Lady, 6–7, 10, 13. See also Victorian Order of Nurses (von) Miry Creek (rm), 37, 81, 92

Index

Michi-Manitou, 58 Montreal, qc, 5, 15, 60 Montreal Lake, 66 Moose Jaw: hospital, 4, 11, 12, 16; mental health clinic, 109; polio clinic, 101; population, 11; school tb survey, 51; tb clinic, 52 Moosomin, 19, 124, 174n23; hospital 7, 9; population 11 Morrison, A., 134 Motherwell, W.R., 18 Mott, F.D. (Fred), 98–9, 102, 163n36, 167n11 municipal doctors, 23, 27–35, 72, 144, 152n11; location, 28 municipal hospitals, 23, 36–40; location in ab, 35 Municipal Medical and Hospital Services Act, 38. See also Anderson, Matt; Matt Anderson plan Munroe Wing (Regina General Hospital), 109 Murray, Walter, 118 Muskeke-O-Kemacan (Great White Physician), 28, 58. See also Ferguson, R.G. Myers, G.W., 99 Myles, Margaret Fraser, 7 National Association for the Prevention of Tuberculosis, 57 National Cancer Institute, 127 National Council of Women, 6

188

National Health Grants Program, 96, 153n34 National Health Insurance Plan (Great Britain), 86 National Research Council (nrc), 55, 124, 129, 134 New Brunswick, 178n10; joined medicare, 141 Newfoundland: joined medicare, 141; medical school 179n17 Newton, il, 25 New York City, 20; Memorial Hospital 119, 173n15 Ninette, mb, 20; Sanatorium, 42 Nipawin, 46 Normal School (Teacher’s College), 46, 47, 51 North Battleford, 114: hospital, 16; psychiatric clinic, 109; psychiatric hospital, 107; school tb clinic, 51; tb clinic, 52, 114. See also Saskatchewan Hospital North Dakota, 41 North-West Mounted Police (nwmp), 4; Royal North West Mounted Police, 19 North West Territories: joined medicare, 141 North-West Territories, 6 North-West Territories Medical Council, 22 Nova Scotia: joined medicare, 141 Nuclear Enterprises, 136

Index

nuclear imaging, 136–7 nurses, student, 49, 55, 60, psychiatric nurse training, 109–10 Ogdensburg, ny, 105 Onoway, ab, municipal union hospital, 35 Ontario, 18, 52, 104, 105, 129, 132, 133; joined medicare, 141 Osmond, Humphry, 112, 114–15 Paddockwood, 38–40, 98, 140, 167n10 Paille, Father (Oblate), 11 Palliser Triangle, 80 para-amino-salicyclic acid, 64 Parsons, Phoebe (nurse), 5 Patrick, T.A., 7 Patterson, W.J., 157n4 pavilion-style psychiatric hospital, 107 Peart, Arthur F.W., 86, 163n33 Pennant, 84 Pépin, Sister, 4 peyote cactus, 112 Philadelphia Cancer Institute, 119 photofluorographic surveys, 61–2 photoscanning, liver and whole body, 136–7 Picker Cobalt units, 136 Pierce, S.J.S., 42 “Pile of Bones,” 6. See also Regina

189

Pittville (rm), 38, 71, 80–2 poliomyelitis, 101 Prebble, Peter, xviii Presbyterian Church, 11, 13 preventorium, 46, 50 Prince Albert, 19, 141; hospital, 6, 8, 15; nwmp hospital, 4; population, 11; psychiatric clinic, 109, 115; sanatorium, 43, 47, 58–9, 64 Prince Edward Island: joined medicare, 141 Protestant Hospital for the Insane, 105 Provost, ab: municipal union hospital, 35 psychedelic therapy, 112–13, 138 Psychiatric Services Branch (Saskatchewan), 113 Public Health Act, 18 Qu’Appelle: nwmp hospital, 4 Qu’Appelle Indian agency, 56; reserve, 56 Qu’Appelle Valley, 18, 20 Quebec: joined medicare, 141 Queen Victoria, 6 radium, 118, 120–1, 123–4, 129 radon, 121 Red Cross, 39, 143, 155n10 Red Cross Outpost Hospitals, 38–40, 98 Regina, 6, 7, 8, 18, 19, 21, 28,

Index

38, 47, 56, 65–6, 71, 81, 88–9, 92–3, 99, 104, 106, 114, 121, 124, 157n4, 158n5, 162n27, 163n34; cancer clinic, 121; hospital, 13; nwmp hospital, 4; polio clinic, 101; population, 11; sheriff, 51; school tb survey, 51; tb clinics, 52; vd clinic, 19 Regina College, 21 Regina General Hospital, 109, 119 Regina Leader Post, 91 Registered Nurses, 72, 102, 107; Registered Psychiatric Nurses, 107, 110–11 Riel Rebellion, 4, 18 Riverside (rm), 81, 84–5 Robertson, Stewart, 81, 85, 87, 90–1, 162n23, 163n42 Roemer, Milton, 75 Roman Catholic, 11, 15 Röntgen, Wilhelm Carl von, 134 Rorem, C. Rufus, 28–30, 152n11 Rosthern, 47 Royal Canadian Air Force Clinical Investigation, 93 Royal Canadian Legion, 66 Royal Cancer Hospital, 123 Royal College of Physicians (mrcp), 48 Royal Institute of Public Health, 23

190

Royal North West Mounted Police, 19 Rural Municipal Act, 53 Rush Lake (municipal doctor), 28 St Boniface, mb, 4, 11 salaried doctors, xix, 27–35, 71, 75, 80–1, 159n22; loss of due to medicare, 34 Saltcoats: hospital, 5 Sanatoria Act, 53 sanatorium. See Clearwater; Fort Qu’Appelle (Fort San); Ninette; Prince Albert; Saskatoon; Trudeau Saranac Lake, ny, 20 Sarnia (rm): (municipal doctor), 19, 25–7, 34 Saskatchewan Anti-tuberculosis Commission, 49–50 Saskatchewan Anti-tuberculosis League, 20, 45, 51, 54, 58, 61–6 Saskatchewan Association of Rural Municipalities (sarm), 33, 53, 65, 71 Saskatchewan Cancer Agency, 176n39 Saskatchewan Cancer Commission, 119, 122 Saskatchewan Cancer Commission Act, 119 Saskatchewan College of

Index

Physicians and Surgeons, xix, 33, 38, 76, 102, 103, 139, 140 Saskatchewan Gazette, 82 Saskatchewan Health Service Board, 32–3 Saskatchewan Health Services Planning Commission (hspc), 77, 81, 98, 159n22, 163n34, 167n11 Saskatchewan Health Survey, 96–7 Saskatchewan Hospital: North Battleford, 107, 114, 117; Weyburn, 109, 112, 114, 117 Saskatchewan Hospital Services Plan (shsp), 98–101 Saskatchewan Lung Association (sla), 63–4, 66 “Saskatchewan mafia,” 134 Saskatchewan Medical Association, 22, 33, 47, 65, 66, 76, 102, 119; Cancer Committee, 119 Saskatchewan Medical Care Insurance Commission, 92 Saskatchewan Medical Quarterly, 75, 84 Saskatchewan Plan, 114–16 Saskatchewan Psychiatric Nurses Act, 111 Saskatchewan Psychiatric Nurses Association, 111 Saskatchewan Sanatoria and Hospitals Act, 54

191

Saskatchewan Social Assistance Plan, 75–7, 97, 100, 122, 140 Saskatchewan Tumour Registry, 120 Saskatchewan Urban Municipal Association (Saskatchewan Urban Municipalities Association) (suma), 54, 168n25 Saskatchewan Wheat Pool, 102, 142 Saskatoon, xviii, 21, 47, 73, 89, 93, 94, 113, 116, 124, 126, 143; betatron, 126–9; closure of sanatorium, 64; cobalt-60, 129–36; gamma camera, 136; hospitals, 11, 13, 119, 126; medical college, 115; polio clinic, 101; population, 11; psychiatric clinic, 109; Riel Rebellion base hospital, 5–6; sanatorium, 43, 47, 49; school tb survey, 51; tb clinics, 52; tb survey, 61; typhoid epidemic, 11 Saskatoon Agreement, 140 Saskatoon Star-Phoenix, 130, 133 Schmitt, Henry J., 19, 25–7, 32, 151n4 Schrijvers, Klaartje, 140–1 Schultz, Milford D., 126 Science, 134 Senlac (municipal doctor), 28

Index

Seymour, Maurice Bain, 18 Seymour, Maurice M., 18–24 Seymour Plan for immunization, 22 Sharp-tailed Grouse, 6 Shaunavon, 84, 153n30, 161n17 Shaunavon Standard, 161n16 Shepley, Earle E., 119, 120 Sheps, Cecil, 167n11 Sheps, Mindel Cherniak 77, 81–2, 158n9, 167n11 Shumiatcher, Morris C., xviii Sigerist, Henry, 71–6, 93, 95–7, 100, 144, 157n4, 158n6, 158n9 Sigerist Commission report, 35, 71, 75, 77, 93, 95, 108, 110 Simes, Austin, 59–60 Sinclair, Lister, 90 Sisley, (nurse, nursing home), 11, 13 Sisters of Charity (Grey Nuns), 4, 11, 15 Sisters of Providence, 15, 16 Sisters of St Elizabeth, 16 Skaggs, Lester, 124 smallpox, 3–4; vaccination, 22 Smith, Colin, ix, 109 Smith, Ivan H., 133 Smythies, John, 112 Social Assistance Medical Care Plan, 75–6, 77, 97, 100, 122, 140 Stapleford, E.W., 21

192

St Elizabeth’s Hospital, 16. See also Humboldt sterilization, 74 Stewart, D.A., 20, 42–3 Stirrett, R.R., 162n31 Stoughton: school tb survey, 51 Strasbourg, 38, 73 streptomycin, 64 Swift Current, 11, 79–92, 115, 162n27, 162n30, 162n31; hospital, 16, 17; psychiatric clinic, 109; tb clinic, 52 Swift Current Health Region, x, 72, 79–92, 96, 102, 138, 144, 162n27, 163n34 Swift Current Regional Hospital Council, 90 Swift Current Sun, 86 syphilis, 19 Taché, Father (later Bishop), 4 Taylor, Lauriston, 123, 174n19, 179n17 Taylor, Lord Stephen, 72, 91, 140 Taylor, Malcolm G., ix, 37, 40, 71, 92, 99–100, 102, 140, 168n29, 178n10 Thompson Advisory Planning Committee, xix Thompson, Walter P., 129 Thomson, James S., 124–5 Tisdale tb clinics, 52 Tizley, Richard, 61 Toronto, on, xx, 106, 123

Index

Toronto Asylum, 106 Trudeau Sanatorium, ny, 20 tuberculin test, 51, 56, 60; of cattle 20, 21 tuberculosis, 20–2, 41–68, 101, 118, 138, 143, 144; bovine tuberculosis, 20; epidemic among First Nations graph, 57; and First Nations, 43, 55–9 Tuckwell, David Grieve, 36 typhoid, 11, 20, 22, 42 Uhrich, J.M. (health minister), 47 union hospitals, 35–9, 82, 96–7, 143 United Farmers of Canada (ufc), 32, 54 United Kingdom, 23 United States, 28, 98, 105, 123, 129 United States Air Force, 59 United States Public Health Service, 98 University Hospital, 74, 93–5, 116, 126, 130 University Hospital Act, 94 University of Alabama, 173n15 University of Alberta, 122 University of California, Berkeley, 99 University of California, Los Angeles, 75 University of Chicago, 29

193

University of Illinois, 124 University of Manitoba, 59 University of Ottawa, 23 University of Pennsylvania, 118 University of Saskatchewan, 64, 66, 93–5; college of medicine, 93–4, 113, 118–19, 124 University of Toronto, 22, 64, 122 University of Western Ontario, 129 Vachon, Father (Oblate), 11 venereal disease, 19, 74 Venereal Disease Act, 19 Venice Café, 91 Verdun, qc, 105 Vermilion, ab: municipal union hospital, 35 Victoria, bc, 134 Victoria Hospital: Prince Albert, 6; Regina Victoria, 6–7; Queen Victoria, Yorkton, 7; London, on, 132. See also 7–10 Victorian Order of Nurses (von), 6–7, 13 Victor X-ray Corporation, 56 Voth, Abe, 116–17 Wadena: tb clinics, 52; union hospital district, 153n30 Wakaw: Anna Turnbull Memorial Hospital, 11 Ward Island, 105

Index

Warwick, O.H., 127 Watson, T.A., 127, 130 Webb (rm), 81, 85, 163n42 Wesley College, 41 Weyburn, 112, 114; rm, 53; asylum, 107, 117; hospital, 16; psychiatric clinic, 109; psychiatric nursing, 111 Wherrett, G.J., 52 Wherrett-Grzybowski report, 52 White, Paul, 49 Willoughby, J.H.C. (private hospital), 11, 14 Wilton (rm), 36 Windsor, on, 18

194

Winnipeg, mb, 5, 6, 41–3, 49, 56, 136, 151n8, 158n9, 165n4, 173n15; general hospital, 5 Women’s Missionary Society, 13 Wolan, Casimir, 90–1 Yorkton, 7, 19, 42, 144, 168n25; Yorkton Queen Victoria Hospital, 7, 9, 144, 179n15; population, 11; psychiatric clinics, 109; psychiatric cottage hospital, 115, 171n43; tb clinics, 52 Yukon: joined medicare, 141

36 Steps on the Road to Medicare

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36 STEPS ON THE ROAD TO MEDICARE H o w S a s k a t c h e w a n L e d t h e Way

C. Stuart Houston and Merle Massie

McGill-Queen’s University Press Montreal & Kingston • London • Ithaca

© McGill-Queen’s University Press 2013 isbn isbn isbn isbn

978-0-7735-4285-3 978-0-7735-4286-0 978-0-7735-8957-5 978-0-7735-8958-2

(cloth) (paper) (epdf) (epub)

Legal deposit fourth quarter 2013 Bibliothèque nationale du Québec Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free McGill-Queen’s University Press acknowledges the support of the Canada Council for the Arts for our publishing program. We also acknowledge the financial support of the Government of Canada through the Canada Book Fund for our publishing activities.

Library and Archives Canada Cataloguing in Publication Houston, C. Stuart (Clarence Stuart), 1927–, author 36 steps on the road to medicare : how Saskatchewan led the way / C. Stuart Houston and Merle Massie. Includes bibliographical references and index. Issued in print and electronic formats. isbn 978-0-7735-4285-3 (bound).–isbn 978-0-7735-4286-0 (pbk.).– isbn 978-0-7735-8957-5 (epdf).–isbn 978-0-7735-8958-2 (epub) 1. National health insurance – Saskatchewan – History–20th century. 2. Medical policy – Saskatchewan – History – 20th century. I. Massie, Merle, 1971–, author II. Title. III. Title: Thirty-six steps on the road to medicare. ra412.5.c3h72 2013 c2013-904662-3 c2013-904663-1

368.4'20097124

CONTENTS

Abbreviations vii Acknowledgments ix Foreword xiii Introduction xvii 1 2 3 4 5 6 7 8 9 10

Saskatchewan Hospitals: Off to a Slow Start 3 Dr Seymour and Public Health 18 Municipal Doctors and Municipal Hospitals 25 Dr Ferguson and Tuberculosis 41 Sigerist and Pensioners’ Care 69 Swift Current Health Region 79 Medical College and University Hospital 93 Provincewide Hospitalization 96 Innovations in Psychiatry 105 High-voltage Cancer Treatment 118 Epilogue 138 Notes 147 Index 181

A B B R E V I AT I O N S

act aecl apha bcg ccf dot hbc hspc iode lsd mb bch mrcp nrc nwmp rm rpn sab

Associated Canadian Travelers Atomic Energy Canada Limited American Public Health Association Bacille Calmette Guérin vaccination (tb) Co-operative Commonwealth Federation Directly Observed Therapy Hudson’s Bay Company Health Services Planning Commission Imperial Order Daughters of the Empire D–lysergic acid diethylamide Bachelor of Medicine, Bachelor of Surgery Member, Royal College of Physicians National Research Council North West Mounted Police Rural Municipality Registered Psychiatric Nurse Saskatchewan Archives Board

Abbreviations

sarm Saskatchewan Association of Rural Municipalities sca Saskatchewan Cancer Agency sdcmh Saskatchewan Division, Canadian Mental Health Association shsp Saskatchewan Hospital Services Plan sla Saskatchewan Lung Association sti Sexually Transmitted Infection uhd Union hospital district von Victorian Order of Nurses

viii

ACKNOWLEDGMENTS

stuart houston I was indebted to many people prior to 2002. Early in the process, Eleanor McKinnon, private secretary to Premier T.C. Douglas; Malcolm Taylor, former secretary to the Health Services Planning Commission; and Hon. Walter Smishek, former minister of health, provided interviews. Hon. Sylvia Fedoruk wrote the foreword and critiqued the chapter on high-voltage radiation. Joan Feather and Lester Jorgenson critiqued the chapter on the Swift Current Health Region, and provided additional information. Dr Colin Smith critiqued the chapter on psychiatry, and Drs Ian McDonald and Frank Coburn provided interviews. Pat Matthews gave me biographical material and a photograph of her late husband; Mrs William Burak provided a small photo of her late husband. The Saskatchewan Archives Board provided most of the photographs. Michael West provided permission to use the copyrighted photograph of Malcolm Taylor. The portrait of Henry Sigerist came from the Alan Mason Chesney Medical Archives at the Johns Hopkins Medical Institutions.

Acknowledgments

Associated Medical Services Inc., through its Hannah Institute for the History of Medicine Program, kindly gave permission to use material from R.G. Ferguson, Crusader against Tuberculosis (1991). The Canadian Medical Association Journal and the Annals of the Royal College of Physicians and Surgeons have each allowed use of portions of four of my articles published in their journals, as cited individually in the references. Dr John W. Aldrich and Dr Brian C. Lentle have allowed extensive use of the Houston and Fedoruk chapter in their 1995 book that marked the centennial of Röntgen’s discovery of xrays. The Canadian Broadcasting Corporation program Ideas kindly allowed use of three excerpts from the radio program of 5 December 1990. Zennon Slowski and Dr Donald S. Houston solved my computer problems. The entire manuscript was read critically in 2002 by Allan E. Blakeney, Mary I. Houston, and J. Frank Roy, and by doctors Ronald M. Bremner, Louis Horlick, Stan Houston, and Robert Lampard. I am grateful for their insightful comments and corrections. With the help of my co-author, Merle Massie, this revised manuscript adds several critical dimensions to the medicare story. The origins and impact of the Swift Current Health Region and Saskatchewan’s psychiatric innovations have received expanded attention. We have reoriented Saskatchewan’s roots in First Nations and fur trade experience. Other additions include coverage of the Red Cross Outpost Hospitals, poliomyelitis, the air ambulance, the Matt Anderson plan, a more in-depth look at Saskatchewan’s advances in cancer treatment, and a tribute to Sylvia Fedoruk. Stuart expresses his personal assessment of the implementation of medicare in 1962, and its continued influence,

x

Acknowledgments

in the epilogue. The revised manuscript was improved by Erika Dyck and Greg Marchildon. Any residual errors or omissions are the responsibility of the authors. merle massie I would like to thank Stuart Houston for allowing me to have a part to play in this revised version of Steps on the Road to Medicare. As a historian, I emphasize the social context behind the remarkable achievements listed here. Stuart is an exceptional collaborator – he kept me fascinated, and often in stitches, with his assessments of Saskatchewan people, places, and events. The revised version holds Stuart’s central narrative voice, but fills out the story of Saskatchewan’s adventures in health care transformation.

xi

FOREWORD B Y S Y LV I A O . F E D O R U K

Saskatchewan has been a leader in many aspects of health care. These developments arose from the co-operation and mutual help necessary among pioneer settlers, sparsely distributed in a relatively hostile environment. House-raising, barn-raising, and the building of community amenities such as schools and curling rinks made it logical for other co-operative developments also to occur. These accomplishments took place in an atmosphere of community, creativity, and trust. Individuals with foresight such as Drs Seymour, Ferguson, Blair, and Johns helped Saskatchewan to lead the world. In 36 Steps on the Road to Medicare: How Saskatchewan Led the Way, Stuart Houston reviews many of the exciting events in a story that reflects the strengths of Saskatchewan people. Stuart, himself, is truly a part of Saskatchewan history. He served on the executive of the Canadian Society for the History of Medicine from 1979 to 1987, including two years as

Foreword

president. His published works in medicine and the history of medicine number 288, including four books, seventeen chapters in books, and sixty-nine original scientific articles. His published works in ornithology and natural history number 681, including eight books, forty-three forewords or chapters in books, and 292 original papers. His interest in ornithology is legendary, especially in bird-banding – he and his wife, Mary, have banded over 147,000 birds of 211 species, with 3,800 recoveries or encounters. Stuart is professor emeritus of medical imaging at the University of Saskatchewan. Our paths have intertwined over many years. We both took our schooling in the Yorkton area of Saskatchewan in the 1940s. For about twenty years, until my retirement in 1986, Stuart and I collaborated in teaching radiation physics, the “Stuart and Sylvia show,” to first-year medical students at the University of Saskatchewan. When I was chancellor, it was my privilege to present him with a DLitt degree (1997), although he had taken no classes and written no exams. Most of the medical students appreciated him – he is the only medical doctor to have been elected honourary president of the Student Medical Society three times, including in his last full year of teaching and practice. Stuart received Saskatchewan’s highest honour, the Saskatchewan Order of Merit, in 1992, and was made an Officer of the Order of Canada in 1993. In 1997, he was the fourth recipient of the Gold Medal of the Canadian Association of Radiologists. His most recent honourary degree was a DCnL, in 2002. The Honourable Sylvia O. Fedoruk, oc, som, dstj, ba, ma, dsc, lld, dhuml, fccpm

xiv

Foreword

authors’ note Sylvia Fedoruk died, independent to the end, in her home, on 26 September 2012 at age 85. As an undergraduate, Sylvia received the Governor-General’s medal “as the most distinguished graduate of any college,” together with the Spirit of Youth award for her achievements in athletics and student governance. She was both the top academic and the top female athlete: a member of twelve university championship teams in basketball, track and field, golf, volleyball, and hockey. Canada’s first women’s world curling title came later. Sylvia’s entire academic career was spent on the campus of the University of Saskatchewan, where she was director of physics services for the Saskatchewan Cancer Foundation, chief medical physicist for the Saskatoon Cancer Clinic, and professor of oncology. She was the first woman member of the Atomic Energy Control Board of Canada. In 1986, Sylvia Fedoruk was the first female chancellor of the University of Saskatchewan (1986–89). Two years later, she served six years as the first woman Lieutenant Governor of Saskatchewan (1988–94). She received five honourary doctorates, the Queen’s Jubilee Medal (1977), and the Taras Shevchenko Award of the Ukrainian Canadian Congress. In 1986 she was made an Officer of the Order of Canada and was awarded the Saskatchewan Order of Merit. In 2009, she was inducted into the exclusive Canadian Medical Hall of Fame. Rarely if ever has any woman anywhere been such an achiever in so many different fields – and never has that achiever re mained to the end so humble and so modest.

xv

INTRODUCTION Medicare is considered to be the most valued social programme in Canada today. Canadians have rated it as their most important concern, ahead of programmes in employment and social welfare … medicare is an essential part of Canada’s national identity and part … of what it means to be Canadian.1

Most of the steps that led to medicare were forged in Saskatchewan. The events described in this book changed the course of health care throughout Canada. There is a certain danger in listing all the times Saskatchewan was “first,” leaving us open to charges of hero-worship, bragging, and jingoism. In this revised edition, my co-author Merle Massie and I enumerate these “firsts,” with one caveat: we do not say that all of these firsts are, therefore, key “steps” on the road to medicare that should be followed by other jurisdictions around the world. Some were. Others showcase Saskatchewan’s vivid and path-breaking leadership. Yet we hope those connected with Saskatchewan will be proud of the recurring themes of co-operation, innovation, and rapid response to need throughout Saskatchewan’s ninety-seven year history of health care. But one question must somehow be addressed. Why was Saskatchewan so consistently the leader? Why not Alberta? Manitoba? Nova Scotia?

Introduction

Allow me to begin with a vignette from my own experience. As an amateur medical historian who in most years meets with the men and women of the Canadian Society for the History of Medicine, I understand full well, from the experiences narrated by friends at these meetings, the need to question conventional wisdom, folk legends, and mythology. I had been told many times that Premier Tommy Douglas of Saskatchewan had okayed development of the world’s first betatron to treat cancer after one visit from Allan Blair and Harold Johns, probably in 1946. This story was surely partly legend, and perhaps apocryphal folklore. Or was it? So, when I had the chance to hear the truth first-hand, I seized the opportunity. T.C. Douglas was coming to Saskatoon to give a speech at a major New Democratic Party (ndp) banquet on 18 February 1983. I phoned Peter Prebble, my ndp Member of the Legislative Assembly, and asked whether I could be booked for a short interview with Douglas. Peter phoned back to say that his schedule was full, but that if my wife, Mary, and I would come to the banquet, we would be assigned to drive Douglas back to his lodgings at the Bessborough Hotel. We accepted this unusually innovative offer with alacrity. I had met Douglas only a few times. The first time, when I was a student, he was a guest in my family home in Yorkton, together with his personal advisor and assistant Morris C. Shumiatcher. I have a vivid memory of these two men standing beside the fireplace after supper, my six-foot-four father towering over both. Early in Douglas’s career as Co-operative Commonwealth Federation (ccf) premier of Saskatchewan, my father had been on the committee that negotiated payments to doctors for treating impoverished people receiving social assistance. Later, Dad served as one of three doctors nominat-

xviii

Introduction

ed by the Saskatchewan College of Physicians and Surgeons on the Thompson Advisory Planning Committee on Medical Care. The interim report of the Thompson committee recommended a system of universal health coverage, financed by direct taxation and general revenues, and run by a non-political commission. Doctors would be paid on a fee-for-service basis, rather than by salary as in a state medicine system. Premier Douglas recommended the commission “because it was requested by the doctors, and because it would assure no political interference.”2 This was surely one of many examples of Douglas’s pragmatism. As a high-school student, I had typed some of Dad’s letters and briefs during his time on this commission. As I drove Douglas back to the hotel in 1983, he asked after my parents and spoke well of both, the rancor of the so-called doctors’ strike in 1962 notwithstanding. Time was short and Douglas needed to go to bed. I asked my well-prepared questions, and as I remember it, the conversation went as follows: csh: Do you remember the day that Harold Johns and Allan Blair dropped into your office to ask for permission to buy a betatron to treat cancer? tcd: Yes, clearly, as if it were only yesterday. csh: Is it true they came unannounced, without an appointment? tcd: Probably. I had an open-door policy, guided by my trusted secretary Eleanor McKinnon. [Later an interview with Miss McKinnon in Regina confirmed that unscheduled visits were the rule. Douglas made it a policy to help any Saskatchewan citizen. The system worked best without fixed appointments.]3 csh: Is it true that you listened to their “pitch,” asked for an approximation of the probable cost, and that they then

xix

Introduction

walked out of your office with a virtual carte blanche to proceed? tcd: Yes. csh: Is it true that you made this decision without consulting your treasurer, Clarence Fines, or any member of your cabinet? tcd: Absolutely. csh: Is it true that you made this important decision without consultation with any other medical doctors or physicists, or any outside agency? tcd: I believe that to be true. csh: How did you justify making such a momentous decision on the spur of the moment? tcd: Well, after all, I was both premier and minister of health. csh: How did you have the courage to do this without consultation with anyone at all? tcd: Well, it was easy. I had complete confidence in the knowledge and the integrity possessed by both men. They assured me that highvoltage radiotherapy offered great promise in the treatment of cancer. Dr Allan Blair had come from Toronto to head up the leading cancer agency in North America. And Harold Johns! Why, when I attended Brandon College, Alfred Edward Johns was my mathematics teacher and my favourite professor. He had been a missionary in Chengtu [Chengdu], West China, until 1924. His son, Harold, had been born in China. I was both poor and undernourished. The osteomyelitis in my femur was chronic, would periodically break down and issue pus, and this ran me down. The Johns family took pity on me and often had me over for Sunday supper in a deliberate attempt to put

xx

Introduction

some weight on my frame. It was evident that their son, Harold, showed unusual promise. So, with my close personal knowledge of both men and my complete faith in their integrity, my permission did not seem to me to be a gamble at all. I told this story in March 2002 to Shirley Douglas on a phonein program on cbc radio, and she thanked me for it.4 I don’t think she really believed her father had been that rash, making so important a decision so quickly. But the story as told above is an example of a visionary in action. Douglas was a leader, the “right man in the right place at the right time,” who moved events forward. This helps to explain why, on 29 November 2001, T.C. (Tommy) Douglas easily topped a month-long national cbc television poll as “The Greatest Canadian.” He was one part of the answer to “How Saskatchewan led the way.”

xxi

CHAPTER 1

S A S K AT C H E WA N H O S P I TA L S Off to a Slow Start

To maintain a little balance in an unabashed book of firsts, it seems only fair to admit that the area that became Saskatchewan in 1905 was slow off the mark – the advent of hospitals was delayed in comparison with adjacent Manitoba and Alberta. Of course, health care, for thousands of years, had been in the hands of medicine men and women in what became Saskatchewan. They had practical knowledge of effective herbal remedies, and a cultural and spiritual connection to community and to the land. When smallpox, that scourge of the North American First Nations, hit Saskatchewan in the winter of 1781–82, traditional medicine was of no use. The fur trade community at Cumberland House organized itself as a de facto field hospital. “Indeed, I have no Medicines to Give him that is fit for that Disorder,” lamented Hudson’s Bay Company (hbc) Master William Tomison on 30 December 1781. Still, Tomison took in the sick, “& they have due attendance Night & Day &

36 Steps on the Road to Medicare

yet there is but little hopes of their recovery, most of them being greatly Starved before they came here.”1 Smallpox returned in 1816. Cowpox vaccinations, developed in Europe, were used in western Canada among the First Nations, stemming what could otherwise have been a severe outbreak. A third epidemic appeared in 1870. The hbc took the lead, through its posts, in providing the vaccine and teaching residents arm-to-arm vaccination techniques.2 It should come as no surprise that, given the fur trade origins, the first hospital established in what is now Saskatchewan was along the fur trade highway of the Churchill River at Ile-àla-Crosse. Three dedicated Sisters of Charity (Grey Nuns), Sisters Agnes, Boucher, and Pépin, arrived there in 1860 with Bishop Grandin after an arduous journey of fifty-seven days in an open barge from St Boniface. This was only fourteen years after Father Taché (later Bishop Taché) set up his mission among the First Nations and a few French-speaking trappers. The three sisters established a convent, a dispensary, and a mission school.3 In 1873 they began the formal operation of a hospital.4 Later, with the construction of each North-West Mounted Police barracks, a building was set aside as a hospital. Fort Walsh in the Cypress Hills was first in 1875, followed by Qu’Appelle in 1881, Regina and Maple Creek in 1883, and Battleford and Prince Albert in 1884.5 When Dr Augustus L. Jukes was appointed senior surgeon to the North-West Mounted Police in 1880,6 and stationed at Fort Walsh, he appointed a pharmacist as hospital steward. In 1885, two temporary military hospitals were created to care for wounded men evacuated from the battles of the Riel Rebellion. The first was a frame building with forty beds erected at Moose Jaw by the government. The head nurse was Hannah Grier Coombs, known as Mother Hannah, who later founded

4

Figure 1.1 Saltcoats cottage hospital (sab r-a23797)

the Anglican Sisterhood of St John the Divine. The second, Saskatoon’s temporary base hospital with up to eighty patients, was staffed by Dr James Bell of Montreal, Miss Millar (head nurse of the Winnipeg General Hospital, on loan), Nurse Phoebe Parsons, and Nurse Elkin. When the last Saskatoon patients were evacuated to Winnipeg by river barge and steamer, via Grand Rapids, the southern half of present-day Saskatchewan was again without a hospital.7 The first public hospital, at Saltcoats, was too far ahead of its time. Built in 1896, it opened in 1897 with a resident medical superintendent, a matron, and three trained nurses (figure 1.1). An early tragedy sullied its record on 4 January 1898. Nurse Biggins went to the basement carrying a coal oil lamp, which hit an overhead beam, broke, and set her clothes on fire. She died the next day. By year’s end, only forty-nine in-patients

5

36 Steps on the Road to Medicare

had been treated, but 374 days of free treatment had been provided. With its record of bad luck, and so many patients unable to pay, the hospital was closed in 1899.8 When the railroad reached “Pile of Bones” in 1882, it became the capital city of the North-West Territories. Canada’s governor general, the Marquis of Lorne, was asked to give the new village a more suitable name. Since he was married to Queen Victoria’s daughter, he christened it Regina in honour of his mother-in-law. Despite their town’s designation as a capital city, Regina citizens requiring hospital care were forced to take the train east to Brandon or Winnipeg until late in 1889. That year the first general hospital in the North-West Territories opened in Medicine Hat, with forty beds and a $5 hospitalization (insurance) option as part of their 1889 fundraising project.9 Regina patients alone accounted for 1,623 days of in-patient care in the Medicine Hat hospital in 1895.10 For nine years, Regina had only the Mary E. Truesdell Nursing Home, founded in August 1889. In 1896 the Regina branch of the National Council of Women began to raise money for a cottage hospital, with nurses supplied by the Victorian Order of Nurses (von). The cottage hospital opened in 1898 (figure 1.2). Meanwhile, in Prince Albert, the Victoria Hospital began with a small building in 1899 (figure 1.3). Its Ladies’ Aid, among other contributions for the hospital, received nightshirts and a tablecloth, as well as a brace of Sharp-tailed Grouse, two dozen eggs, and six cakes to feed the patients.11 At the end of 1899 there were two hospitals, each with seven beds, to serve about 90,000 people in fast-growing Saskatchewan.12 In 1899, the foundation was laid for a new twenty-five-bed hospital on Hamilton Street, just south of 14th Avenue in Regina. The von contributed $1,500, with the proviso that the new hospital be named the Regina Victoria. Lady Minto, wife

6

Off to a Slow Start

Figure 1.2 Victorian Order of Nurses Hospital, Regina (sab r-b535)

of the governor general, formally opened it in September 1901 (figure 1.4). A nursing training school began at once, with three students in the first class. The hospital continued to expand and was taken over by the City of Regina in 1907. It has been the largest hospital in Saskatchewan ever since. The third permanent hospital in southern Saskatchewan, the Queen Victoria Hospital (figure 1.5), opened in my hometown of Yorkton in 1902; the drive for $1,800 was sparked by one of my heroes, Dr T.A. Patrick. The von contributed $3,000. Here began the second school of nursing. One of the graduates of this unaccredited school in 1917 was Margaret Fraser. After her husband died, Margaret Fraser Myles took upgrading and returned to be matron of the Yorkton hospital in the late 1920s. She then moved to Aberdeen, Scotland, where she became the author of the world’s best-selling Textbook of Midwifery, ten editions of which appeared between 1952 and 1985.13 The Moosomin hospital, the first between Brandon and Regina, also opened in 1902 (figure 1.6).

7

Figure 1.3 Victoria Hospital, Prince Albert (sab r-a1679)

Figure 1.4 Regina Victoria Hospital, Regina (sab r-b386)

Figure 1.5 Queen Victoria Hospital, Yorkton (Howard M. Jackson)

Figure 1.6 Moosomin Hospital (sab r-a218)

36 Steps on the Road to Medicare

Figure 1.7 Lady Minto Hospital, Indian Head (sab r-b10943)

The fifth and sixth hospitals opened in Maple Creek in 1904 and Indian Head (figure 1.7) in 1905. Both had nursing training schools. Maple Creek began as an eight-bed cottage hospital, but moved into a twenty-bed brick building in 1908. Nursing training continued until 1925 at Indian Head and 1935 at Maple Creek.14 When Saskatchewan was proclaimed a province in 1905, there were six hospitals in operation, four of them with nursing schools. Their seventy-five beds served over 250,000 peo-

10

Off to a Slow Start

ple. In the 1901 census, populations of the main towns were as follows: Regina 2,249, Prince Albert 1,785, Moose Jaw 1,558, Moosomin 868, Yorkton 700, Battleford 609, and Maple Creek 382. By 1906 two more centres had grown to more than 1,000 in population: Saskatoon with 3,011 and Indian Head with 1,545 inhabitants. Two of the eleven new towns with between 500 and 918 people in 1906 (Battleford 824 and Swift Current 554) soon built hospitals. Thus each centre with a population of 500 in 1900 or of 1,000 in 1906 had a hospital by 1912. In 1906, a twenty-eight-bed, four-storey general hospital opened in Moose Jaw (figure 1.8), just in time to care for victims of a typhoid epidemic. The building was steam-heated, but it had no elevator. That year a small rented building opened as a hospital in Lloydminster,15 and the Presbyterian Church opened the Anna Turnbull Memorial Hospital (figure 1.9) near their mission house in the hamlet of Wakaw.16 With the 1906 typhoid epidemic in the rapidly growing town of Saskatoon (which grew from 2,000 to 3,000 during the year), the eight beds in Nurse Sisley’s nursing home (figure 1.10) were quickly filled; cots were set up in surrounding buildings and even in the open grounds. The overflow of typhoid patients was taken to the new Roman Catholic rectory on Fifth Avenue, where Oblate Fathers Vachon and Paille cared for them around the clock. Propitiously, two Sisters of Charity from St Boniface came through Saskatoon in September. Although on a fundraising mission, they were pressed into service. In temporary quarters they cared for thirty-four severely ill typhoid patients, four of whom died. On 22 February 1907, the Grey Nuns purchased Dr J.H.C. Willoughby’s private home on Pleasant Hill, just west of the Saskatoon city limits. They opened it with seventeen patient beds on 10 March 1907 (figure 1.11).17 A three-storey

11

Figure 1.8 General Hospital, Moose Jaw (sab r-a7260)

Figure 1.9 Anna Turnbull Memorial Hospital, Wakaw (sab r-a12696)

Figure 1.10 Nurse Sisley’s Nursing Home, Saskatoon (A. Becker)

brick building was added in 1913 (figure 1.12). A new Saskatoon City Hospital opened with fifty-six beds in April 1909; its official history claims it as the first municipal hospital in western Canada (figure 1.13).18 In 1907 the Grey Nuns Hospital was founded in Regina and the twenty-three-bed Lady Minto Hospital, operated by the von, opened in Melfort. The Women’s Missionary Society of the Presbyterian Church established a small hospital in Canora, which

13

Figure 1.11 Dr J.H.C. Willoughby’s home, Saskatoon (A. Becker)

Figure 1.12 St Paul’s Hospital, Saskatoon (sab r-b1358)

Off to a Slow Start

Figure 1.13 City Hospital, Saskatoon (sab r-a3511)

expanded to become the thirty-bed Hugh Waddell Memorial Hospital in 1914. The Lashburn Hospital was built with a $10,000 bequest. In 1909, it offered the first hospital insurance scheme: a $5 ticket entitled one person to three weeks of hospitalization.19 The growing need for hospitals in other cities and towns was filled by Roman Catholic sisters. Sisters of Charity came from the Maritimes to open the twenty-five-bed Holy Family Hospital in Prince Albert in 1910, and Sisters of Providence came from Montreal to found Notre Dame Hospital in North

15

Figure 1.14 Notre Dame Hospital, North Battleford (sab r-b5148)

Battleford in 1911 (figure 1.14). In 1912, Sisters of St Elizabeth came from Austria to launch St Elizabeth’s Hospital in Humboldt and Sisters of Providence from Kingston opened the thirty-bed Moose Jaw Providence Hospital in 1912.20 That year, general hospitals opened in Swift Current (figure 1.15) and Weyburn (figure 1.16).21 By 1912, in terms of availability of hospitals, Saskatchewan was beginning to catch up with its two neighbouring provinces.

16

Figure 1.15 Swift Current Hospital (sab r-a3351)

Figure 1.16 Municipal Hospital, Weyburn (sab r-b129)

CHAPTER 2

DR SEYMOUR A N D P U B L I C H E A LT H

Maurice M. Seymour is the pacesetter in our story. Born 7 July 1857, in Goderich, Ontario, Seymour was one of three children of Captain Maurice Bain Seymour, who hailed from Ireland, and Maria MacDonald, who came from Scotland. He began his studies at Assumption College, Windsor, Ontario, in 1873 and then obtained his medical degree from McGill University in 1879. Rather unusually for those times, he took two years of postgraduate study before he went into practice.1 After employment with the Canadian Pacific Railway during its construction in 1881–83 and service in the Riel Rebellion in 1885, Seymour practised in the beautiful Qu’Appelle Valley, forty-five miles northeast of Regina. He moved to Regina one year before Saskatchewan’s formal birth and was appointed Provincial Medical Health Officer on 10 April 1906.2 He spent the rest of his professional life in charge of public health in the new province. For his first seventeen years, public health had a low profile, as a mere branch within the large and powerful Department of Agriculture (under Hon. W.R. Motherwell), and then within Municipal Affairs. In 1909, Seymour was instrumental in preparing the Public Health Act, which established a Bureau of Public Health.3

Dr Seymour and Public Health

Whatever his title and whichever government department he worked within, Seymour laid a solid, achievement-filled, and logical foundation for public health. His enforcement arm was the Royal Northwest Mounted Police. In the new province in 1905, Seymour saw that financial aid, 50 cents per patient day, was needed for the six hospitals – in Prince Albert (1899), Regina (1901), Yorkton and Moosomin (1902), and Battleford and Indian Head (1905). One of Seymour’s strengths was his ability to react rapidly to provincial needs by drafting forward-looking legislation that would receive support from members of both political parties. Some of his actions were firsts for Canada. Responding quickly to the needs of the Rural Municipality (rm) of Sarnia #221, which had used $1,500 of tax money in 1915 to retain Dr Schmitt in that community (see chapter 3), the legislature the very next year amended the Municipalities Act to allow use of municipal taxes to build a hospital, hire a nurse, or expend up to $1,500 to hire a doctor – a first in North America. Seymour also drafted Saskatchewan’s Venereal Disease Act in 1920, with a revision in 1923. This was not a first in Canada, for Alberta had passed its own act and had begun offering free treatment in 1918. Venereal disease (vd, now known as sexually transmitted infection or sti) was relatively common, particularly syphilis. Saskatchewan offered free diagnosis and treatment. On a single day in 1924, in Regina, the vd clinic treated 100 adults, half of them for syphilis and half for gonorrhea, and five children for congenital syphilis.4 In 1912, only one birth in twenty occurred in hospital. By 1923 this figure had risen to one in six. Sadly, childbirth continued to take a toll on mothers. In 1926, Saskatchewan had the highest maternal mortality rate in Canada.5 Nevertheless, to help with the financial costs of hospital births, Seymour designed a “Maternity Grant” of $25 in 1914 as a boon to farm 19

36 Steps on the Road to Medicare

women in particular, providing $15 for the attending physician and $10 for clothes and bedclothes for the baby.6 In 1920, seventeen mothers applied; in 1921, 125; in 1922, 253; in 1923, 286; and in 1924, 427.7 By 1923, there were 2,253 hospital beds in a province of 770,000, or 3.4 beds per thousand population. Since people were often quite sick before they entered hospital, it is not surprising that the average stay was 12.7 days.8 One of the biggest public health problems was tuberculosis (tb). Soon after Seymour’s son was treated at the famous Trudeau Sanatorium at Saranac Lake, New York, Seymour organized the public meeting on 17 February 1911 that formed the Saskatchewan Anti-tuberculosis League. He persuaded the league to build its first sanatorium in an attractive coulee nestled in the Qu’Appelle Valley, facing Echo Lake and protected from north winds. At that time, bovine tuberculosis caused 25 per cent of tb deaths among Saskatchewan children; 18 per cent of 456,000 cattle tested were positive for tb.9 Eventually, Seymour achieved uniform, free tuberculin testing of cattle. On the advice of Dr D.A. Stewart of Ninette, Manitoba, Seymour hired Dr R.G. Ferguson to run the province’s tuberculosis program (see chapter 4). With typhoid fever, bovine tuberculosis, and summer dysentery all taking a toll, the Canadian Public Health Association appointed Seymour chairman of a countrywide study of milk problems in Canada from 1924 through 1926. Seymour’s group sent fifty-two questions to every Canadian city with a population over 20,000 and published the results.10 They reported that Canada’s per capita milk consumption was 0.4 litres/day (compared to New York City at 0.3). More deaths in Canada were due to milk than to any other food. For example, there were 42 deaths from 619 instances of typhoid

20

Dr Seymour and Public Health

Figure 2.1 Dr Maurice M. Seymour (sla)

and scarlet fever and an unknown number due to tuberculosis, all presumed to have been transmitted by milk. Dr E.W. Staple ford, president of Regina College, told a hearing about the deaths of 8 of his 204 students and 1 of his teachers from raw milk delivered daily from a farm a few miles outside Regina. Stapleford described “nine coffins being carried out.”11 Saskatchewan led in the tuberculin testing of cattle. In April 1917, the City of Saskatoon was the first in Canada to inspect

21

36 Steps on the Road to Medicare

and license all dairy herds supplying the city; cows were tested by the Dominion Health of Animals Branch. Five other Saskatchewan cities and four towns followed. An additional thirty-one towns and seventy villages had organized preliminary inspection and licensing. Seymour recommended pasteurization of milk (heating to 142–145°f for thirty minutes, then cooling until delivered), but his suggestion was difficult to implement during hot summer days. Diphtheria was another serious problem; in 1917, Seymour began giving out free antitoxin to be dispensed by the medical profession. Seymour was not an unduly modest man (figure 2.1). In 1926 he published his Atlantic City presidential address to the Conference of State and Provincial Health Authorities under the title “The Seymour Plan.” He asked general practitioners to immunize against diphtheria in September and October, smallpox during November and December, and typhoid during January and February.12 He tried to make public health simple and easy to understand, with such slogans as “Do not spit” and “Swat the fly.” Cancer increased steadily during his tenure, until it edged out tuberculosis by exactly one death in 1924. That year, however, Saskatchewan had the lowest general death rate of any portion of the British Empire.13 Seymour was a member of the North-West Territories Med ical Council from 1885 to 1905 and served twice as president. He organized the Saskatchewan Medical Association in 1906. He was one of the first in Canada to obtain a diploma in public health from the University of Toronto. In 1915 he served as president of the Canadian Public Health Association and as vice-president of the American Public Health Association (apha). In 1923 he represented Canada at the Health Section, League of

22

Dr Seymour and Public Health

Nations. In 1925 he was elected president of the Conference of State and Provincial Health Authorities. He was honoured as a fellow of the Royal Institute of Public Health in the United Kingdom, a fellow of apha, and a recipient of an honourary lld degree from the University of Ottawa in 1925. Dr Lillian Chase described him as “a great organizer, a man of varied gifts and charming personality, [who] enjoyed the esteem of all.”14 Why was Seymour so successful? In part the answer is personal: he was a capable administrator, with unceasing energy. His greatest strength was his ability to harness Saskatchewan’s highly developed co-operative spirit. He could achieve support from municipal councils (in enforcing health laws for the common good, even when this might seem elsewhere to impinge too much on personal freedom); teachers (one year he sent a letter to each teacher in the province); clergymen (when launching a vaccination campaign, he would ask that an announcement be read from the pulpit on the preceding Sunday); rural Homemakers’ Clubs (who assisted, gratis, the doctors and nurses during his vaccination campaigns), and weekly newspapers (which published his weekly article on health). Seymour’s success was also based on the province’s strength: while he was in charge of public health, Saskatchewan grew to be the third most populous province in Canada, flowing with investment, agricultural wealth, and new people. Seymour was not superannuated until 1 November 1927, at age seventy, when he became medical advisor to the government on public health matters. His greatest gift to the people of Saskatchewan was his unbelievably rapid response to the grassroots development of municipal doctors and municipal hospitals. He also laid a sound foundation for Saskatchewan’s future leadership in health. Policy analyst Robert McLaren declared that Seymour, in serving Saskatchewan so long and so well in

23

36 Steps on the Road to Medicare

his specialty of public health on the provincial, national, and international stages, serves as the prototype of a proactive public servant fostering services to enhance the well-being of the citizenry.15 He died on 16 January 1929, at seventy-one, fifteen days after Saskatchewan initiated the first universal free treatment for tuberculosis, the next stepping stone on the road to medicare.

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CHAPTER 3

MUNICIPAL DOCTORS AND MUNICIPAL HOSPITALS

Saskatchewan’s early population growth required new innovations in municipal medical services, and from 1915, laid the foundation for modern medicare. Both municipal doctor plans and municipal hospital schemes found traction first in Saskatchewan.

1. The first municipal doctor in North America: Dr Henry Schmitt of Holdfast, 1915 One major step on the road to medicare occurred in the Rural Municipality of Sarnia. The Holdfast history book, History and Heritage, quotes the motion passed by the council of the rm of Sarnia #221 in January 1914: “That Council advertise for a doctor … Also first correspond with Dr Schmitt of Newton, Illinois, in regard to locating here.” Perhaps Schmitt wrote to Holdfast in response to advertisements, which talked of “The Last Great West” and the “Beautiful Last Mountain Valley

36 Steps on the Road to Medicare

Figure 3.1 Dr H.J. Schmitt, graduation photo (Mary Bradshaw)

where crop failures are unknown,”1 or the contact may have been made by a farmer who had moved from Illinois, lured by the promise of free land in Saskatchewan. In the Sarnia Council minutes of 25 June 1914 it is recorded that Dr Schmitt was “appointed Medical Health Officer for the village [of Holdfast] to take effect on 1 July and that Dr Chapman of Dilke [should] be notified to that effect.”2

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Municipal Doctors and Municipal Hospitals

According to the Holdfast history, “Dr Schmitt covered great distances to minister to the sick” (figure 3.1). Since the rm of Sarnia included nine townships and most roads were prairie trails, his early mode of travel was horse and gig in summer, and horse and cutter in winter. In 1915, he bought a Model T Ford for summer travel when roads permitted.3 That year Dr Schmitt had difficulty collecting enough money from the impoverished farmers and considered moving on to the larger and more prosperous community of Craik.4 Because the people of the municipality were much concerned, the Sarnia council agreed to vote funds from tax money to pay a retainer to Dr Schmitt. This agreement was the first municipal doctor arrangement in North America.5 To keep Schmitt in the community, the rural municipality paid him a stipend of $1,500 in 1915 and $2,500 in 1916.6 Minister of Agriculture the Honourable George Langley, in charge of health matters, wrote to rm Sarnia, “We watch your experiment hopefully but skeptically.” But as the Holdfast history recorded, Langley “need not have worried. Every settler in the area would soon attest to the fact that Dr Schmitt’s services far outweighed the remuneration he received.”7

2. The first municipal doctor legislation in North America, 1916 In 1916 the Saskatchewan Legislature, influenced by provincial Commissioner of Health Maurice Seymour, enacted the Municipal Hospital Act, permitting rural municipalities to make a grant to physicians to supplement their income, such grants not to exceed $1,500. This made legal what rm Sarnia had already done. In 1919, legislation was enacted whereby a rural municipality might engage a physician on a salary – not to

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36 Steps on the Road to Medicare

exceed $5,000 – to provide medical care to the residents of the municipality. In 1932, provision was made whereby portions of municipalities might engage the services of a physician, or two or more municipalities could co-operate. By 1935, provision was made in the Town and Village acts for an assessment of up to $2 per head of population, according to the last Dominion census, to engage a physician. In 1937, a further change permitted the raising of a sum of $5,000 for a surgeon. Finally, in 1941, the Rural Municipality Act was amended to permit physicians to be paid on a fee-for-service basis from public funds. how successful were the municipal doctor plans?

The report of the Committee on Municipal Physicians, presented by Dr D.S. Johnstone, a Regina surgeon, to the Canadian Medical Association annual meeting in Regina in 1927 provides a snapshot of Saskatchewan’s success. That year there were thirteen municipal doctors in Saskatchewan, practising in twelve localities: Holdfast, Craik, Beechy,8 Bethune, Birsay, Brock, Chamberlain, Freemont, Leroy, Lintlaw, Rush Lake, and Senlac. Most municipal doctors were paid between $3,500 and $5,000. All medical needs of ratepayers and their hired help were covered. The Johnstone committee stated that Craik and Holdfast were “old and well settled municipalities, where the practice was quite able to sustain one or more doctors in each municipality – it was apparently a straight case of going out to hire a doctor in the hope of saving money [and] attendance fees.”9 The municipal doctor system attracted the interest of the Committee on the Costs of Medical Care in the United States. They sent C. Rufus Rorem, an economist, to study the situation in 1929 and 1930. His studies resulted in an eighty-fourpage book in 1931.10 Rorem’s map (figure 3.2) showed the

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Municipal Doctors and Municipal Hospitals

Figure 3.2 Rorem’s map of where municipal doctors were located in Saskatchewan (courtesy University of Chicago Press)

location of the thirty-two municipalities with municipal doctors in Saskatchewan.11 Twenty employed a total of twenty-one fulltime doctors; twelve other municipalities had part-time agreements with sixteen physicians.12 Seven municipalities engaged municipal doctors for the first time in 1929, while another four did so in 1930. In 1930, Saskatchewan had 558 licensed practitioners and a total hospital bed capacity of 3,357, but only one of the municipal doctors had a hospital to work in. Of

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36 Steps on the Road to Medicare

Saskatchewan’s inhabitants, 69 per cent lived on farms, 9 per cent in 377 villages, 7 per cent in 80 towns, and 15 per cent in eight cities with a population of 5,000 people or more.13 Rorem found that most doctors were pleased with the system because their incomes were assured. Annual salaries ranged from $2,800 to $5,000, but the doctors were responsible for paying automobile and office upkeep. The statistics collected by Rorem, who did not name any of his informants, showed that one doctor made 426 country calls in a year, necessitating travel of 5,580 miles by automobile. Most municipal doctors pocketed an initial charge of $1 to $3 for the first call; they were allowed to charge mileage for such visits and an extra $7 for obstetrical care. One municipality allowed a doctor to charge $7 for simple fractures, and another allowed a fixed fee of $5 for minor operations. One insurmountable difficulty facing municipal doctors was the complete rigidity of the Federal Income Tax Division, which insisted on treating the entire income as salary. Even though each doctor had to maintain an office, equipment, and an automobile, these costs could not be deducted as expenses because the Income Tax Division viewed municipal doctors as salaried employees. The medical profession was unable to obtain any redress of this unfair practice, except for a few municipalities, which reimbursed expenses separately from the stipend.14 Despite this, most doctors who had previously been in private practice reported that bad debts had so reduced their cash incomes that they were better off with the annual salary of the municipal scheme, although they worked harder after the impediment of the patient’s financial status was removed. One doctor told Rorem, “I am lucky to be on a salary.” Several stated that freedom from financial worries improved the quality of their service to patients and that patients co-operated by

30

Municipal Doctors and Municipal Hospitals

seeking services earlier in an illness. On the other hand, some doctors felt insecure because they could be dismissed on three months’ notice. Several felt that state medicine would not be appropriate outside the special rural situation. One doctor mentioned three families who tended to abuse the scheme, but admitted that they would have been a nuisance to a doctor under any payment system. Physicians agreed that the plan did not interfere with the doctor-patient relationship, and that they could spend more time on prevention, such as vaccination programs. Each municipal doctor served as medical health officer for the municipality and the villages within it. One reported that this was the first year in which there were no cases of diphtheria in his municipality, a situation he attributed to his intensive vaccination program. Municipal officials were even more enthusiastic; one of them said, “If you get a good man who is interested in his work and the health of the municipality, the system cannot be beat.” Another said, “The municipal physician’s system is here to stay, for the simple reason that it works out to the benefit of both parties concerned.” One official reported that this was the first time he had seen all taxpayers satisfied over a rise in taxes.15 In one municipality the candidate for reeve (the rural equivalent of mayor), who ran for office in 1928 on a platform of discontinuing the municipal doctor plan, was defeated by 231 to 30 votes. In another municipality, at the annual ratepayers’ meeting, a taxpayer moved that the council dismiss the present municipal doctor, but no one seconded his motion.16 No individual patient was heavily burdened, yet the taxation basis recognized the difference in financial ability to pay, since the more land one held, the more one paid. Only a few large landowners complained.17 Once the municipal doctor system had been adopted, no community returned to a private practice basis. The

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36 Steps on the Road to Medicare

only downside was that the presence of municipal physicians had unfavourable economic effects upon the practice of independent physicians in adjoining towns and cities.18 Municipal doctors worked hard. Dr Schmitt’s successor at Holdfast in the early 1930s was Dr C.S. McLean. Each year in the early 1930s McLean drove 14,000 miles to make 1,400 house calls, saw another 1,500 patients in his office, and attended fifty to seventy maternity cases.19 A circular sent by the United Farmers of Canada, Local Council, to taxpayers of one municipality before a vote on introducing the municipal doctor system there stated: At present we are committing to pooling our wheat and other farm products. The municipal doctor scheme is in reality a pooling of our doctor’s bills … an insurance against unduly high doctor bills in any one year – an equalization scheme. Are you willing to invest $4.50 per quarter section in the health of our section of the nation? A nation’s first wealth is health, and levies to protect our first wealth should have priority over all others.20 Things got worse during the “dirty thirties” for those doctors not under a municipal plan. The minister of health reported that the “average cash earnings of 130 doctors in the drought area, over a period of two years,” was $27 a month.21 In order to retain these doctors in the province, the Saskatchewan government provided a monthly stipend of $75 to those in the most drought-stricken areas, a program that continued for five years.22 To oversee and regulate the municipal doctor system, the Health Services Board was set up, with equal representation from the province, the Saskatchewan Association of Rural

32

Municipal Doctors and Municipal Hospitals

Municipalities (sarm), and the College of Physicians and Surgeons.23 By October 1938, at the time of Dr R.G. Ferguson’s report on municipal doctor schemes to the Saskatchewan Medical Association, 121 of the 546 provincial doctors were under remarkably varied types of municipal contract. For example, 28 received the $1,500 retainer grant, 36 received a salary of up to $5,000 for regular medical services, and 13 had a contract to supply surgery within the competence of the doctor. In only 15 instances was a physician permitted to charge a flat $2 deterrent fee for the first call, and a reduced fee for maternity cases, fractures, and surgery. Of 546 private family practitioners in the province, 121 cared for ninety-two municipalities, two towns and forty-two villages, a total of 116,421 persons in a Saskatchewan population of 930,893 (12.5%).24 In 1937, the average amount owing the doctor by the municipality was $2,503, while one drought-stricken municipality owed its doctor $13,387.60 in unpaid salary.25 In 1941 Dr John J. Collins, a municipal doctor at Ituna, sent a questionnaire to Saskatchewan rural doctors; ninety replied. They were almost unanimous in declaring that private practice was no longer feasible. One replied, “Any system is to be preferred to the present. Collections appear hopeless. I do not know how medical men can hope to carry on out here [all year] under present and future conditions.” In 1941, municipal doctors reported a mean net income of $3,290, after expenses of $2,012, for serving, on average, 1,998 people (roughly $2 per capita). Thirty per cent of income was privately earned, mainly from treating patients from outside the municipality.26 By 1942, a model contract was drawn up by the Health Services Board of the Saskatchewan College of Physicians and

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36 Steps on the Road to Medicare

Surgeons. Each municipal doctor was to be paid at the rate of one cent per day per quarter section, $432 per township, or $3,888 for a nine-township municipality. This payment was to be for 300 days in any calendar year, the doctor to have all Sundays and statutory holidays off. This was a striking departure from tradition, whereby rural doctors were on call twenty-four hours a day, seven days a week. For country calls, the model contract suggested that doctors be paid ten cents per mile each way by car in summer, fifteen cents from 1 November to 31 March, twenty cents for snowmobile travel and thirty cents per mile each way for a horse-drawn vehicle.27 In 1944, there were at least 101 municipal doctors in Saskatchewan. By the peak year of 1947, they cared for 210,000 people, nearly a quarter of the population.28 In 1950, there were still 173 municipal doctors in Saskatchewan.29 Since the municipal doctor system offered immediate guaranteed payment, it was often preferred by young doctors in their first few years of practice. They saw it as an alternative to “starving” in a city while they built up a practice against competition, and waited months or years for patients to pay their bills. The municipal doctor system was beneficial for patients as well, since it encouraged doctors to practice in rural areas. When medicare was introduced in Saskatchewan on 1 July 1962, the need for salaried municipal doctor schemes vanished. With immediate payment from the provincial government, new doctors could begin practice in a city; as a result, totally unplanned and unforeseen by government, many a village, especially one without a hospital, soon lost its doctor. The trend for doctors to cluster in the cities accelerated. Municipal doctor schemes were developed locally in response to need. The councillors of the rural municipality of Sarnia

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Municipal Doctors and Municipal Hospitals

deserve much credit for an innovative idea quickly put into practice; Seymour merits recognition for his rapid response in making it legal. Municipal doctors were another step on the road to medicare.

3. The first legislation in North America to allow Union Hospital Districts, 1916 Municipal hospital programs paralleled those for municipal doctors, but require separate mention. In 1916, legislative provision was made “for the combining of towns, villages and rural municipalities in union hospital districts” (uhds) to erect and maintain a hospital. By 1920, there were ten uhds in Saskatchewan;30 by 1930, twenty; by the early 1940s, twenty-six.31 Alberta was not far behind Saskatchewan in this respect, with its first municipal hospital in the village of Mannville in 1919, followed quickly by hospitals in Bassano, Cardston, Drumheller, Islay, Onoway, Vermilion, and Lloydminster, the last shared with Saskatchewan.32 By 1922, hospitals were added in Hanna, High River, and Provost. Capital, maintenance, and operation costs were provided by the people in the district: the only revenue received from the Alberta government was a grant of fifty cents per day per patient.33 In Saskatchewan, the Sigerist Report in 1944 (chapter 5) gave sudden impetus to building new hospitals and to forming new Union Hospital Districts34 – forty-four new uhds were created in three years. By 1947, the seventy-eight uhds “covered more than one-third of the settled area of the province, included approximately one-third of the population, and provided about three-eighths of the … hospital beds.”35

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36 Steps on the Road to Medicare

4. The first municipal hospital legislation in Canada, 1916 As an exception to the long lists of other Saskatchewan “firsts,” priority in municipal hospital legislation was shared between Alberta and Saskatchewan in the border town of Lloydminster. Here the local hospital, opened in 1906, closed for financial reasons in 1912. David Grieve Tuckwell, editor of the Lloydminster Times, later mayor of Lloydminster 1913–15 and a new arrival from Australia, promoted the idea of a union hospital, supported by the town and six surrounding municipalities. The hospital reopened in October 1913 (figure 3.3). Rural municipality residents contributed one cent per acre; Tuckwell proudly noted that the homesteader, and his wife, family, and dependents, gained hospital accommodation for $1.60 per year, the “very maximum of protection for the very minimum of cost.”36 In 1916, Saskatchewan (first) and Alberta (second), each passed appropriate legislation. In Saskatchewan it read: “The Council of the Town of Lloydminster, the Rural Municipality of Britannia and the Rural Municipality of Wilton may enter into agreement with each other to provide money for the maintenance and extension of the said hospital and for the payment of the [hospital] expenses of their respective ratepayers and residents.”37 The legislation served as an example for other areas.38 Saskatchewan passed a more general Union Hospital Act in 1917. To improve and streamline administration, the Rural Municipality Act was amended in 1927, 1928, 1929, and 1934. The Village Act and the Town Act were amended in 1936.39 As a result of legislation, there were ten Union Hospital districts in 1920; by 1938, there were twenty.

36

Figure 3.3 Lloydminster Union Hospital (sab s-b150)

5. The first legislation in Canada to allow personal taxation for health purposes, 1934 Although Saskatchewan citizens were willing to work together to improve local medical and hospital service delivery, financing these initiatives required creativity and innovation. Previously, health service could be financed only by a tax on property. In 1934, the Rural Municipality Act40 “was amended to empower the council to fix an annual tax for non-ratepayers. This appears to be the first instance in which statutory authority was granted for the levying of a personal tax for health services … in Canada,” asserted medical historian Malcolm Taylor. This legislation made sense: why should rural ratepayers with a land base carry all the costs? Villages and towns had many citizens who did not own a farm, but needed medical and hospital care. Some municipalities began to “break the mould” on munic ipal hospital plans. The rm of Miry Creek, for example, began a hospital plan in 1937 that allowed their residents to

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36 Steps on the Road to Medicare

be hospitalized anywhere in Saskatchewan, not just at the local hospital in Abbey. By 1943 the rm of Pittville used its medical services levy to pay for residents’ medical bills with any doctor, anywhere. Both moves ran contrary to the Rural Municipality Act, but continued nonetheless (for more on these plans, see chapter 6).41 municipal medical and hospital services act: the matt anderson plan, 1939

In 1939, the forward-thinking reeve of rm McKillop at Strasbourg, Norwegian-born Matt Anderson, initiated the Municipal Medical and Hospital Services Act.42 Known as the “Matt Anderson Act,” the plan permitted payment of both hospital (up to a 21 day stay) and medical services through a $5 personal taxation, limited to $50 per family. It combined municipal and hospital plans under one act. The core of the Anderson plan involved choice of doctor: patients were not limited to the local municipal doctor, but could visit one of several doctors in Regina connected to the scheme through medical service agreements. Under these agreements, the doctors would accept 50 per cent of the Saskatchewan College of Physicians and Surgeons schedule of fees as payment in full, when visited by patients under the health plan. By 1944, thirteen rms operated under the “Matt Anderson Act,” 92 had salaried doctors under the Rural Municipality Act, and 118 rms provided hospitalization.43

6. The first Red Cross Outpost Hospital in the British Empire, 1920 A separate initiative, related to municipal hospital plans, was the Red Cross Outpost Hospital program, which started at Pad-

38

Municipal Doctors and Municipal Hospitals

dockwood, Saskatchewan in 1920 – a first in the entire British Empire. Following the First World War, the Red Cross (using funds left over from the war effort) designed cottage hospitals in conjunction with soldier settlement communities. These communities, often in remote rural areas, needed local medical services but were unable to support municipal hospitals through land taxation. Pioneer homesteaders without patent on their land did not pay municipal taxes. Land taxes require ownership. In this scheme, the community would provide the building and look after its maintenance; the Red Cross would find and pay for the staff and supplies. A resident charge nurse, not a doctor, triaged the patients and planned care. Patients with serious illness or injuries were transferred to a hospital or doctor in the nearest large centre. Other patients were capably and routinely stitched, set, delivered, or dispensed by the charge nurse. Patients were expected to pay if they could, but often paid through barter, or fees were waived. Most maternity patients took advantage of the provincial Maternity Grant. Over time, twenty-four outpost hospitals operated in Saskatchewan. By 1946, over 37,000 inpatients and 27,000 outpatients, as well as 8,800 births, had been recorded in Red Cross hospitals. As communities matured and roads improved, outpost hospitals either transformed into municipal hospitals, or closed (see figure 3.4). The outpost hospital initiative allowed poor pioneer and remote communities with a limited taxation base access to medical care, which in essence placed medical care as a right, not a privilege of local wealth.44 By 1948, eighty-eight municipalities provided their residents with hospital service at municipal expense. Sixty-six financed this through a property tax and twelve utilized the Municipal Medical and Hospital Services Act, which allowed a personal tax.45 By 1954, there were 104 union hospital districts.46 As

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36 Steps on the Road to Medicare

Figure 3.4 Paddockwood Red Cross Outpost Hospital, 1948, with nurse Ruth Dulmage Shewchuk in front. (sab Ruth Shewchuk collection)

historian Malcolm Taylor noted, “the construction and maintenance of hospital facilities and the prepayment of medical and hospital services through municipal tax levies – are a tribute to local initiative and the understanding of the importance of health services … a remarkable development not duplicated on such a scale elsewhere in Canada.”47 Once again, Saskatchewan residents worked together to give health a top priority, to a degree not seen in the rest of the country.

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CHAPTER 4

DR FERGUSON AND TUBERCULOSIS

In fighting the disease that for many years took the greatest toll on health and productivity, Robert George Ferguson was one of the most consistent and effective leaders in North America. Sixth in a family of sixteen, he was born 12 September 1883 near the Red River at Joliette, North Dakota, only seventeen miles south of the forty-ninth parallel. At age nineteen he was delegated by his family to choose a farm in Saskatchewan, of similar size to the one being vacated in North Dakota. He selected one at the south edge of Yorkton and moved his parents, brothers, and sisters there. Four years later his father died. George managed the farm in summer and attended Wesley College in Winnipeg in winter, obtaining his ba in 1910, intending a career in the ministry. When his husky voice, the result of childhood diphtheria, did not allow him to preach three sermons each Sunday, he chose medicine as next best, graduating with his md in 1916 (Figure 4.1).1

Figure 4.1 Dr R.G. Ferguson, graduation photo (sla)

Ferguson’s interest in research stemmed from his student experience in Dr S.J.S. Pierce’s laboratory in Winnipeg, making typhoid vaccine for Canadian troops in the First World War. His interest in tuberculosis had been stimulated by his work, while still a medical student, with Dr D.A. Stewart, medical superintendent at the Ninette Sanatorium in Manitoba. Stewart had so much faith in Ferguson’s integrity and ability that he left him, still a final-year medical student, in administrative charge of the sanatorium for a few weeks to go on his honeymoon.

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Dr Ferguson and Tuberculosis

Ferguson’s first year in medical practice in Winnipeg under Dr A.B. Alexander was the best possible preparation for his later career, with first-hand responsibility at the King George, the infectious disease hospital, and the King Edward, the city’s tuberculosis hospital. During 1916–17 he developed his three postulates of tuberculosis control: 1 Early discovery means early recovery 2 Reduce the level of infection in the community 3 Interrupt the transmission of the tubercle bacillus As Dr G.D. Barnett later commented, these three postulates became the foundation on which the Saskatchewan program was built. In July 1917, Ferguson was appointed acting superintendent of the new sanatorium at Fort Qu’Appelle, Saskatchewan (Figure 4.2), on the recommendation of Dr Stewart. Almost immediately the site became known as Fort San; a full post office by that name existed in the administration building from 1926 to 1966. As the only doctor, Ferguson was on call twenty-four hours a day; he was known to sit up all night holding the hand of a dying patient. In 1919, he attracted two equally dedicated assistants, Dr Harvey Boughton and Dr R.W. Kirkby, whom Ferguson later promoted to direct the new sanatoria in Sask atoon (15 April 1925) and Prince Albert (7 January 1930), respectively. At that time, tuberculosis was epidemic among the First Nations population. It was also much the commonest cause of death in white adults between the ages of twenty and forty-five,2 killing or disabling more able-bodied wage earners and homemakers than did heart disease, cancer, or other infections. Before the widespread advent of x-ray machines, symptoms were insid-

43

ious and non-specific; many patients were in the advanced stage before a correct diagnosis was made. Poverty, overcrowding of large families in small prairie shacks, and malnutrition favoured tuberculosis and in turn led to more poverty. The disease spread through coughing and by the unregulated sale of milk from infected cows.

7. The first grassroots public support for an anti-tuberculosis campaign, 1917–48 Nowhere else in North America did the attack on tuberculosis, or perhaps any other single disease, have as much grassroots support. In spite of the apparently unpromising outlook, Ferguson galvanized, educated, and cajoled an entire province.

44

Figure 4.2 Fort Qu’Appelle Sanatorium, 1918 (sla)

He harnessed the co-operative spirit needed for survival in a new province with poor roads and harsh winters. Rural communities were fertile ground for his persuasive talents. Under his guidance, schoolchildren, teachers, nurses, doctors, service clubs, municipalities, and the provincial government co-operated in a costly but seemingly effective effort, unequalled anywhere else on the continent. The aims were to raise money for the Antituberculosis League and to keep public concern alive. Often the responses were simple, but symbolic. Groups of farmers’ wives, scattered throughout the province and organized as Homemakers’ Clubs, would each donate dozens of eggs or chickens

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36 Steps on the Road to Medicare

to feed patients. The Imperial Order Daughters of the Empire, better known as the iode, made tuberculosis its main concern; members raised money to build the children’s pavilion, furnish the schoolroom, buy books for the library, pay the bills of indigent children, and build and staff a preventorium, where mothers could be isolated from their infants from birth.3 Radio announcers donated their time to put on weekly amateur shows. There was an annual tuberculosis essay contest for schoolchildren. Prospective teachers were taught about tuberculosis at the Normal School, the name then given to the Teachers’ College. Twice, snowstorms led to important, long-term fundraising activities. Ferguson’s timing in each instance was impeccable. In 1934, his car was stuck in the snow and he walked to a railroad car on the track nearby. In it were members of the newly formed Associated Canadian Travelers (act), a group searching for a public service project. When they heard Ferguson’s needs, they agreed to help in the annual Christmas Seal campaign. On another occasion, other act members, stormbound with Ferguson in Nipawin, agreed to try amateur radio broadcasts as a means of raising money, and eventually broadcast these over six stations for more than thirty years. The act raised $813,000 to combat tb between 1934 and 1955.4 In a predominantly rural province, Ferguson, as a son of the farm, understood farmers and spoke their language. He represented the anti-tuberculosis campaign by means of an agrarian metaphor in his 1942 annual report: The people of Saskatchewan know that tuberculosis is a bad weed. In the language of the farmer, it is a perennial which, if not uprooted, will shed its seeds from year to year. When these weeds or cases are sparse the best practice is to find them and remove them before the seeds are shed.

46

Dr Ferguson and Tuberculosis

To do this everyone must learn to identify tuberculosis in the seed, in the sprout, in the leaf, in the flower, or in the ripe shelling. That is why the educational campaign for the prevention of tuberculosis goes on in schools, Normal Schools, families, communities, and throughout the province generally. From past results our people have the faith, confidence and will to eradicate this disease. Come peace, come war, prosperity or depression, this life-saving campaign goes on, resulting in less infection, less new cases, and in the end less deaths.5 In the early years Ferguson made certain that both legislators and doctors were familiar with the sanatorium and its work. On 26 November 1920, he gave a tour of the sanatorium to thirty members of the legislative assembly, and in June 1922 the Saskatchewan Medical Association held its annual meeting at the Fort Qu’Appelle Sanatorium. After I published Ferguson’s biography, I learned of another method he used to ensure legislative awareness. As superintendent, based at Fort Qu’Appelle, he was required to pay a monthly visit to the other two sanatoria, in Saskatoon and Prince Albert. Depending on whether he felt the premier (J.G. Gardiner, 1926–29 and 1934–35) or the minister of health (Dr J.M. Uhrich of Rosthern, 1923–29 and 1934–44) most required some gentle prodding, Ferguson would have his secretary telephone that person’s secretary in Regina to learn when the dignitary was travelling north and on which train (there were four each day to Saskatoon). Ferguson would then be sure he was in Regina in time to catch the same train. This would give him three hours (four-and-a-half hours in the case of Health Minister Uhrich, if he was destined for his home constituency at Rosthern) to chat. Thus, those in authority, the decision-makers,

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36 Steps on the Road to Medicare

knew all about the problems and needs of all three sanatoria, the monthly field clinics in each major city and town, and so on. No person in a position such as Ferguson’s in our faster, busier age has the slightest hope for such close personal contact with those in authority. Ferguson was a rare person, superb in every aspect of his work. He had skills in teaching, clinical work, and research, and was also talented in administration and public relations. He knew exactly how to comfort the suffering, homesick, and lonesome. In his quiet way, by example and conviction, he taught everyone who came in contact with him and his work: doctors, nurses, medical students, patients and their families, and the general public. Ferguson was one of the first sanatorium administrators in Canada to give a high priority to continuing education for his medical staff. Even when the San was hopelessly in debt during years of drought and depression, even when short-handed during wartime, he sent his staff away to learn. In spite of the time and expense to get there, London, England, was one of the most popular destinations because of its renowned teachers and the wealth of clinical experience available. Members of the medical staff often took an entire year of postgraduate training at the sanatorium’s expense; each year at least one sanatorium physician went away for special studies. Training was sometimes rewarded by success in the Royal College of Physicians (mrcp) examination.6 Over the years, this education proved to be a good investment. Radiographers, nurses, and dietitians were regularly sent away for short courses and practical experience in another institution. There was no requirement of years of service to become eligible for further education. If the sanatorium needed someone trained in a new technique and a young staff member was

48

Dr Ferguson and Tuberculosis

eager to learn, an educational opportunity was available after only one or two years of employment. Dr Harvey Boughton was the first to take educational leave; he spent two weeks in Winnipeg in 1920. Next, Ferguson went to Boston for two months in 1920; he spent one month studying heart disease with Dr Paul White, a world-renowned cardiologist, and three weeks taking a $100 course in internal medicine at Harvard University. Ferguson believed that the physician who is limited to treating one disease is “apt to develop a blind side, and to lose his true perspective in the interpretation of symptoms which are the common stock of widely different diseases.”7 To recognize early tuberculosis, one had to keep in touch with the whole field of internal medicine. In Boston, one of the first centres to provide courses for graduates in medicine, alongside a splendid medical library, a doctor’s medical experience and perspectives could be broadened. Later, Ferguson arranged for every student nurse in Saskatchewan to attend an eight-week affiliation course at a sanatorium. Between 1 June 1945 and May 1964, 3,774 student nurses had this practical experience at either the Fort Qu’Appelle or the Saskatoon sanatorium. Transportation and sickness expenses were paid by the sanatoria. The affiliate nursing course ended at Fort San in October 1962 and at the Saskatoon San in May 1964.

8. The first province to determine the prevalence of tuberculosis, 1921–22 After only four years as head of the tuberculosis program, Ferguson convinced the powers-that-be that little was known about the disease anywhere in North America. He persuaded the government to form the Saskatchewan Anti-tuberculosis Commission

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36 Steps on the Road to Medicare

to determine the prevalence of tuberculosis in the Saskatchewan population and to plan future sanatorium beds on the basis of the findings. Not only was his wish granted, but he was made secretary of the commission when it was appointed by Orderin-Council on 22 July 1921, thereby gaining the staff and funds to research the extent of the tb problem in Saskatchewan. Thus, he was able to write his own ticket. The recommendations of the final report of the commission did not gather dust on a shelf, as do many government reports today, but instead formulated Ferguson’s lifelong objectives. Few medical men have had, early in their careers, an opportunity to document the extent of a target disease and in doing so, to plan for ways to combat it, setting the direction of their life work. Of the commission’s recommendations, published in October 1922, the first four were considered mandatory:8 1 Hospital and sanatorium accommodation must be increased to care for those who are spreaders of the disease. The Commission recommended the construction of two new sanatoria of at least one hundred beds each, to allow the average patient twelve months of treatment. 2 There must be provision for the care of children from homes where open tuberculosis is found. A preventorium should be established to prevent the newborn infant from contracting tuberculosis from its mother. Children should be separated from actively tuberculous parents. 3 The system of financing the cost of treatment must enable all those who need treatment to obtain it with the least delay. 4 Diagnostic facilities must be improved and extended to all parts of the province, along with a nursing service and follow-up of all ex-tuberculous patients.

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Dr Ferguson and Tuberculosis

As an additional bonus, when the commission disbanded, Ferguson co-opted its chairman, A.B. Cook, Regina’s sheriff, to become managing director of the Saskatchewan Anti-tuberculosis League and thus ensured its success.

9. The first representative cross-sectional school studies of tuberculosis, 1921 As part of the research necessary for the commission report, arrangements were made with school boards to examine about 200 children between the ages of six and fourteen in each of seven representative communities: Regina, Saskatoon, Moose Jaw, North Battleford, Cupar, Stoughton, and Heward. Each child received a physical examination by a chest specialist; an ear, nose, and throat specialist; and a dentist. Eighty of these children were selected, on the basis of physical findings, for a chest radiograph.9 Of the 1,184 children examined, ten had active tuberculosis; another fifteen were found to have tuberculosis on the followup chest radiograph. A positive tuberculin test in 56.6 per cent of children indicated they had been exposed to tuberculosis (44% by age six and 61% by age fourteen). Of an additional 162 First Nations children examined in residential schools, 93.1 per cent had a positive tuberculin test. Normal School students had a 75.6 per cent positive tuberculin test rate, and 0.9 per cent had active tuberculosis. They were followed up annually throughout Ferguson’s career; he watched with satisfaction the steady drop in the rate of positive tests. Of 185 dairy cows in the same communities, 18.5 per cent tested positive.

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36 Steps on the Road to Medicare

These baseline studies were, for their era, unusually sophisticated proportional samplings of representative communities. In his history of tuberculosis in Canada, Wherrett confirms that these studies were the first in Canada.10

10. The first traveling tuberculosis clinics, 1923 The Wherrett-Grzybowski report in May 1966 acknowledged that the credit for sponsoring Canada’s first traveling clinics was shared between Saskatchewan and Ontario.11 Clinics began in Regina in September 1923 and in Moose Jaw in May 1928, and for some years were held one day per week. Follow-up clinics were also offered in two Saskatoon hospitals and at Fort San. Once-a-month clinics, chiefly for patients referred by general practitioners for diagnosis of lung disease, were held in North Battleford and Swift Current (beginning in 1930), Yorkton and Canora (1933), Tisdale and Melfort (1934), and Wadena (1940).12

11. The first universal free diagnosis and treatment of tuberculosis, 1 January 1929 Ferguson worked systematically to gain grassroots support for free treatment of tuberculosis, advocated in the commission report in 1922. It took seven years. Few could afford to pay for a year or more of treatment in a sanatorium. But from 1917 until 1928 it was Saskatchewan’s policy that “all who were able to pay were required to pay.” In 1924, twenty-nine of 295 patients (9.8%) paid part of the costs for their treatment, even though some were bankrupted and returned home penniless. By 1928, only 2.5 per cent could pay for their treatment. The other 97.5 per cent required at least

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Dr Ferguson and Tuberculosis

partial financial help from their urban or rural municipal government. Saskatchewan’s Rural Municipal Act of 1920 required each rm to contribute $100 annually to the sanatorium. In 1921, the $30,100 from 301 rural municipalities was set aside as the nucleus of a pool to pay for the treatment of indigent rural patients. Rural municipalities in this way got a four-year head start on their urban counterparts, on the path towards “free treatment.” The Saskatchewan Association of Rural Municipalities (sarm), then the most influential organization in the province, complained at its annual meeting in March 1921 that the urban municipalities were exempt from this levy. In 1925, an urban pool was formed. Without both rural and urban municipal contributions, the sanatoria would have been insolvent. The first resolution to advocate totally free treatment for tuberculosis was introduced at the sarm annual meeting in 1925. Only six of the 600 representatives voted for it. Yet the seed had been planted and the idea grew. In 1926, there were twenty votes in favour. In 1927, a different motion, that the provincial government take over direct control of the sanatoria, carried by a small majority. The government, normally very responsive to resolutions from sarm, countered that they could not afford it. At the annual meeting of sarm in March 1928, a momentous resolution was moved by rm Weyburn #67 to petition Saskatchewan legislators “to amend the Sanatoria Act so that all classes of T.B. patients shall have free treatment available at the public expense … paid partly by the [provincial] government [and] partly by all rural and urban municipalities.”13 In the midst of the discussion, an ex-patient of Fort Qu’Appelle Sanatorium, now cured and employed as secretary of his

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municipality for nine years, stood up. There, before the eyes of all doubting Thomases, as was remarked later, stood a living example of what could be and was being done through efficient and timely treatment of tuberculosis. This time the motion passed unanimously. A similar resolution was later passed by the Saskatchewan Urban Municipal Association and by the United Farmers. Times were good just before the stock market crash and the depression. As soon as the legislature next met, early in December 1928, the Liberal government of James G. Gardiner presented the Saskatchewan Sanatoria and Hospitals Act. As a government bill, it passed readily. What was amazing was the speed of implementation. The new system of free treatment came into effect in less than a month, on 1 January 1929. The Honourable Sam J. Latta, minister of municipal affairs, characterized the new act as “a great social experiment – and a costly one at that.”14 Roughly half of the league’s operating funds came directly from the rural and urban municipalities, a greater participation than in any other province, “a distinctly Saskatchewan approach.”15 The municipal funding, of course, was not subject to competition from highways and welfare in annual government budgets. It was not unusual for a rural municipality in a given year to spend more money on one disease, tuberculosis, than on roads! There were immediate benefits. As Ferguson reported, “the effect of removing the financial barrier is earlier treatment, earlier isolation, and an [initial] increase in the number of days treatment and the gross cost, but the end result will be more cures and a shorter period of disability, lessened spread of the disease, a lower death rate, and eventually [fewer] new cases.”16 It was seven years before the next province, Alberta, offered free treatment in 1936. Manitoba followed in 1946.

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Dr Ferguson and Tuberculosis

Saskatchewan’s health minister, Allan Blakeney, said in 1964, “the introduction of diagnosis and treatment of tuberculosis at public expense was one of the early and essential steps in developing a program of health services available to all.”17 To have Saskatchewan lead all other jurisdictions in North America, the first to provide free treatment of tuberculosis, the most expensive disease that took longest to cure, was one of Ferguson’s greatest accomplishments. Saskatchewan’s success with universal availability of tuberculosis diagnosis and treatment became an important stepping stone toward universal hospitalization insurance and medicare.

12. The first epidemiologic study of susceptible First Nations people exposed to tuberculosis, 1928 Ferguson’s landmark study of the prevalence of tuberculosis as it reached “fertile ground,” a population with no previous history of exposure to the disease, is one of the best of a very few epidemiologic accounts of such a process anywhere in the world. A new infection, arriving for the first time, hits with great severity, affects almost any body organ at any age, and has a high mortality. Then, as the most susceptible die off and only the more resistant individuals survive, there is a natural and inevitable drop in the number of new cases of that disease. It is more humane and more efficient to prevent disease than to cure it. With his deep concern for First Nations people, Ferguson obtained annual research grants from Canada’s National Research Council (nrc), from 1926 until his retirement in 1948. These grants financed his studies of tb prevalence on adjacent Indian reserves, the first Bacille Calmette-Guérin (bcg) vaccination of First Nations infants, and the first in student nurses. The nrc had been formed on 29 November 1916, and

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its eleventh committee was formed in 1925 to study tuberculosis, initially in cattle. Ferguson graphed the rapid increase in deaths from tuberculosis among First Nations at the Qu’Appelle and File Hills agencies (figure 4.3) as they settled in small houses in close proximity to each other on reserves. Under the new conditions of stationary life, intermittent hunger, and cultural demoralization, the annual death rate from tuberculosis among First Nations was roughly 1,000 per 100,000 population in 1881. It quickly increased to reach the proportions of a serious epidemic by 1884, and became maximal in 1886 at 9,000 per 100,000 per year, about double the birth rate and accounting for two-thirds of all First Nations deaths. By 1895 the rate had dropped to 3,000, by 1901 to 2,000, and by 1907 was back to 1,000 per 100,000. Changes in living or sanitary conditions did not explain the drop. Ferguson recognized that this was the inevitable and natural course of a new epidemic on what researchers call “virgin soil” or a new population. Virtually all Indian children were “tuberculized”; by the age of eleven to fifteen, over 96 per cent had a positive tuberculin test.18 His field work began in 1926 with a thorough examination of children on the File Hills and Qu’Appelle reserves and those attending the Lebret and File Hills Indian schools. Such surveys became annual events. Ferguson recognized the need to determine the prevalence of tuberculosis in First Nations adults as well. How was he to get them together for chest radiographs in rural areas far from electrical sources? He had the brilliant inspiration to join the annual treaty party, when First Nations congregated to receive treaty money of $5 each. He persuaded the Victor X-ray Corporation of Winnipeg to supply a portable x-ray machine and the Delco Light Company of Regina to supply a portable generator. In the

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Dr Ferguson and Tuberculosis

second week of July 1927, all this equipment accompanied the treaty party to the File Hills Reserve, where full compliance was achieved and 130 adults were x-rayed. In 1928, Ferguson presented his landmark report at the prestigious meeting of the National Association for the Prevention of Tuberculosis in Great Britain: The moral and physical weakening of the Indian has to do with the introduction of the horse … firearms … liquor, the exchange of their fur tunics for the blanket, the exchange of the clothes necessary for warmth for alcohol, the extermination of the buffalo and the beaver, the concentrations upon reserves, the change of housing, the change of food, the exclusion of sun … by the clothing of the children; the compulsory concentration of children in

Figure 4.3 Graph of tuberculosis epidemic among First Nations (sla)

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schools, the change of occupation from hunting and warring to agricultural pursuits, and, on the mental side, the psychical depression of conquest by the whites, dependence on Government rations for food, visible ravages of white man’s diseases, desertion by, or incompetency of, their Michi-Manitou and triumph of Kitchi-Manitou, and failure of even the white man’s religion to protect them … The nudity of the Indian children in summer … was ended abruptly … The agents, in their zeal … instructed the parents to clothe their children. Thus for the first time in the history of the race the bountiful summer sun’s rays were largely excluded … a lowering of resistance to disease developed.19 Ferguson’s dedication to First Nations is exemplified by the four-week canoe trip he took in 1927, departing from the end of steel at Big River, to inspect those with tuberculosis at Ile-àla-Crosse and La Loche. Six years later, Dr Andrews from the Prince Albert Sanatorium made the first airplane flight to Ile-àla-Crosse. Ferguson treated First Nations patients as equals, as any compassionate doctor would. They in turn respected him. In 1935, they gave him what he considered the greatest honour of his life, a ceremony naming him as an honourary chief – MuskekeO-Kemacan (figure 4.4). First Nations people were not legally a responsibility of the Saskatchewan Anti-tuberculosis League, a provincial organization, but of the Government of Canada. In spite of this, one of Ferguson’s top priorities throughout his life was to reduce the ravages of the disease among that population. He engineered an agreement with the federal government in 1924 whereby forty beds were allocated for First Nations at the San as a means

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Dr Ferguson and Tuberculosis

of paying off some of the capital advanced by the province near the end of the First World War. Once the Prince Albert Sanatorium opened on 7 January 1930, there were adequate beds for Saskatchewan’s First Nations population, both adults and children. In striking contrast, Manitoba First Nations gained access to sanatorium treatment only in 1946 when the Clearwater Sanatorium opened in wartime United States Air Force buildings.

13. The first statistically controlled BCG vaccination among newborn First Nations infants, 1932–49 Between 1933 and 1943, Ferguson and his former University of Manitoba medical school classmate Dr Austin Simes, of the

Figure 4.4 Muskeke-O-Kemacan, Great White Physician (sla)

36 Steps on the Road to Medicare

Indian Health Unit, vaccinated 306 First Nations infants at birth. Another 303 infants served as controls. Their study was statistically sophisticated for its time – although through imperfect randomization by Dr Simes (tossing a coin for each subject would have been sufficient!), the bcg study lost the opportunity to be the world’s first fully randomized clinical trial.20 Ferguson and Simes’ joint paper showed that the incidence of tuberculosis was nearly five times greater in the unvaccinated, whose disease was more severe and more widespread than in the vaccinated group.21 The bcg studies were carried out in the face of frank hostility to bcg throughout the English-speaking world, apart from the strong support of the Canadian bcg pioneer, Armand Frappier in Montreal. Other North American doctors mistrusted live-bacteria vaccines in general and bcg in particular.

14. The first 1934–43

BCG

vaccination among student nurses,

Because 5 per cent of student nurses and nurses in western Canadian hospitals “broke down” (the term used in standard medical parlance) with tuberculosis, all tuberculin-negative student nurses in Saskatchewan hospitals and all tuberculin-negative sanatorium and mental hospital employees were given bcg vaccination. Ferguson reported in 1946 that this measure reduced the number of cases of manifest tuberculosis to less than a quarter of the previous rate for nurses, to one-fifth of the previous rate for sanatorium employees, and to one-fifth of the rate among student nurses in adjoining Manitoba.22 In subsequent years, this vaccination was extended to tuberculin-negative members of families in which tuberculosis had occurred.

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Dr Ferguson and Tuberculosis

15. The first provincewide photofluorographic surveys, 1942–47 Ferguson organized the first provincewide photofluorographic survey in North America, 1942–47. Since no machines were available commercially, he encouraged his radiographer, Robert Connell (figure 4.5), to develop a method of photographing a fluoroscopic screen with a 35-mm camera (figure 4.6). Connell was aided by Richard Tizley, a welder hired on the day the Second World War began. A second-hand van was purchased for $250 and trial mobile community surveys began in 1941. The aim was to achieve early diagnosis, when the disease would respond most readily to the simple measures then available – bed rest, fresh air, and good food. During the second Saskatoon survey in 1948, 41,082 of the 43,016 residents were radio graphed – the highest rate of participation ever reached (95.5%). About one new, active case of tuberculosis was found per thousand people.23 The survey was staffed by unpaid local volunteers in each village or town, all vying for a higher turnout than in the neighbouring town. Other expenses were met through funds raised by the act amateur hours on all Saskatchewan radio stations and by the annual Christmas Seal campaign. The survey of the entire province was completed in 1947; a second survey began immediately. In 1948, the Anti-tuberculosis League began to pay for a chest radiograph of every patient admitted to hospital. This program was fully operative in every one of 109 Saskatchewan hospitals by 1950. Since people admitted to hospital were more apt to be ill, this became one of the most effective means of detecting new cases of tuberculosis and, as a side effect, detected a roughly equal number of unsuspected lung cancers.

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Figure 4.5 Robert G. Connell (Mrs. G. Connell)

Figure 4.6 Photofluorograph machine used for mass tb surveys (sla)

Dr Ferguson and Tuberculosis

16. The first province with sufficient beds for tuberculosis patients, 1942 From 1921 through 1940, Saskatchewan had a lower tuberculosis mortality rate than any other province.24 Saskatchewan was the first province “to provide sufficient sanatorium beds to treat all tuberculous patients,” the aimed-for ratio being three beds for every tuberculosis death.25 The necessary facilities were disproportionate in size and cost considering the up-and-down finances of an agrarian province. High capital costs were combined with high costs of identifying patients with the disease. why was saskatchewan a leader?

The answer relates, in part, to the calibre of Ferguson, the strong support his own conviction generated, and the administration of the entire program by a “semi-official body, mainly lay and voluntary in its operation.”26 Where else could Ferguson have reached out to every farmer? Where else could he have garnered such solid grassroots support? Where else was such a highly developed social conscience and community co-operation the basis of everyday life? As Premier T.C. Douglas said at the fiftieth anniversary of the founding of the Anti-tuberculosis League, Saskatchewan people had developed “a special capacity to meet and solve problems that by far excels more fortunate places.” Douglas was right. The league had obtained “the support and co-operation of the public to a greater degree than [in] any other province.”27 This public- spirited group has continued its work in preventive medicine since 1981 as the Saskatchewan Lung Association, now the Lung Association of Saskatchewan.28

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lowest tuberculosis death rate in canada

Ferguson’s work bore fruit. He witnessed the decline of case rates from 98 per 100,000 population in 1925 to 51 per 100,000 in 1948. However, incidence and death rates also declined in regions that lacked sanatoria, representing the natural course of any epidemic. Then, with the advent of streptomycin and para-amino-salicyclic acid in 1948, tuberculosis death rates fell sharply. The Prince Albert Sanatorium was closed in 1961, Fort San in 1972, and the Saskatoon San in stages: it stopped taking inpatients in 1978 and outpatients in 1982, and its lab closed in 1986. Overall, though, Saskatchewan had the lowest tuberculosis death rates in Canada from 1921 through 1944 and again in 1954, 1957, 1958, and 1966.29 ferguson in later life

Ferguson was made a Member of the Order of the British Empire (mbe) on the king’s birthday in 1935. He received an honourary lld from the University of Saskatchewan in 1946. He retired on his sixty-fifth birthday, 12 September 1948. His next six years were spent in researching and writing his highly acclaimed book, Studies in Tuberculosis, published by the University of Toronto Press in 1955.30 He received the prestigious Charles Mickle Fellowship in 1961. His portrait, by artist Nicholas de Grandmaison, was commissioned by his friends in 1962. Ferguson died on 1 March 1964. some reasons for ferguson’s success

Ferguson was an unassuming, soft-spoken, compassionate doctor. His personal charm, vision, strength of purpose, and scientific methodology were to make him a leader in North America’s fight against tuberculosis. His quiet influence with the premier and the Department of Health and his compelling per-

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suasiveness worked wonders. He had a lifelong knack for getting what he wanted from governments. Ferguson had the full support of the Anti-tuberculosis League’s dedicated board of directors. Peter McAra was mayor of Regina when he became the founding president of the league; McAra continued on the board of directors after he stepped down as first president, and he served again as president from 1930 to 1941. E.G. Hingley represented sarm for forty years and was president of the league from 1945 until his death in 1958. Dr F.W. Hart of Indian Head, an original trustee from 1911 to 1918, returned to the board as representative of the Saskatchewan Medical Association from 1932 to 1946. His son, Bob, married Ferguson’s daughter, Helen. Ferguson’s timing throughout the first thirteen years of his campaign was perfect. The return of veterans after the First World War caused the federal government to pour needed money into new buildings at Fort San; the higher federal per diem rate also helped augment the league’s bank balance. Free tuberculosis treatment passed the legislature in 1928, in part because the farm economy was buoyant in the late 1920s. The First World War had also changed public attitudes more than anyone realized; few other “charities” had as much appeal. All three Saskatchewan sanatoria took great care to maintain good relationships with all practising doctors. As Boughton said later of Ferguson, “One of his long suits was to play hand-inglove with the doctors who referred patients.” Ferguson consistently gained maximum government support, yet he kept a tight rein on management. There was no patronage and no featherbedding. The league provided a marvellous bargain to Saskatchewan in terms of service per patient day per dollar. Whether the Liberals or Conservatives were in power, Ferguson had immediate access to the premier and the minister

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of public health. (When the ccf gained power, Tommy Douglas confided to my father that the province’s recommendation to Ottawa that Ferguson be named Saskatchewan’s lieutenantgovernor had not been successful.) The league, followed by the Saskatchewan Lung Association, operated the sanatoria and clinics – the entire tuberculosis program – until 1987. Members of each successive government realized, sometimes contrary to dogma, that the arrangement was mutually beneficial. The various levels of government put up the money, and the league ran the incredibly cost-efficient organization, with a great deal of help from many volunteers and private organizations. At the same time the league attracted exceptionally dedicated people and provided a high standard of care. Ferguson’s other appointments and awards included: president of the Saskatchewan Medical Association (1922); fellow of the American College of Chest Physicians; member of the Senate of the University of Saskatchewan (1923–28); life member of the Royal Canadian Legion. R.G. Ferguson, mbe, ba, md, lld, 1883–1964, is remembered with respect and affection. His name is commemorated by the R.G. Ferguson professorship at the University of Saskatchewan, by the Dr George Ferguson School in Regina, and by one of Saskatchewan’s largest islands, Ferguson Island in Montreal Lake. “His resting place is in the valley he loved, but his shrine is in the hearts of the people of Saskatchewan.”31 George Ferguson! You should be here today. Saskatchewan needs you: she believes that tuberculosis Is controlled, That public health is no longer at risk,

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That the province’s wealth should be used to acquire luxury. Wake us up; show us again with your towering wisdom How to walk the common path of man; And perform the lowliest task with cheer.32 postscript

The number of new cases of tuberculosis among the non-First Nations population in Saskatchewan decreased from 931 in 1926 to 43 in 1990. In 1962 the mobile x-ray took chest radiographs of 3,462 Aboriginal people in northern Saskatchewan, those in the highest risk area, and found not one new case of tuberculosis. But the apparent defeat of the disease, especially in northern Saskatchewan, was short-lived. Sadly, the optimism so evident in 1964, the year Ferguson died, has since palled. Saskatchewan is no longer a leader. In 1987, its largest census area, the northern half of the province, had the highest rate of active new cases of tuberculosis (248.6 per 100,000) of any complete census region in Canada, and the Meadow Lake census division had the eighth-worst record in the country. Two reserves, Buffalo River and Portage la Loche, had rates of 1,000 per 100,000, 400 times that of Caucasians in southern Saskatchewan.33 In 1965, treaty Indians comprised 3 per cent of the Saskatchewan population, yet they had 75 new (not previously reported) cases of tuberculosis. These accounted for 34 per cent of the provincial total, a rate of 260 per thousand. In 1990, First Nations comprised 6 per cent of the population; their 156 new cases of tuberculosis accounted for 75 per cent of the total, at a rate of 267 per thousand.34 In 2012 the rates of new and relapsed cases of tuberculosis in Saskatchewan had dropped to 8.2 per 100,000. That year there were 55 new First Nations

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cases of tuberculosis, a rate of 49 per 100,000, and only 8 of those had primary tuberculosis, a marked improvement.35 Directly Observed Therapy (dot) was introduced into Saskatchewan in the autumn of 1989, to diminish the frequency of treatment failure and of very costly drug resistance. With another person identified to watch patients swallow their pills twice a week, selective breeding of resistant tb bacilli has greatly diminished. In the first four years with dot, compliance rose to over 85 per cent, drug resistance diminished from 13 per cent to 2 per cent, costs decreased to one-fifth the amount for self-administered treatment, and there were fewer hospital admissions.36

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CHAPTER 5

SIGERIST AND PENSIONERS’ CARE

Saskatchewan took a bold step toward medicare in 1944, not through health research or policy or management, but through politics. The province elected:

17. North America’s first social democratic government, 1944 “No person has had as profound an effect on the restructuring of health services in Canada as Tommy Douglas, that doughty little Scottish socialist fighter and orator”1 (figure 5.1). Douglas was “among the greatest political campaigners Canada has known.”2 His Co-operative Commonwealth Federation (ccf) party won a landslide victory, forty-three of the fifty-two seats, in the Saskatchewan election of 15 June 1944 and took office 10 July 1944. The ccf had a triumphant convention following this victory on 13 July 1944.3 Health was Tommy’s number one priority then and throughout his tenure as premier.4 To be certain that health matters were

Figure 5.1 Premier T.C. Douglas (sab r-a3421)

Sigerist and Pensioners’ Care

front and centre, Douglas assumed the health portfolio himself.5 For his first four-year term of office and into his second term, he carried this heavy burden in addition to his responsibilities as premier.

18. The Sigerist Commission, 1944: The first forward-looking provincewide survey to plan for future health needs One of Douglas’s very first priorities, the day after the election, was to contact Dr Henry Sigerist (figure 5.2), professor of the history of medicine at Johns Hopkins University,6 and author of a book that took a rosy view of Soviet medicine,7 to head a health study commission. Although Sigerist was a “physician of international reputation,” as Malcolm Taylor wrote, “there was a great deal of criticism later that a professor of the history of medicine … had been chosen rather than an expert in health services organization and administration.”8 Dr J. Lloyd Brown of Regina was the representative of the medical profession.9 The working group was known as the Saskatchewan Health Services Survey Commission (shssc). Sigerist and the other members began work on 6 September 1944. The commission visited various points across the province and conducted hearings to allow rural health advocates a place to present their initiatives. The files for the survey are held in the Saskatchewan Archives Board, and provide a snapshot of health ideas and concerns brewing in that moment. Several briefs stand out. sarm presented a ten-page brief that outlined various municipal hospital and salaried doctor schemes operating successfully in the province (see chapter 3).10 William J. Burak, reeve of the rm of Pittville, provided details of Pittville’s plan, which paid for hospitalization and doctor visits

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anywhere, for any length of time. His brief emphasized comprehensive coverage, freedom of choice, and local control.11 Matt Anderson, who spearheaded the “Matt Anderson Act” passed in 1939, emphasized the importance of free choice of doctor by the patient.12 Charles H. Chapin, secretary of rm McKillop, presented the full financial statements of what was known as Health Insurance District #1 (which was different from Swift Current Health Region #1; see chapter 6). Chapin pointed out that the health insurance scheme devised in his area of the province “relieved our residents of the financial worry of sickness and taught them to take early actions when any illness or symptoms appear.”13 Sigerist completed visits and hearings by 23 September, finished the report at five minutes after midnight on 1 October,14 and presented his formal report on 4 October 1944.15 As was the case with Lord Stephen Taylor, a medical doctor who gained the confidence of the profession and resolved the medicare dispute in 1962, Sigerist served without pay. His stay in Saskatchewan was too short, yet he accomplished a great deal. He recommended establishment of district health regions for preventive medicine, each centred on a district hospital equipped with an x-ray machine, a medical laboratory, and an ambulance. He advocated rural health centres with eight to ten maternity beds, staffed by a registered nurse and one or more municipal doctors. The municipal doctor plans, he wrote, should be “main tained and developed.”16 He noted that the public must be educated to seek medical advice at the centres, so that each doctor would no longer “spend a large part of his time driving around the country.” Patients were slowly becoming accustomed to seeking medical care in a centralized location. Recognizing that municipal doctors were overworked and underpaid, Sigerist suggested that they receive annual vacations

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Sigerist and Pensioners’ Care

Figure 5.2 Henry Sigerist at desk

with pay. Dr Elden Hitsman of Strasbourg in the rm of McKillop, which operated under the Matt Anderson plan, regularly took vacations while the health district paid a locum (replacement).17 Sigerist proposed “free hospitalization,” which he estimated would cost $3.60 per person per annum,18 and would require another 1,000 to 1,500 hospital beds in Saskatchewan,

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including a 500-bed university hospital attached to a new medical college in Saskatoon. He analyzed succinctly the thencurrent situation and offered solutions. It is easy, with hindsight, to realize that Sigerist’s crystal ball left much to be desired. His recommendation to build or improve many small village hospitals would have been appropriate in the 1930s but not as forward planning for the 1950s and 1960s. By following his report, Saskatchewan was saddled with too many small, one-doctor hospitals. Sigerist did not foresee that, farther down the road, the larger hospitals with better facilities and two or more doctors could, with improved highways, be reached more quickly in subsequent decades. Nor did he realize that doctors would desire relief from being on call twenty-four hours a day, seven days a week. Sigerist, a historian of medicine and not a futurist, also failed to foresee the rapidity of technological change that was already on the horizon. He overlooked the fact that larger farm machinery and highway improvement would contribute to rapid decline in the population of rural municipalities and villages and to increasing use by rural people of business and professional services in the cities. In the hospitals, rather than suggesting there be training of more x-ray technicians, or of combined laboratory and x-ray technologists appropriate for one-doctor hospitals, he recommended that “one nurse in every hospital be trained to handle the x-ray machine and the routine clinical laboratory work.”19 When he advocated consideration of sterilization for mental defectives, then popular in many jurisdictions, he failed to appreciate the ethical considerations involved. He demonstrated incredible naïveté when he prophesied that the complete eradication of venereal disease could be achieved in the near future.

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Sigerist and Pensioners’ Care

Professor Milton Roemer of the University of California, Los Angeles, nonetheless described the Sigerist report as “one of the most advanced health services reports of its time.”20 It provided the “blueprint” for medical care in Saskatchewan for half a century. Sigerist, in looking back on his life in 1950, admitted that he had rarely experienced “a warm feeling of having accomplished a job well,” but that one of these occasions was in 1944, on returning from Saskatchewan.21 douglas’s promises to doctors

At no time did Douglas make a salaried medical service a ccf platform plank.22 Indeed, his letter to J. Lloyd Brown dated 19 September 1945, published in the Saskatchewan Medical Quarterly that December, promised the medical profession that: (1) “a health insurance scheme shall be administered by a Commission which shall be free from political interference and influence”; (2) this commission “shall be representative of the public, those giving the service, and the Government”; (3) the commission “shall have sufficient power and jurisdiction to establish and to administer a plan”; (4) the chairman “shall be a physician”; (5) “no commissioner, representing a profession, shall be appointed except with the approval of the profession concerned”; and (6) “the professional committees shall have unrestricted jurisdiction over all scientific, technical, and professional matters.”23

19. The first comprehensive Social Assistance Plan for pensioners and widows, 1945 Douglas’s next urgent health priority was to provide comprehensive health care for those requiring social assistance, “old

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age and blind pensioners, widows on mother’s allowance, and their dependents.” There were 28,000 such people on the government rolls.24 On average, each doctor would have about fifty of these people as patients. Douglas met with the council of the College of Physicians and Surgeons of Saskatchewan on 23 August 1944 at Hotel Saskatchewan, two weeks before the arrival of Sigerist. The profession co-operated to the fullest. My father came home from the meeting bemused by the course of events. Douglas had asked the council for their estimate of what such a program would cost. The doctors did not know. They asked Douglas for his best guess. He didn’t know. Both sides recognized that these patients required an above-average amount of medical care. Nevertheless, they amicably agreed to use the figure suggested as the cost of medical care by the federal Heagerty Interdepartmental Advisory Committee on Health Insurance in December 1942 – $9.50 per person per year.25 At the annual meeting of the Saskatchewan Medical Association in September 1944, doctors agreed to monitor and police the plan for the agreed-upon fixed lump sum, on a one-year experimental basis. Final agreement was concluded on 1 October 1944, for implementation on 1 January 1945 of what was named the Saskatchewan Social Assistance Plan. By 1957 this plan had over 30,000 beneficiaries.26 This cordial agreement, reached “with extraordinary speed,”27 was welcome to everyone – what we would call today a win-win decision. The patients gained the right to health care without incurring a debt they had little hope of paying. Their families were relieved of responsibility. Municipalities were freed from any obligation to pay for indigents’ care. The doctors were paid for caring for individuals who had rarely been able to pay them in the past. The profession’s cornerstone method of payment – fee-for-service – had not been challenged.

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Sigerist and Pensioners’ Care

The key benefit for the government side, lost in all subsequent financing of health care, was that it could budget for an exact sum, the “ceiling principle,” without risk of over-expenditure. The doctors agreed to accept a fixed sum for any given year. Further, the government’s right to fund a major medical care program had been acknowledged with the new Saskatchewan Social Assistance Plan.28 Douglas had achieved his first health goal and his government had scored on the public opinion front. This scenario was as close to perfection as was ever possible in an imperfect world. The scheme was a success. The doctors themselves policed this scheme to ensure an equitable division of earnings. They could be much tougher on an over-billing member than any government agency. A doctor submitting an account was paid fifty cents on the dollar. The residual was divided proportionately at the end of the year, depending on the number of dollars unexpended in the fund. In 1945, the final payment brought that year’s earnings to 77.5 per cent of the fee schedule, and then in 1946, with increased utilization by patients, earnings dropped to 59 per cent. That year each doctor received a cheque at the end of the year for the final 9 per cent.29 In 1949, the profession negotiated a raise to $12 per capita,30 then to $15, and finally to $21 in 1958.31 Following the Sigerist report, the government moved to create the Health Services Planning Commission (hspc) in November 1944. Its mandate was to shepherd the report recommendations and other briefs and ideas relating to medical needs into policy. Dr Mindel Sheps acted as secretary, alongside Clarence Gibson (an experienced hospital administrator) and Tommy McLeod (Douglas’ financial wizard). The Sigerist report and the Social Assistance Plan were solid achievements in the first six months of North America’s first social-democratic government. The Sigerist report laid out a

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blueprint for change and created a forum for innovative discussion and ideas, and paved the way for Saskatchewan municipalities to band together to establish health districts. Douglas deserves full credit for giving health a higher priority than any political leader before or since. His dedication was coupled with charisma, a legendary sense of humour, and a remarkable adaptability which made the best of any situation. McLeod and McLeod note that Douglas had “brought to the political life of the country a civility that enriched the Canadian scene,” while carrying “a remarkably light load of ideological dogma.”32

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CHAPTER 6

S W I F T C U R R E N T H E A LT H R E G I O N

Joan Feather opens her two landmark articles on the history of the Swift Current Health Region with the following statement: Southwestern Saskatchewan seems an unlikely place for a major experiment in universal, prepaid health services. Rolling grassland, short, hardy crops struggling against drought and wind, vast expanses without signs of human dwelling – how can such a place give rise to a sophisticated service structure? The explanation is to be found in the unique combination of past experience, local leadership, and government policy, skillfully merged into an experiment with remarkable staying power.1 What was the “past experience and local leadership” that contributed to the creation and success of the Swift Current Health Region? Four rural municipalities within Saskatchewan’s southwest drybelt led the way (see map, figure 6.1). Anchoring

36 Steps on the Road to Medicare

Figure 6.1 Map of Health District #1 (Carol Beaulieu)

the old “Palliser Triangle” region of western Canada, these communities were particularly hard-hit by the dual whammy of dust and depression between 1914 and 1937.2 Residents were eager to think of new, collective solutions to reform the care system. In 1937, rm Pittville #169 at Hazlet paid Dr A.L. Caldwell of Cabri a municipal doctor salary of $2,700 per year even though Pittville constituted less than half of his practice area.3

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Swift Current Health Region

When Caldwell joined the army in November 1941, the ar rangement evolved so that residents paid a personal tax and carried an insurance card that paid any doctor, anywhere in Saskatchewan, 50 per cent of the fee schedule as payment in full, and paid any hospital $2.75 per day.4 Pittville residents thus were not restricted to the services of a single salaried doctor, as was the case with municipal doctor plans. This freedom of choice was popular. The plan, though, was contrary to the Rural Municipality Act and in fact, not legal – but legality did not stop the rm from continuing.5 In 1943, 1,200 Pittville residents were covered for a total cost of $13,031, or $10.91 per capita, a bargain for medical and hospital insurance combined.6 A similar renegade plan, which disregarded some of the conditions of the Rural Municipality Act controlling taxation and health, evolved in rm Miry Creek, directly north of rm Pittville. In 1937, the Abbey Cottage Hospital closed. In that same year, Miry Creek began a hospital plan. Funded through an additional land tax levy, Miry Creek residents could seek hospitalization in any hospital in Saskatchewan. They added a medical plan in July 1943, which paid for visits to any Saskatchewan doctor.7 Under guidance of its secretary-treasurer, Stewart Robertson, rm Webb #138, south and east of rm Pittville, operated its medical insurance scheme under the “Matt Anderson Plan” (see chapter 3). Fee-for-service payments were made to doctors visited by rm Webb patients both locally and in larger centres. It cost $7 per person or up to $50 per family.8 North of rm Webb, rm Riverside set out its plan in late 1944, modeled largely on the rm Pittville’s any-doctor, anywhere plan.9 Dr Mindel C. Sheps of the newly created Health Services Planning Commission in Regina presented a Memorandum on Organization of Health Regions to Premier Douglas on 20 April 1945. Any ten

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municipal councils could provide resolutions to form a health district, which would break open local health schemes to consider and provide for medical and hospital needs on a regional basis.10 The memorandum paved the way for what was to come. While the small rural municipalities in Saskatchewan’s southwest corner experimented with medical insurance plans, Swift Current, the pivot city of the region, needed a new hospital. In August 1945, Sheps arrived in Swift Current to discuss the possible formation of a union hospital district.11 She found a local advocate with a much larger agenda: Pittville’s secretary-treasurer, William J. Burak (figure 6.2). Burak was convinced that his Pittville plan should be extended throughout Saskatchewan’s southwest region. In January 1945, before the memorandum on health regions was formulated, Burak wrote to each municipality, proposing that they organize to form a health region to offer not just preventive medicine but a full health plan. The council of rm Pittville was the first to ask the government to establish a health region after the provincial government set out the regulations concerning the creation of health regions, published in the Saskatchewan Gazette on 31 July 1945.12 Rather than have separate meetings to discuss both a new hospital and a health region, Sheps suggested to Burak that “the question of organizing a health region could be discussed” when Sheps visited Swift Current on 18 August 1945.13 The ccf government, uncharacteristically, was dragging its feet. Douglas had given Sheps license to discuss public health, to steer the Swift Current region to set up a union hospital, which would become the central hospital in a district that would emphasize preventative medicine. Burak offered a complete health service plan instead. As a spinoff from that meeting, Burak was appointed a committee of one “to sound out the surrounding municipalities.”

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Swift Current Health Region

Figure 6.2 William J. Burak (Mrs Pola Burak)

A veritable whirlwind, a “mover and shaker,” as Lester Jorgenson called him,14 Burak lost no time. He sent a four-page single-spaced mimeographed letter on 23 August and a followup three-page letter on 30 August to thirty-one rural municipalities, thirty-six villages, six towns, and the City of Swift Current,15 offering his vision of a much larger enterprise, the formation of a region that would offer “complete medical, surgical and hospital services.” Burak also took his personal crusade to the regional weekly newspapers16 and attended regular council meetings of five rural municipalities to advance his proposals.17 He then called a meeting, which he chaired on 15 Sep tember 1945; forty-eight of the invited municipal governments sent delegates. The other two members of Burak’s organizing

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36 Steps on the Road to Medicare

committee were Walter Melrose of rm Big Stick #141 at Golden Prairie and Carl Kjorven of rm Riverside #168 at Pennant.18 Premier Douglas had expressed doubt about the Swift Current priorities; he thought it prudent to have a slower evolution to full medical care. In a radio broadcast Douglas downplayed the necessity of a full regional plan.19 In an article in the Saskatchewan Medical Quarterly in December 1945, Douglas wrote that he wished to introduce a health program, “step by step.” He wrote of regional public health districts and hoped that “at least one public health district [would] be organized as soon as possible” – intending to begin with preventive services.20 Joan Feather confirms this; the government had planned an experimental health region “with a focus on public health services and diagnostic and specialized facilities. But … popular pressures forced a commitment to complete health services at public expense for the region.”21 Burak, who had given a lot of his time and spent his own money, never reimbursed, for “stamps, stationery, telephones, travelling and all other expenses,”22 won out with his grandiose plan.23 By 1 November 1945, the requisite petitions from ten municipalities had been collected, and a vote was held in these municipalities on 26 November 1945.24 The ballot read: “Do you want a comprehensive system of health insurance, hospital and medical care and preventative services?”25 By a 71 per cent vote (Shaunavon’s voters were barely in favour, 137 to 136),26 the residents of southwestern Saskatchewan voted to establish a health region. The Douglas ccf government, to its credit, responded promptly to regional wishes. It passed an Order-in-Council on 11 December 1945 authorizing formation of Swift Current Health Region No. 1.27 On 17 January 1946, the organizational meeting at Gull Lake,28 attended by sixty of the eligible eighty delegates, passed

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Swift Current Health Region

Figure 6.3 Carl Kjorven (Lester Jorgenson)

Figure 6.4 Stewart Robertson (Leah Robertson Koldingnes)

a simple resolution: “That the Regional Board of Health be instructed to provide hospital, medical, and limited dental care as soon as possible and that the funds required be raised by 25 per cent from a land tax and 75 per cent from a personal tax.”29 Carl Kjorven from rm Riverside was selected as chair (figure 6.3), and Stewart Robertson from rm Webb as secretary-treasurer (figure 6.4), bringing their experience to the table.30 The representatives from the district medical society31 met with the executive of the regional board on 3 May 1946. They accepted payment at 75 per cent of the Saskatchewan medical fee schedule, and agreed to have a meeting once a year between themselves and the board. Each side trusted the other. The meeting lasted only fifteen minutes.

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20. The first comprehensive regional health care and the first comprehensive hospital plan in North America, 1946; first region in Canada to combine public health with medical care, 1946 Dr Arthur F.W. Peart, the district medical health officer, arrived in January 1946 and the full-blown preventive program began on 1 May. The Swift Current Sun boldly announced the story as winds of change.32 The new board established an office in Swift Current 7 May 1946. Peart moved on after only nine months and was replaced by Dr Lloyd Davey.33 Universal medical and hospital care came into force throughout Health Region No. 1 on 1 July 1946, two years ahead of Great Britain’s National Health Insurance Plan, which began on 1 July 1948.34 Dr Vincent L. Matthews (Figure 6.5), the third medical health officer, from 1 July 1948 through February 1957,35 provided seamless integration of preventive work with medical care36 and acted as accounts assessor and statistician for the regional board. A man of integrity, Matthews quietly earned the respect of both the medical profession in the area and the general public.37 The drought-stricken Swift Current Health Region comprised an area of 13,932 square miles and a 1946 population of 53,597.38 From the time the region was opened for homestead settlement in 1908, only one year in approximately seven had provided a sound financial return to farmers.39 When the scheme began, only nineteen medical doctors resided in the region, including four specialists in Swift Current.40 With assured payment and, as doctors returned from service in the armed forces, increased availability, the number of doctors jumped to thirty-four in 1947 and thirty-six in 1948. As Lloyd Brown reported: “a fine spirit of co-operation between the doctors and laymen on the Board was evident … and a very evi-

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Swift Current Health Region

Figure 6.5 Dr Vince Matthews (Pat Matthews)

dent desire … to run their own affairs with a minimum of interference or control from the outside.”41 The region’s staff, all paid by the Saskatchewan government, consisted of the medical health officer, seven public health nurses, a health educator, and three sanitary inspectors. Stewart Robertson, functioning as a chief executive officer, held this position until he retired at the end of 1966. Robertson was a frugal Scot who had left Scotland in 1920 at age twenty. Not only did he obtain full value for each dollar spent, but his own office was small, with second-hand furniture, bare wood floors, and no drapes. His first secretary, Pat Ditner, describes him as “caring, kind, sensitive, even-tempered, compassionate, patient … hard working and willing.”42 Nothing flustered him. Each rural municipality and the City of Swift Current had an elected representative; all were laymen. Dr Orville Hjertaas of the Department of Health, assigned to organize health regions,

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remembered the “outstanding board of bright and caring people … basically farmers.”43 The board contained “staunch Liberals and Conservatives and hard line C.C.F.ers, but they all left their politics on the doorstep.”44 The regional health scheme was financed by a personal tax – $15 for one person, $24 for two, $30 for three, and $35 for a family of four or more – and a property tax, calculated to raise 25 per cent of the total, set at 2.2 mills. The provincial government contributed twenty-five cents per capita and paid one-half the cost of x-ray, children’s dental, and out-patient services. The provincial contribution to the Swift Current plan in 1948 came to $63,691.45 For the first six months of the scheme, hospitalization costs were 42 per cent of total expenditures, having been underestimated by about $75,000.46 Fortunately, the advent of provincewide universal hospitalization on 1 January 1947 removed hospital expenses from the six-month-old region’s budget and thus saved the Swift Current plan from bankruptcy. Other measures which brought the budget under better control included: reducing specialist fees from 75 per cent to 50 per cent of the provincial rates in 1948; introducing utilization fees, which controlled “double doctoring” and “shopping around” for medical services, as well as overuse for minor ailments; and the “ceiling principle,” which introduced a budget ceiling in the expectation that the health region as a group had to adhere to strict guidelines.47 Expenditure for medical services within the region, on a feefor-service basis, was $410,453 in 1947 and $453,925 in 1948. In 1948, doctors received an average gross revenue of $12,880 – a net income averaging $8,114, since the overhead for a doctor in the area was estimated at 37 per cent.48 Referrals to specialists outside the region, mainly Regina, came to $58,547 in

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Swift Current Health Region

1947 and $67,909 in 1948. The per capita cost for medical service in 1947 was only $9.83 and in 1948, $10.23.49 For the first time, as Dr J. Lloyd Brown pointed out, statisticians had access to reliable figures concerning the cost of medical care, a valuable side benefit from the operation of the Swift Current plan. The region’s doctors were aware that specialists in Regina and Saskatoon looked askance at this experiment in “socialized medicine.” Dr J.A. Matheson of Gull Lake said, “there have been times when we in the Swift Current area felt like black sheep … We have been trying out some ideas that have not been approved.” He went on to tell of the benefits of the scheme: “security and stability … better incomes … The patients are getting a better service … partly due to an increase in the number of physicians.”50 Payment was in cash from the provincial government, no longer in chickens or sides of beef. Dr Gordon Howden, a family practitioner in Maple Creek before he left to specialize in ophthalmology, gave a well-reasoned account of his experience. He found the scheme did not affect the doctor-patient relationship, but the doctor’s work increased considerably and “many have acquired a taste for xrays … because of the good feeling and spirit of co-operation between ourselves and the Regional Board, we have had an excellent opportunity to present our case under favourable circumstances.”51 One measure of success: the infant mortality rate is reputed to have fallen from a high level (before 1946) to the lowest rate in Saskatchewan in 1965 – 14.4 per thousand live births.52 Dr Arthur D. Kelly, deputy secretary of the Canadian Medical Association, visited the area in 1946. He found that the regional board enjoyed “a large measure of local autonomy.”

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He characterized the region as “a successful experiment in the large-scale provision of medical care, courageously applied, efficiently managed and remarkably free from attempts to make the facts fit preconceived ideas, financial or otherwise.”53

21. The first regional hospital board in Canada, 1951 Vince Matthews’ reminiscences include the information that the Swift Current Regional Hospital Council, formed in 1951, was the first regional hospital organization in Canada, an early precursor of a system that came into vogue, for better or for worse, in most Canadian provinces only in the 1980s and 1990s.54 As Maureen Matthews55 said on her superlative cbc Ideas program with Lister Sinclair, 5 December 1990, “The basic idea was that every citizen deserved equal access to adequate medical care.”56 The following comments excerpted from that cbc program, provide the inside experience of two doctors in the scheme. dr gordon howden: The one thing that doctors and the municipal people felt … that it was our plan. It was a local plan, we could change things, we could communicate, there wasn’t a political overtone at all. It was purely for the benefit of the people in the plan … the fact that it was on a small scale, the fact that it was a give-and-take situation with the municipalities and the doctors, both willing to learn, and being able to change the plans … the doctors did feel that they had input. dr cas wolan: the Health Region trusted the doctors and the doctors trusted the Health Region … after one of these meetings with Stewart Robertson for a few hours, we decided that for the balance of the year we’d go on fifty-one percent of our

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Swift Current Health Region

usual payments … it was kind of a hard deal to take but I agreed to this thing, Stewart agreed to it, and I went back to the physicians and told them why and they accepted it.57 The secret of the success of the Swift Current Health Region was the integrity, pragmatism, and openness of all concerned. Dr Vince Matthews, Stewart Robertson, and Dr Cas Wolan, the doctors’ representative for financial matters, would have coffee together most mornings at the Venice Café in Swift Current. It was, Matthews recorded, “the best buzz group in which I have ever been involved.”58 If a doctor new to the area was overservicing his patients or wanting to install an x-ray machine as a money-maker in his private office, the three would reach an amicable agreement to resolve the problem. Carl Kjorven, a farmer from near Cabri, was a skillful chairman. When Robertson retired on 31 December 1966 after twenty-one years of service, the Regina Leader Post argued that he had achieved greater “closeness of the operating between the doctors and the health region board, and between the patients and the health region board.”59 Before the withdrawal of services of most Saskatchewan physicians in the still-remembered “doctors’ strike” between 1 and 23 July 1962, the Swift Current Health Region “asked to remain autonomous and carry on with their own successful plan.”60 But events became so emotional and so polarized that on 1 July the doctors within the region closed their office doors in concert with those elsewhere in Saskatchewan. After Lord Stephen Taylor’s negotiated compromise on 23 July 1962, many doctors returned to work throughout Saskatch ewan. The Swift Current area continued to operate separately from the provincial health plan, offering advantages over the

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rest of the province: no extra billing and no hospital privilege problems.61 An extra fee of $14 was added to pay for a children’s dental plan. Collection of taxes and doctors’ billings remained separate from the provincial plan.62 In 1953, short of revenue, the Swift Current board added deterrent fees ($1 for an office visit and $2 for a house call).63 By 1972, as part of a new federal-provincial agreement, the province assumed direct responsibility for medical services to those over 65, relieving the board of responsibility for this age group. By 1974, the region ceased levying its own personal taxes. Until 1980, regional cards continued to be issued annually by each rm and town office, but in 1981 the province moved the region medical accounts into Regina.64 Only in 1988 was the region fully merged into the Saskatchewan Medical Care Insurance Commission, and the Swift Current office closed. The last regional information meeting was held on 3 June 1993, the final vestige of local involvement.65 The Swift Current Health Region was unique. It was a success. It was thoroughly tested. It was made to work. As Taylor says, “It had attracted a higher ratio of doctors-to-population than any other rural part of Saskatchewan.”66 The public, the doctors, and the inordinately small administrative staff felt a sense of ownership, of empowerment.67 Swift Current became a major stepping stone on the road to medicare.68 Lester Jorgenson of rm Miry Creek #229 emphasizes that this was a local, grassroots phenomenon. Although supported by the province, “the widely held concept that the Swift Current plan was a provincially directed pilot project does not fit the recorded facts.”69

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CHAPTER 7

MEDICAL COLLEGE AND UNIVERSITY HOSPITAL

The success of any future medicare program in Saskatchewan required a first-rate medical school. Although a two-year medical course had been offered at the University of Saskatchewan since 1926, Saskatchewan medical students had to move to other provinces for their clinical training. Sigerist’s report in 1944 recommended construction of a full, five-year medical school and a 500-bed university hospital in Saskatoon. Sigerist predicted the building and equipping of the hospital and medical school would cost $2 million,1 with annual operating costs of $150,000. university of saskatchewan college of medicine, 1955

Even before the 1944 election, T.C. Douglas was planning for a five-year medical college if and when he took power. In thinking of possible candidates for a dean of medicine, he took advice from Dr W.C. Gibson, then serving at the Royal Canadian Air Force Clinical Investigation unit in Regina.2 Gibson suggested

36 Steps on the Road to Medicare

his former teacher at McGill University, Dr J. Wendell Macleod.3 However, it was not until July 1951 that the provincial budget and Macleod’s personal circumstances allowed him to accept the position. Macleod was a man of vision; he spent a year studying medical education and recruiting department heads before settling in Saskatoon.4 Meanwhile, in the spring of 1945, the legislature voted $100,000 to begin construction of the medical college; the cornerstone was laid by T.C. Douglas on 26 August 1946. The official opening took place on 8 May 1950.5 The first medical class was admitted in the fall of 1953 and graduated in 1958. There are benefits from a small class size. In spite of usually inadequate funding for the medical college, Saskatchewan medical graduates have done well. The history of the medical college has been chronicled through 1976 by Dr Douglas J. Buchan,6 and from 1976 through 1998 by Dr Louis Horlick.7 university hospital

Premier Douglas established the Board of Governors for the university hospital in September 1946. In December 1946, he agreed to an expenditure of $7 million for a 550-bed hospital, to be connected to the medical building.8 The legislature passed the University Hospital Act in 1947. Construction of three wings of the hospital began in 1948, but due to worrisome delays for financial reasons, the cornerstone was not laid by Premier Douglas until 19 September 1952. In his address, he wisely said, “we wanted no medical school at all unless we could have the best possible.”9 The hospital opening ceremony took place on 14 May 1955. Delays and inflation caused the price of the university hospital to rise far above the “ballpark estimate” of $1,500,000 given

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Medical College and University Hospital

by Dr W.S. Lindsay, dean of the two-year basic science course in medicine, and adopted by Sigerist in his report. The final cost of the hospital was seven times higher – $10,589,703.10 The university hospital brought top-notch specialists and subspecialists and greatly raised the standards of medical care in Saskatchewan, as recorded by Louis Horlick.11 The medical college and university hospital were necessary ingredients in the preparation for medicare.

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CHAPTER 8

PROVINCEWIDE H O S P I TA L I Z AT I O N

Hospital services are costly. They require support from municipal and provincial governments to provide funding and sound policies. Above all, the primary concern should be for the patient. With momentum gained from experience with cottage and union hospitals and the Swift Current Health Region No. 1, Saskatchewan moved toward provincewide hospitalization.

22. The first province to provide capital grants for widespread hospital construction, 1945 Saskatchewan took Sigerist’s advice to heart in becoming the first province to provide funds for capital construction of hospitals, a major step on the road to medicare.1 Between 16 March 1945 and 1 March 1949, the government provided $653,714 in outright construction grants and $173,500 in loans.2 The National Health Grants Programme in 1948 added substantial federal funds to support hospital construction; Saskatchewan,

Provincewide Hospitalization

sadly, having been too quick off the mark, was ineligible for matching federal funds for new construction since most of its hospitals had already been built. The province was in double jeopardy because some of the operational health programs had also been launched in anticipation of federal support; it was learned only too late that, because they were already underway, they were disqualified from receiving federal assistance.3 Nonetheless, the Saskatchewan program moved hospital construction costs out of tight municipal budgets, allowing larger, better equipped hospitals to be built. Larger centralized hospitals could incorporate modern conveniences and technologies, from plumbing and heating infrastructure to power, which led to specialized laboratory and x-ray rooms. Twenty-one new hospitals were established over four years, and forty-one union hospital districts formed.4

23. The first universal hospitalization insurance program in North America, 1 January 1947 Introduction of the first provincewide, compulsory hospitalization insurance program in North America was achieved in Saskatchewan with remarkable speed and efficiency. Hospitalization was expected to cost even more than physician services and thus be the more expensive “half” of the medicare equation. Sigerist estimated that universal, provincewide hospitalization insurance would cost $3.60 per person (about $3.5 million)5 per year and would require another 1,000 to 1,500 hospital beds in Saskatchewan,6 including a university hospital of at least 500 beds.7 The first steps toward provincewide hospitalization insurance included: the Saskatchewan Social Assistance Plan (1 January 1945; see chapter 5), which paid for both medical and hospital services for the province’s most

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needy; free hospitalization and treatment for cancer patients; and full coverage for hospitalization and treatment for mental illness.8 The move to provincewide hospitalization insurance would spread the cost of hospital care across all citizens and ease financial pressure on smaller municipalities. It would also be least likely to disrupt the balance between the doctors’ professional considerations and provincial or regional purse strings.9 The doctors in Saskatchewan enthusiastically and almost unanimously supported the introduction of provincewide hospitalization insurance on 1 January 1947. Doctors could now admit patients to hospital whenever necessary, without concern for cost. Patients could be treated in whichever hospital was best for their care, for the time needed to recover, whether that was a few days or many months. Small hospitals rejoiced, for a time. The Red Cross Outpost Hospital at Paddockwood, for example, no longer needed to rely on intermittent and sporadic local upkeep or payment – hospital costs were covered by the new plan. Still, consolidation and construction in larger centres with provincial support led to rural hospital closures.10 dr mott and the saskatchewan hospital services plan (shsp), 1 january 1947

Dr Fred D. Mott (figure 8.1), a graduate of the McGill Medical School and a senior officer with the United States Public Health Service, became chairman of the Saskatchewan Health Services Planning Commission on 1 September 1946. Tommy Douglas deserves credit for making such a wise choice. Mott’s appointment was welcomed by the medical profession.11 Mott, a man of integrity and a good listener, as well as a man of action, moved the plans for the Saskatchewan Hospital Services Plan (shsp) “into high gear.”12

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Figure 8.1 Dr Fred D. Mott (sab r-a7994)

The provincial hospital plan broke new ground. The administrative machinery had to be invented “from scratch,” and became the model for all subsequent plans. Malcolm Taylor, an interested graduate student of health administration from the University of California, passing through Regina, describes the unprecedented pioneering effort as follows: The new uniform hospital accounting system was finalized under G.W. Myers; the point system was completed,13 the tax collection procedures agreed upon with the municipalities; and the organization of shsp decided upon; scores of clerical, secretarial, and tabulating personnel were appointed and trained, and a massive publicity program was mounted to encourage early registration and tax payment.

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It was a period of feverish activity, reminiscent of mobilization in 1939. The only office space available was in an ancient, vacated store building; clerical desks were long rows of plywood-on-trestles, with clerks sitting elbow-toelbow, processing the registration and tax collection payments.14 The annual hospital premium was $5 for each adult and child, with a maximum of $30 per family. Each municipality received a 5 per cent commission for collecting the premium. The plan provided “complete hospital benefits to all residents of the province. It included public ward care, X-ray and laboratory services, common drugs, and other hospital services. It also provided for the payment of a flat per diem amount toward the cost of out-of-province hospitalization for any Saskatchewan resident.”15 Each resident received a hospitalization card with a number. The shsp was administratively separate from the Department of Health but was not the “independent, nonpolitical commission” the doctors had desired. The deputy minister of health sat on the commission, which oversaw both the shsp and the Medical Services Division, which administered the Social Assistance Medical Care program (see chapter 5). Sigerist’s financial projections were wildly short of reality. The hospitalization costs for the first year were almost exactly twice his forecast – $7,560,763, a per capita cost of roughly $9.69. In subsequent years that $7.5 million seemed a bargain. Per capita costs of hospitalization rose rapidly, to $11.42 in 1948 and $13.59 in 1949. The most economical component in the early years was administration, which consumed only about 5 per cent of total expenditures.16 The $5 per person hospital tax initially covered 60 per cent of the cost of provincewide hospitalization.17 As Taylor says, “The tax collection system was

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successful to a degree unexpected for a regressive ‘poll’ tax.” He adds, “In Saskatchewan, the plan became popular before it was expensive; in B.C., it was expensive before it was popular … a main issue defeating the [British Columbia] government in 1952.”18 Historian James McAllister noted that until 1944, health spending comprised only 1.4 per cent of the Saskatchewan provincial budget. Within four years of implementing the hospitalization plan, health’s portion of the provincial budget rose to 13.1 per cent.19 poliomyelitis treatment

The hospital plan was put to an early test in its first year: 277 polio cases were reported in Saskatchewan, with twelve deaths. Poliomyelitis “was one of the most feared diseases” of the twentieth century.20 The polio clinic in Saskatoon was augmented by the addition of polio clinics in Regina and Moose Jaw. Unlimited free hospital, medical, and nursing services were financed through shsp. In 1952, Saskatchewan was the epicentre of the Canadian polio epidemic. The government took the threat seriously. By the end of 1960, 99 per cent of Saskatchewan children had been immunized.21 Polio joined tuberculosis, cancer, and mental illness as special diseases requiring full provincial medical support. saskatchewan air ambulance

The move toward health regions and centralized hospitals gave support to an innovative initiative. On 3 February 1946, an air ambulance service was put in place. The service speeded up the transfer of residents from remote or rural areas for treatment at the larger regional centres and offset rural hospital closures.22 New hospital construction, universal hospitalization insurance, and a vigorous response to special diseases broadened

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health care in Saskatchewan. By 1958, “the volume of hospital service received by Saskatchewan residents (2,100 days per 1,000 persons per year) was “the highest in North America … their needs are being met.”23 the saskatchewan health survey, 1949–51

On 28 July 1948, the government of Canada announced that it would make funds available for each province to survey “present health services and facilities.”24 Saskatchewan was allotted $43,506 for the provincial survey. A committee of twelve had one representative each from registered nurses, dentists, urban municipalities, rural municipalities, labour, the hospital association, the farmers’ union, the Swift Current Health Region (Carl Kjorven), and two from the medical association (C.J. Houston and G.G. Ferguson, registrar of the Saskatchewan College of Physicians and Surgeons). Dr Mott was chair and Malcolm G. Taylor (figure 8.2) was research director and secretary. In the middle of the health survey, on 14 November 1949, Douglas turned over the Ministry of Health to T.J. Bentley, the member from Gull Lake. It was probably more than simple coincidence that Bentley, a farmer, and later on the field staff of the Saskatchewan Wheat Pool, represented a riding within the Swift Current Health Region. The diverse group met amicably.25 Mott listened to each viewpoint and then asked for overall consensus. As each question came up, it was hammered out to the point of agreement. No minority report was submitted, nor were interim reports supplied to the organizations that each member represented. After more than two years’ work and twenty-five meetings, the twovolume report contained a full catalogue of Saskatchewan’s health resources and an estimate of needs in future.26 Ken McTaggart, in The First Decade, wrote that the Saskatchewan

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Provincewide Hospitalization

Figure 8.2 Malcolm G. Taylor (sab rws-a11567, by permission of Michael West)

Health Survey report surpassed that for any other province; he described it as “the classic of such projects.”27 In addition, as C.J. Houston reported to the College of Physicians and Surgeons, the Saskatchewan committee “established a precedent in working out health matters. It has proved that a widely representative type of Commission can work.”28 Of 115 recommendations, the first was that “a comprehensive health insurance program should be undertaken at the earliest possible date.”29 hospitalization universal throughout canada, 1961

British Columbia’s hospitalization plan, the second in Canada, followed in 1949 but, lacking Saskatchewan’s superb organization, was an administrative nightmare that suffered horrendous problems. Federal funding for hospitalization, on a cost-sharing

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basis of 45 per cent, started 1 July 1958.30 On 1 January 1959, Ontario’s plan went into effect. By 1961, all provinces were participating, with Quebec the last to join. Each province, watching the Saskatchewan example, sent administrators to Regina to learn how to do it right. Federal funds through the cost-sharing agreement to support the hospital plan eased Saskatchewan’s purse strings. The money provided the Saskatchewan government with the funds it needed to undertake its long-sought goal of universal medicare, covering both hospital and medical services.

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CHAPTER 9

I N N O VAT I O N S I N P S Y C H I AT RY

When Saskatchewan became a province in 1905, psychiatry and mental hospitals across Canada were in a backwater compared to the rest of medicine. The first opportunity to show leadership was scuttled by unfortunate advice from Ontario. a missed opportunity to pioneer small, humane psychiatric cottage hospitals, 1908

Dr David Low of Regina, the provincial health officer (figure 9.1), was sent in 1907 to visit mental hospitals in eastern Canada and the United States. He was asked to consult widely and to make recommendations for construction of a mental hospital in the new province. He visited two up-to-date mental hospitals in New York State, at Ogdensburg and Ward Island, and the Protestant Hospital for the Insane at Verdun, Quebec. At these three hospitals, “instead of measures of restraint such as padded cells and straight-jackets,” there was sufficient staff and patients were allowed their freedom and even were allowed to use the libraries that were provided.1

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Figure 9.1 Dr David Low (sab r-a3569)

Low recommended “a cottage system.” However, Dr C.K. Clarke, superintendent of the Toronto Asylum, was asked to be a consultant to the Toronto architectural firm of Darling and Pearson, who were concerned about “scattered plumbing and heating lines” if a cottage plan were chosen. Clarke admitted that the cottage system is “ideal for the patients themselves, and provides means for breaking up the patients into smaller distinct groups,” yet he advised against it on economic and climatic grounds.2 With the devastating winter of 1906–07 firmly in the rear-view mirror in Saskatchewan, it is perhaps not sur-

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prising that heating issues at public institutions carried weight. With coal and wood prices factored into maintenance costs, the Canadian climate would indeed have an impact.3 It is nonetheless a pity that the government chose to follow “expert advice” from Toronto and ignored Dr Low’s recommendations. In retrospect, a series of cottages with closed-in connections between them, suitable for a cold climate, would have made Saskatchewan a leader, giving mentally ill patients more humane treatment. Sadly, the government opted for a pavilion-style institution at North Battleford,4 which opened on 4 February 1914 with 314 patients. The patient population increased to 853 in 1920 and 985 in 1930. A second pavilion institution opened in Weyburn in 1921; it had 1,058 patients in 1930 and about 1,500 in 1963.5 By 1948, including those in the “training school for mental defectives,” 4,500 mental patients were institutionalized in Saskatchewan, “the highest institutionalized rate per capita” in Canada, with “not more than ten Registered Nurses in the three institutions.”6 Weyburn’s hospital has been cited as the last asylum-styled psychiatric care facility, and the largest in the British Commonwealth. Large mental hospitals were inherently counterproductive. “Patients came from long distances, tended to stay a long time and fairly often were not discharged. Deaths were high.”7 “The huge corridors and indefinite spaces would clearly be extremely damaging to people whose perceptual apparatus was already out of gear … the large overcrowded institution not only did not help patients, it hurt them.”8 Yet, the Saskatchewan mental hospitals and their managers deserve credit for some unusually fine care. J.W. MacNeill, first medical superintendent at the Saskatchewan Hospital North Battleford, abolished restraints, removed bars from windows, and changed the use of the term “asylum” to “hospital.” Farm

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and irrigation projects, including extensive gardens, supported the value of beautiful surroundings and meaningful work in helping patients live more fully. Those at the hospital were not inmates but patients, humans with illnesses in need of care.9

24. The first province to provide free psychiatric treatment, 1 January 1946 Medical historian Erika Dyck noted that Douglas “deplored the tradition of placing people with mental illnesses in custodial institutions.”10 Instead, he advocated community care as much as possible, with an emphasis on intervention and preventative medicine. By 1945, Douglas was publicly advocating early diagnosis and treatment, as well as an aggressive public awareness campaign in an attempt to remove the stigma of mental illness: “to get the public to know that there is no more disgrace for one member of the family to get mentally ill than there is for any other member of the family to [get] pneumonia.”11 The Sigerist Commission, as well as Douglas’s own thoughts on mental health and his position as health minister, no doubt combined to push forward the move, in the throne speech of 1945, to full hospitalization and treatment coverage for mental health patients.12 As a result, the government considered the patients and took steps to differentiate those who had mental or physical handicaps from others who experienced mental illnesses or drug and alcohol addictions. Treatment paths diverged.13 Mental health reforms, as well as a new emphasis on treatment, research, and care, placed Saskatchewan at the forefront in the postwar period. Dyck contends that the “delicate and complicated set of historical and psychological factors gave

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rise to a new vision” of mental health innovation.14 Medical historian Colin Smith went further, declaring that the Douglas government initiated a “halcyon period” of mental health services.15

25. The first free outpatient service for mental health patients in Canada, beginning 1947–51 On 1 November 1946, Dr D.G. (Griff) McKerracher became Commissioner of Psychiatric Services for Saskatchewan. Described as a “man of immense charm,” McKerracher was enthusiastic about his role and sympathetic to both the needs of mental health and the innovations required to change how things had been done.16 He “strongly urged a reconceptualization of mental health as an area indistinguishable from general medicine, meaning that its treatment would take place in a general hospital.”17 He moved quickly, establishing an outpatient clinic, the Munroe Wing, of the Regina General Hospital in 1947. Part-time or full-time clinics were operating in Weyburn, North Battleford, Saskatoon, Moose Jaw, Assiniboia, Swift Current, Yorkton, and Prince Albert by 1951.18 Saskatche wan’s per capita expenditures on mental health patients were the highest in Canada.19

26. The first 500-hour psychiatric nurse training program in Canada, 1947 Psychiatric nurses had traditionally trained “on the job.” In 1930, a more formalized “ward attendant” training program began in Saskatchewan.20 Dr F.S. (Sam) Lawson, director of the Saskatchewan Hospital, Weyburn (figure 9.2) wished to upgrade

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Figure 9.2 Dr F.S. Lawson (sdcmh)

the training of attendants to support more expert and humane care for the patients. Supported by McKerracher (and following recommendations in the Sigerist report), Lawson in 1947 devised a three-year (500-hour) program, one or two hours of lectures each day from October to June, to upgrade the training and status of the caregivers.21 Those who completed the course successfully earned a Registered Psychiatric Nurse (rpn) diploma.22 The graduates from this program eventually formed “about 90% of the psychiatric nursing staff” in the two large mental hospitals and tended to be “the most stable members of the community psychiatric team,” remaining for longer periods. Registered Psychiatric Nurses throughout the province provided continuity of patient care, made regular home visits, demon-

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strated a genuine concern, and fulfilled “the traditional helping role.”23 Dyck recorded instances of women coming to Weyburn to take the course, drawn by both the expanded role of women as psychiatric nurses and the provincial system of loans and bursaries to support the training.24

27. The first Psychiatric Nurses Act in North America, 25 March 1948; first Psychiatric Nurses Association in North America, 1948 On the heels of the move to formalize psychiatric nurse training, Saskatchewan enjoyed two more firsts: it shepherded the creation of the Psychiatric Nurses Act, a North American first, in 1948, which led to the first Psychiatric Nurses Association, which registered psychiatric nurses.25

28. The first provincial government to emphasize and fund psychiatric research, 1950s The change toward improving psychiatric care and mental health led to Saskatchewan’s revised Mental Health Act, passed in 1950. It classed mental health as a medical function,26 giving doctors a supportive base for medical intervention. The 1950s spawned a new era of experimentation and research, with Saskatchewan in the lead. Medical historian Dr John Mills asserted that Saskatchewan was the first jurisdiction to commit to a fully funded, provincewide program of psychiatric research, which was comprehensive in humane treatment of mental illness.27 Dyck notes that the 1950s were a period of “unbounded optimism” toward psychiatric research, where McKerracher “nurtured novel perspectives in mental health.”28

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the first province to explore psychedelic therapy, 1953–63

Two of the most innovative researchers facing the challenge of treating mental illness on an equal basis with other medical concerns were Dr Abram Hoffer and Dr Humphry Osmond. Hoffer, a native of Saskatchewan, came to medicine by way of agriculture, through biochemistry. He became the director of the provincial psychiatric research program.29 Hoffer, “an outstanding physician and researcher,” supported “adventurous, questioning, experimental, and optimistic attitudes at a time when they had been lacking.”30 Osmond, a Brit, was baptized as a physician during the Second World War. The war taught him that mental illness could be just as damaging, and sometimes more so, than physical stressors. He began, with his colleague John Smythies, to research mescaline, a chemical substance derived from the peyote cactus plant. The two of them also began working with d-lysergic acid diethylamide (lsd) to induce hallucinations not unlike those suffered by schizophrenic psychotic patients. Osmond came to Weyburn, Saskatchewan, in 1951, first as clinical director and then as medical superintendent at the Saskatchewan Hospital. He pursued his research studies in the bold Saskatchewan medical environment.31 By explaining mental illness as a metabolic dysfunction,32 Osmond and Hoffer were among an elite group of psychiatric researchers intent on researching drug therapies to alleviate psychotic symptoms. But the Saskatchewan experiments underscored more than a simple biochemical connection: mental illness and mental health involved both biological and social considerations. The lsd experiments fused the two.33 The “psychedelic” experience as therapy, as it became known, was

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Figure 9.3 Dr D. Griffith McKerracher (McKerracher Centre, Saskatoon Health Region)

a Saskatchewan first, but has failed to achieve acceptance by psychiatrists.34 29. The first open psychiatric ward that included psychotic patients in a general teaching hospital in Canada, 1955 On 1 July 1955, Dr McKerracher took the post of Head of the Department of Psychiatry, University of Saskatchewan and Dr Lawson took over as Director of the Psychiatric Services Branch of Saskatchewan.35 When the university hospital opened its doors in 1955 in Saskatoon, psychiatric patients were treated almost exactly as were those on medical and surgical wards, being free to visit the cafeteria and obtain passes to visit outside the hospital. Windows were not barred. No one was re strained. From 660 admissions, psychiatric patients left the

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ward without permission on seventy-seven occasions; forty-four returned of their own accord, fifteen were returned by relatives, eight by police, and six by hospital staff.36 McKerracher (figure 9.3), admitted ninety unselected patients who had been committed to the Saskatchewan Hospital at North Battleford and concluded that almost all mentally ill patients could be treated in a general hospital.37 Family practitioners could visit their patients and some could take part in their care. The average length of stay was twenty-one days,38 much shorter than the average stay (18.2 years, often until death!) at North Battleford.39

30. The Saskatchewan Plan, a first in Canada, 1956 Despite advances, the situation at the Saskatchewan Hospital, Weyburn, was appalling. Overcrowded and unclean, it was symbolic of the old institution-style incarceration methods. To address these conditions and find new solutions, in 1956, Dr Sam Lawson and Regina architect Kiyoshi Izumi boldly presented their theoretical and unproven plan, named “The Saskatchewan Plan.” The Saskatchewan Plan hoped to keep patients closer to their families through building eight or more small regional cottage hospitals designed by Izumi. Sam Lawson wrote in 1958: “The older concept of the mental hospital as an asylum where the mentally ill could be stored out of harm’s way is no longer acceptable.”40 Lawson and Izumi presented their plan to a meeting of the American Psychiatric Association Mental Hospital Institute in Denver, Colorado.41 Dr John Mills believes that Sam Lawson, Griffith McKerracher, and Humphry Osmond (figure 9.4), the three senior psychiatrists at Weyburn, developed the plan through study and many long discussions,

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Figure 9.4 Dr Humphry Osmond (sdcmh)

during the year or two before McKerracher accepted the headship of psychiatry at the new medical college in Saskatoon. Lawson expected that construction of the first regional cottage hospital, a radical departure in function and architecture and designed to “give the patients living conditions that are as near those of domestic living as possible,”42 would begin in Swift Current in 1957, but it was delayed by four years and was then built in Yorkton instead.43 At the Yorkton facility, Lawson explained, “all patients from one district are seen by the same team,” thus providing “continuity of care.”44 The cottagestyle Yorkton unit with 148 beds proved to be larger than required. It was the only one of the planned eight hospitals that was built; although the second was authorized for Prince Albert in 1965, that promise was never kept.45 In many ways, the Saskatchewan Plan hoped to reverse the missed opportunity

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to develop humane regional cottage hospitals first proposed by Dr Low in 1908. In striking contrast to the jail-like treatment in North American mental hospitals with large wards, where some patients were naked and others were kept in restraint, cottage hospital operation would be governed by the following six principles: 1 No human being should be incarcerated in an institution when any better solution can be found. 2 The mentally ill should have an equal standard of care to that given to the physically ill. 3 The continuity of care which is provided to the physically ill should also be provided to the mentally ill. 4 There should be integration of psychiatric care with general medical and surgical care. 5 Comprehensive care in the patient’s home area should be made available. 6 In-patient facilities should be designed in such a way that they assist the patient’s recovery.46 The key to the Saskatchewan Plan, as enunciated by McKerracher, was “community service, especially follow-up … through a home-care program.”47 the first psychiatric ward to invite a general practitioner to treat mentally ill patients, 1957

Dr Abe Voth was the first (1957) and Dr Wilf McCorkell (1958 through 1 July 1961) the second family practitioner allotted two beds on the psychiatric ward of the new university hospital in Saskatoon.48 Each had an interest in mental illness, attended psychiatric teaching rounds, and was asked by other family prac titioners to see their patients. McKerracher said that McCorkell

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“participates in teaching with unusual success.”49 McCorkell published his experiences in treating sixty-four psychiatric patients.50 His patients were discharged in an average of twenty-one days, although twenty-one of the sixty-four returned for further treatment.51 Both Voth and McCorkell, from their contact and training, became more confident in dealing with mental patients in subsequent office practice.52 The innovative advances in psychiatric care and clinical research in Saskatchewan had dramatic results. The numbers of in-patients at both Saskatchewan Hospitals declined. Between 1963 and 1966, psychiatric residents at Weyburn declined from 1,519 to 421, a 72 per cent reduction. Dr John Mills contends that it was “the highest rate of de-institutionalization ever recorded in any mental institution anywhere in the world.” Many of the discharged patients were initially “placed in approved homes under the overall supervision of psychiatric nurses.”53 Such de-institutionalization is the hallmark of contemporary psychiatric care.

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CHAPTER 10

H I G H - V O LTA G E C A N C E R T R E AT M E N T

Saskatchewan was slow off the mark in using radiation to treat cancer but, once up to speed, it led the world. As with the initial provision of radium in 1932, high-voltage treatment could be available only with government support. In 1922, Dr Ellice McDonald,1 a Saskatchewan man who had been raised at Fort Qu’Appelle2 and later specialized in cancer research at the University of Pennsylvania, visited University of Saskatchewan president Dr Walter Murray. McDonald informed Murray that the province of Quebec had just purchased a gram of radium for $75,000 and suggested that Saskatchewan should take similar action. In response, Murray wrote to Saskatchewan Premier Charles A. Dunning on 6 October 1922 to offer the services of university physicists if the province should decide to follow Quebec’s example and offer cancer treatment to its citizens.3 Dunning replied that the province’s higher health priority was tuberculosis.4

High-voltage Cancer Treatment

31. The first cancer control agency in Canada, 1930, with government-sponsored cancer clinics, 1931 In 1929, the Saskatchewan Medical Association formed a Cancer Committee. This committee proposed the establishment of a voluntary lay-medical Canadian Society for the Control of Cancer, which gradually developed into today’s Canadian Cancer Society.5 The Saskatchewan Cancer Committee enlisted Dr E.L. Harrington (figure 10.1), professor of physics at the University of Saskatchewan, as their only non-medical member.6 Harrington’s advice led to the drafting of the Saskatchewan Cancer Commission Act, passed by the Conservative government of J.T.M. Anderson in 1930.7 This act established the first cancer control agency in Canada and probably the first in North America. North America’s first government-sponsored, part-time (two mornings a week) consultative, diagnostic, and treatment clinics were staffed by radiologists: Dr Earle E. Shepley (figure 10.2) at the Saskatoon City Hospital (beginning in 1931),8 and Dr Clarence M. Henry at the Regina General Hospital (1932).9 Patients were treated with what were then called “high-voltage” machines, operating at 400 kilovolts peak.10 Treatment and hospitalization were the financial responsibility of the patient,11 but the government funded the equipment.

32. The first cancer registry system in Canada, 1932 In 1931, Dr Shepley visited the leading cancer centres, particularly the Cancer Institute in Philadelphia, operated by Ellice McDonald, and the New York Memorial Hospital, under Dr James Ewing. On his return, Shepley submitted to the Sask atchewan Cancer Commission a thoughtful document, “The

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Figure 10.1 Dr Ertle L. Harrington (University of Saskatchewan Archives)

Figure 10.2 Dr Earle E. Shepley (A. Becker)

Essentials of an Ideal Cancer Policy.” In the following year, the Saskatchewan Tumour Registry began, requiring compulsory reporting of all new cancer cases. It was the first cancer registry system in Canada.12 The Saskatchewan government allocated $115,000 for the purchase of radium in 1931, an extraordinary measure given

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Figure 10.3 Dr Allan W. Blair (sab r-b11015)

the fiscal constraints of the Great Depression.13 From the university, Dr Harrington distributed radon to each of the cancer clinics in small gold tubes or “seeds” which had a 3.8-day halflife. Harrington was a proficient and enthusiastic glass-blower who built and operated the radon plant from 1931 until 1962, extracting the radioactive gas emitted by radium in solution.14 The average number of patients referred per year to the two clinics increased, from 575 to 735 to 1,065, in the first four three-year periods until the end of 1943. In 1939, Dr Allan W. Blair (figure 10.3), a Regina boy, a graduate of McGill University, and a radiotherapist at the Toronto General Hospital, took over as director of the Regina cancer clinic.15 On 1 April 1944, the outgoing Liberal government of W.J. Pat terson, under pressure from Dr George Dragan, who had been a backbench Liberal member from Kelvington in the eighth legislature, proposed a bare-bones cancer bill, An Act Respecting the Control and Treatment of Cancer. The bill died on the floor as the ninth legislature prorogued, leading to an election.

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33. The first Cancer Control Act in North America, 1944 Following the landslide victory of the ccf on 15 June 1944, T.C. Douglas lost no time. Dr Blair was promoted to director of cancer services for the province. The first session of the legislature began on 19 October and ended on 10 November 1944. High on the Douglas agenda was the Cancer Control Act, which passed in October. Any person who had resided in the province for three months was now eligible for all services necessary for the diagnosis and treatment of cancer, without charge.16 The program was paid entirely from government revenues and took effect 1 January 1945, at the same time as the new Social Assistance Care plan (see chapter 5). With free treatment, between 1944 and 1946 the number of patients jumped twofold to reach 2,626 in 1946.17

34. Canada’s first full-time cancer physicist, Harold Johns, 1945 Blair was extremely foresighted in his recognition that the radiation treatment program would benefit from a full-time radiation physicist. Blair’s first letter, dated 12 December 1944, to Dr Harrington at the university, suggested that a full-time physicist be hired jointly by the Saskatchewan Cancer Commission and the university. Six days later, Harrington replied, offering full co-operation. On 25 March 1945, Harrington hired Dr Harold E. Johns (figure 10.4) for this joint position, with the rank of assistant professor, at $3,600 per annum. Johns was a thirty-year-old instructor at the Radar School at the University of Alberta, working for Canada’s war effort. He had received his bachelor’s degree in physics from McMaster University in 1936, his master’s from the University of Toronto in 1937, and

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Figure 10.4 Dr Harold E. Johns (sca)

his PhD from Toronto in 1939.18 In his previous work at Edmonton, Johns had used a radium source to obtain industrial photographs of steel propeller shafts to search for metal fatigue, a very early example of industrial radiography. In Saskatchewan, he was to give “half his time to supervision of the radium and x-ray therapy equipment of the two cancer clinics.” Johns later told Lauriston Taylor19 that he thus became Canada’s first full-time cancer physicist.20 In May 1946, Johns was given a travelling scholarship of $800,21 which allowed him to visit, by train, the leading radiation physics centres in Canada and the United States. While in Toronto, he attended a series of lectures given by Professor M.V. Mayneord, a senior medical physicist from the Royal Cancer Hospital in London, England. Mayneord, probably the first to do so, mentioned the possibility of using cobalt-60 as a radiation source. Harrington picked up on the idea; the next year

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in his presidential address to the Chemical, Mathematical and Physical Sciences Division of the Royal Society of Canada, he predicted that cobalt-60 “may become a more suitable source than radium itself in the treatment of cancer.”22 Meanwhile, Johns returned home in 1946 with the conviction that another type of high-energy radiation source under development, the betatron, offered immediate promise. After a quick visit to Premier and Health Minister Douglas in Regina (see introduction), Johns and Blair asked for a betatron of perhaps 35 MeV. The first 2.3-MeV betatron had been built in 1940 by Dr D.W. Kerst at the University of Illinois in Urbana and a 20-MeV prototype had then been built in 1942, based on the preliminary work of Dr Lester Skaggs. University of Saskatchewan President James S. Thomson wrote to Blair on 18 November 1946: “I called last week upon Dr C.J. Mackenzie, President of the National Research Council, to discuss with him the use of a betatron in connection with the cancer treatment in this province. Dr MacKenzie … expressed some doubts as to whether research was fully advanced to make such a project practicable … Matters affecting the use of atomic energy are really under the control of the Atomic Energy Commission of which General A.G.L. McNaughton is the chairman.” It did not hurt the cause that McNaughton was a native of Moosomin, Saskatchewan.23 Blair’s reassuring letter to Mackenzie on 11 December 1946 was the cornerstone of all future developmental research in radiation therapy: “It is not planned to use it for any actual treatment until the physical measurements have been completed to everyone’s satisfaction.” This time-consuming attention to fine detail by Saskatoon physicists allowed those in another province, without such scruples, to, five years later, be the first to treat a patient with cobalt-60.

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Meanwhile, other centres viewed the progress in Saskatchewan with suspicion. Harrington indicated their concerns in a letter to University of Saskatchewan President James S. Thomson on 20 February 1947: In the earliest part of the discussion regarding the betatron, it appeared that a certain member of the Atomic Energy Commission, to which this matter must be referred for decision, had expressed the belief that if the reason for the betatron was mainly medical it would be in the interest of the country as a whole to locate it in a large medical centre, say, in Toronto. In the mind of Dean Mackenzie, the chance of obtaining a favourable action on our request for this equipment would be better if any possible uses in medicine of the betatron were given but little emphasis.24 The price tag for the betatron was high – $80,000. The Atomic Energy Control Board provided $30,000. Johns was disturbed because this amount was insufficient, but Blair was jubilant. “Spend that money, Johns,” he said, “When it is gone more will be found.”25

35. The first concerted clinical use of the betatron in the world, 1949 On 3 May 1948, Johns, accompanied by Drs R.N.H. Haslam and L. Katz of the physics department, arrived in Milwaukee to examine “their” betatron. Where else could an agricultural province have found a manufacturer of heavy-duty machines more suitable than an agricultural equipment company, in this case, Allis-Chalmers in Milwaukee, Wisconsin? Johns wrote back to Blair on 12 May 1948:

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The betatron is finished but has not been tested. The machine which we are getting is the one ordered by the University of Pennsylvania, but they have no building finished to house it and have allowed us to have it … Professor Kerst has been more than cooperative. First he introduced us to all his men and gave us full access to all blueprints, all reprints, keys to the building … Kerst then presented us with two donuts [sic] for nothing and one electron donut for a nominal sum … Kerst is amazed at the rapidity with which we have pursued our program and in the fact we are getting the first betatron to be installed in any university or hospital … The University of Illinois medical school gets the third betatron (second to the University of Pennsylvania) and I heard yesterday that the University of California is getting one, at Berkeley.26 The 24-MeV betatron was installed in the physics department at the University of Saskatchewan that summer (figure 10.5). In keeping with the earlier promise, about seven months were spent in meticulous calibration of this machine for its first use, and dose distribution measurements were ongoing.27 The first patient was treated on 29 March 1949.28 Sadly, Dr Blair (Saskatchewan’s director of cancer services) did not live to see this historic day: he suffered a sudden and untimely death from a heart attack on 9 November 1948. As Milford D. Schultz said of this Saskatoon machine in his historical review in 1975, “Thus started the really first concerted clinical investigation of the usefulness of multimegavoltage as a radiotherapeutic tool.”29 The location of the betatron, in the physics department on the university campus, meant that patients were brought across the river from Saskatoon City Hospital and then across the campus. Even after University Hospital was completed on campus

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in 1955, there were still difficulties in transporting patients outdoors for a distance equivalent to several city blocks. The operating costs of the betatron were also exorbitant. Dr T.A. Watson (figure 10.6), head of radiation oncology at the University of Saskatchewan, reported on 10 November 1949 to Dr O.H. Warwick of the National Cancer Institute that each betatron tube or “doughnut” cost $3,800 (figure 10.7). Although “guaranteed” to last for 150 hours, “No doughnut which has so far been used has lasted nearly as long as this … [T]he cost of the doughnut alone is $25.70 an hour … eleven patients were treated at an average cost of $224 per patient.” In seventeen years, only 301 patients were treated with the betatron.30

Figure 10.5 Betatron (sca)

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Figure 10.6 Dr T.A. Watson (sca)

Figure 10.7 High-energy tube or “doughnut” (sca)

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Nevertheless, as with any high energy source, the betatron offered “a method of delivering easily a high dose to tumours at a depth, without appreciably affecting the overlying skin … Radiation sickness and blood changes are much less likely.”31

36. The first use of calibrated cobalt-60 in the world, 1951 In June 1949, Johns, keen to develop cobalt-60 as a more economical source of high-energy radiation, visited the Chalk River reactor in Ontario, the only installation in the world then capable of producing large quantities of radioactive cobalt. There he visited with Drs A.J. Cipriani and W.B. Lewis of the Atomic Energy Project. On 15 July 1949 Johns wrote to University of Saskatchewan President W.P. Thompson, asking for an effective source of 1,000 curies of cobalt-60, about 100 times the activity of any radium unit. Johns asked for “between $2500 and $7000 to cover the total cost of construction.” Johns, Cipriani, and Lewis agreed that this project would receive greater priority if it were considered as a research project, not a cancer treatment project. Saskatchewan’s simple two-page, three-copy application for the isotope was sent to the National Research Council at Chalk River on 13 August 1949.32 It was a timely application. Three radioactive cobalt sources were placed in the Chalk River pile to “cook” in the fall of 1949.33 Saskatchewan received Chalk River’s first cobalt source on 30 July 1951 and the University of Western Ontario received its source on 16 October of that year. These dates are of crucial importance, as will become evident. The third source was released for use in the United States in 1952. Each cobalt source was 2.5 cm in diameter and 1.25 cm thick. Sybil Johns, Harold’s wife, later described these as “a little half-

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inch stack of these cobalt discs about the size of a quarter.”34 As Johns had forecast, the approximate strength was 1,000 curies, or 37 GBq. The Saskatoon unit was designed by Johns and Lloyd Bates, a graduate student, and was built by Johnny MacKay, the proprietor of Acme Machine and Electric in Saskatoon. It was installed in Room 167 in the newly constructed cancer wing of University Hospital, adjacent to the medical college, on 17 August 1951. The room was hardly ready for use: the walls were still being plastered and the concrete floor had not yet been poured. Rigorous depth-dose measurements, using phantoms, soon began.35 The unit, weighing approximately 0.9 tonnes, consisted of a steel-encased cylinder suspended from an overhead carriage. A rotating, circular platform, flush with the floor, permitted rotation therapy (figure 10.8). A variety of treatment fields could be obtained by using interchangeable lead plugs, developed and manufactured by MacKay. In order to turn the machine on and off, Johns and MacKay in essence reinvented the wheel (figure 10.9). The radioactive cobalt source was mounted on the circumference of a wheel near the centre of the head. By rotating the wheel, the source could be moved 180 degrees from its shielded resting position until it was opposite an opening through which the radiation emerged.36 The Saskatoon Star-Phoenix on 18 August 1951 printed a photograph of the installation (figure 10.10). The Saskatoon unit was officially commissioned on 23 October, but even more rigorous measurements were continued until 8 November, when the first patient was treated by Watson. Watson modestly but sincerely downplayed attempts to publicize the importance or the priority of Saskatoon’s achievement, saying this was “merely a device that might provide more efficient and economical cancer treatment.”37 Steadfast to scientific integrity, being first

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Figure 10.8 Cobalt-60 unit with Sylvia O. Fedoruk (sca)

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Figure 10.9 Diagram of Cobalt-60 (sca) Figure 10.10 Installation of Cobalt-60 (sca and Saskatoon Star-Phoenix)

was not important to any of the Saskatoon players, whereas London seems to have viewed it as a race to be won at almost any cost. Eldorado Mining and Refining had completed the second unit for installation at Victoria Hospital in London, Ontario, on 23 October. Their unit, using a somewhat different design, consisted of a head pivoted between the arms of the horizontal “Y”

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that could be raised and lowered. The beam was turned on and off when a pool of mercury was introduced between the source and a conical opening in the head. The field size was varied by means of four lead blocks at right angles to each other. This was the prototype of the Atomic Energy of Canada Limited (aecl) cobalt unit.38 Dr Ivan H. Smith quickly treated the first patient in London, Ontario, on 27 October, four days after installation. The first cobalt treatment at London was widely publicized in the Canadian press. The Saskatoon Star-Phoenix commented on the “cobalt race” in an editorial on 7 November 1951: We hope Messrs Truman, Stalin, Peron, et al won’t think someone is trying to steal their thunder, but we think they ought to know theirs is not the only atomic race going on in the world. Another has been declared by The London Free Press which claims, editorially, “the world’s first cobalt bomb” for … the Ontario city. With all due respect to the preservation of national peace and goodwill, that is a boast which this newspaper cannot allow to go unchallenged – especially since the Free Press reports that “one is also being installed at Saskatoon, Sask.” One is indeed. Or, to be more accurate, one has been installed. Historians can assess the relative merits of the two claims. Suffice it to say that the first patient at London was treated with a machine that had not been calibrated. The patient had no hope of cure and died soon afterwards. The first patient at Saskatoon had advanced carcinoma of the cervix at age forty, unlikely to be cured by any treatment regimen then known. She received a precise dose to an exact area, with the radiation depth dose carefully plotted at each level. Not only was she cured of her

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cancer, but she lived to the advanced age of ninety years in Victoria, British Columbia. She died on 26 October 1998.39 London was first in the public relations competition, but would its methodology have passed an ethics committee? In retrospect, one might question the ethics of “treating” a patient with an approximate dose of radiation to an approximate area of her body, with an uncalibrated machine, and with little hope for palliation, much less cure. The Saskatoon group may have come out second in boasting to the public, but they were first in achievement and in promulgation of their results to the scientific world. The first formal publication giving details of cobalt therapy was from Saskatoon, not London. It was brief and to the point, much as Wilhelm Carl von Röntgen’s first published description of x-rays had been fifty-four years earlier.40 The authors of the report from Saskatoon, sometimes referred to privately and affectionately as the “Saskatchewan mafia,” were H.E. Johns, L.M. Bates, E.R. Epp, D.V. Cormack, and S.O. Fedoruk, all from Saskatchewan, and three University of Saskatchewan physics graduates (A. Morrison, W.R. Dixon, and C. Garrett), working at the radiology laboratory in the physics division of the National Research Council in Ottawa. Their paper was fasttracked and appeared in print in London, England the very next month, December 1951. The paper describes both Canadian cobalt units and concludes, “The cobalt units are flexible, simple to operate, and should require little servicing. They may prove to be very convenient sources of high-energy radiation.”41 A second paper by the same authors appeared in Science in March 1952.42 More detailed papers on depth doses and use of the two units and the Saskatchewan betatron filled an entire issue of the Journal of the Canadian Association of Radiologists

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in March 1952. The Saskatchewan cobalt-60 depth-dose data43 were included in a regular issue and a special supplement to the British Journal of Radiology in 1951 and 1952. Additional Saskatoon contributions to dosimetry appeared in other American, British, and Swedish radiology journals. Sylvia’s July 1951 Master’s thesis (ma rather than MSc in those years) was titled simply “Depth Dose.” The Saskatchewan-based depthdose charts were on the walls of active radiotherapy departments throughout the world.44 Johnny MacKay of Acme Machine and Electric turned his attention to designing a new collimator system, whereby a large number of interleaved diaphragms replaced the lead plugs, to direct the rays precisely (figure 10.11). MacKay’s small engineering firm in Saskatoon produced these collimators for over

Figure 10.11 Collimation apparatus for Cobalt-60 (sca)

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100 Picker Cobalt units that were distributed around the world. The original Saskatoon cobalt-60 unit treated 6,728 patients over twenty-one years until finally it was replaced by a commercial aecl cobalt-60 machine in 1972. Since the cobalt-60 unit was compact and economical to purchase and maintain, it became the “workhorse” for high-voltage radiotherapy for thirty years. By 1984, there were about 2,500 cobalt-60 units in routine use in the free world, 1,500 of which had been built in Canada by aecl.45 These machines remain the only affordable radiotherapy option in some third-world countries. liver and whole body photoscanning

Sylvia Fedoruk was a pioneer in nuclear imaging. She modified a Reed Curtis scanner to image the size and shape of the liver in 250 patients, the first images of isotope liver scanning published in the world’s most prestigious medical journal, the New England Journal of Medicine46 in 1960. Sylvia Fedoruk47 and Doug Cormack supervised Trevor Cradduck for his MSc thesis in 1962, for which he constructed a whole-body rectilinear scanner.48 That scanner was soon joined by the first gamma camera in Canada, designed by Sylvia Fedoruk and Trevor Cradduck in collaboration with Nuclear Enterprises of Winnipeg, and installed in the Saskatoon Cancer Clinic in 1964.49 Fedoruk also served on an International Commission on Radiation Units that recommended, in the late 1960s, use of modulation transfer function (mtf) as the most appropriate means of measuring collimator resolution for both rectilinear scanners and gamma cameras. mtf was regarded as the standard into the 1970s.50 Although Fedoruk’s nuclear medicine research tended to be forgotten, in October 2012, the year-old, 47-million-dollar

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Figure 10.12 Photoscan of normal liver (Sylvia Fedoruk collection)

Canadian Centre for Nuclear Innovation at the University of Saskatchewan was posthumously named in her honour. As Sylvia Fedoruk and I wrote in our chapter in the book produced to celebrate the 100th anniversary of Röntgen’s discovery of the x-ray: “Though born of war-time nuclear research, the cobalt bomb was in practice a ploughshare rather than a sword, and a largely Canadian contribution to medical care. With its flair for trend-setting performance in medicine, Saskatchewan had led the way.”51 Yes, indeed, Saskatchewan had led the entire world!

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EPILOGUE

The ccf government, from its election in 1944, had a clear goal: to build on Saskatchewan’s unique fifteen years of free diagnosis and treatment of the most expensive disease, tuberculosis, by adding health care for pensioners and widows, for those with cancer and mental diseases, and then provincewide hospitalization. These represented step-wise progressions from innovative policy formation, a view of community-based health and wellness, direct attacks on insidious diseases, to psychedelic experimentation – always within the annual provincial budget. Success in provincewide hospitalization as well as the example of the Swift Current Health Region became models upon which to build the gift for which both Saskatchewan and ccf Premier Tommy Douglas are now famous: universal medicare. The introduction of medicare became one of Saskatchewan’s defining moments.

Epilogue

the first universal medicare in north america, 1962

Medicare became law in Saskatchewan on 1 July 1962. It was a tumultuous time. Inadequate communication and bad timing between the physicians and the government bred misunderstanding and confrontation, which led to an action not contemplated by the government: withdrawal of services by the great majority of doctors. Each side, government and medical profession, “was convinced of the legitimacy of its role, the rightness of its goals, and of its power to achieve them.”1 My father, Dr C.J. Houston, believed that the impasse resulted first from the misguided attempt by the medical profession to use advertising to influence the 1960 provincial election. The doctors hired a public relations firm from central Canada, possibly more experienced in selling soft drinks or motor cars, who had no understanding of the Saskatchewan psyche, or the inappropriateness of such an intervention from a professional group. Dr Noel Doig’s recent book, Setting the Record Straight: A Doctor’s Memoir of the 1962 Medicare Crisis, refers repeatedly to the harmful effects of political intervention by a profession.2 Tommy Douglas had been minister of health from 1944 to 1949, but gave up the health portfolio on 14 November 1949. T.J. Bentley, who succeeded Douglas as minister, changed tack. He wished the health scheme to be under the direct control of the Department of Health, not an independent commission. Relations had been changing, hardening between the doctors and the department. Douglas and his ministers, when they put forward the medicare plan, “believed – indeed, were confident – that a consensus could be achieved”3 between the College of Physicians and Surgeons and the government over the details of the plan. But Douglas, by 1961 had resigned to lead the federal ndp and was succeeded as premier by Woodrow Lloyd. My father felt that Douglas, had he remained premier, would have

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permitted a commission rather than allow the doctors to carry out their threat to strike. Given his previous experience during the give-and-take setting up the Social Assistance Plan, Dad was sure that, if an arm’s length commission with representatives from both sides had been established, the doctors might have agreed to certain payment schedules, including a cap on fee-forservice or a prorated schedule of fees per year. During the dispute, Douglas’s previous unequivocal support for the commission model no longer seemed an option for Woodrow Lloyd. The withdrawal of medical services, the so-called doctors’ strike in July 1962, brought tension even to those outside the doctor-government divide. Mary Kirychuk and Sargent Mc Gowan of Paddockwood had a wedding date of 28 July 1962. Sargent later recalled: “This was the year of the doctors’ strike regarding the imposition of Medicare and there was concern about whether prospective couples could get blood tests which are essential prior to marriage. In this, as in so many others, the public ‘hue and cry’ was much greater than the actual threat and to my knowledge little real difficulty was experienced by people who were either physically ill or merely in love.”4 Under the distinguished arbitration of Lord Stephen Taylor, a socialist and a medical doctor, who shuttled back and forth between the government and representatives of the Saskatchewan College of Physicians and Surgeons, and earned the trust of both sides, the Saskatoon Agreement was signed on 23 July.5 One objective account of this trying time is provided in chapter 5 of Malcolm Taylor’s 1978 book.6 Although a public poll in 1965 still preferred a voluntary health plan, rather than a compulsory one,7 the doctors saw an immediate benefit: in 1963, Saskatchewan physicians’ incomes had quickly become the highest in Canada.8 Greg Marchildon and Klaartje Schrijvers

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noted that “the government was generally perceived to have won the strike.” But the truth supports a deeper victory for the doctors: “organized medicine was able to improve the economic position of its members even while it preserved the contractual system of remuneration and private practice, protected the role of physicians at the centre of the healthcare system, and prevented major changes to primary healthcare.”9 medicare in other provinces

The national initiative of Prime Minister John G. Diefenbaker, the Member of Parliament from Prince Albert, Saskatchewan, prepared the way for medicare in the rest of Canada. Diefenbaker appointed Mr Justice Emmett M. Hall, chief justice of Saskatchewan, to chair a commission. The other six members were not appointed until July 1961.10 The commission’s report was released on 19 June 1964. It recommended that “as a nation, we now take the necessary … decisions to make all the fruits of the health sciences available to all our residents without hindrance of any kind.”11 The medicare bill was not passed by the federal government until 16 December 1966. Federal medical care insurance program funding did not become available until 1 July 1968, the date on which the second province, British Columbia, joined. Manitoba, Newfoundland, and Nova Scotia joined in on 1 April 1969; Alberta on 1 July 1969; Ontario on 1 October 1969; Quebec, 1 November 1970; Prince Edward Island, 1 December 1970; New Brunswick, 1 January 1971; and the North West Territories and Yukon on 1 April 1972.12 Thus, it took almost nine years for medicare to reach all of Canada. Saskatchewan had led, not only in many steps on the road to medicare, but in the implementation of medicare itself.

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Epilogue

why did saskatchewan take the lead?

Medicare got its start in Saskatchewan because, as in the biblical parable, the seeds fell on fertile ground. In 1941, despite the scourge of the Depression, Saskatchewan still had the third highest population in Canada. Although stable, its status relative to the rest of Canada quickly declined: other provinces surged, and by 1961 Saskatchewan had fallen to fifth place.13 Despite (or perhaps because of) the “Great Divide” of the Depression, where people faced terrible choices due to extreme poverty,14 Saskatchewan consistently led all of Canada in public health innovations and legislation, including the many Canadian, North American, and world “firsts” recounted in this book. Even more remarkable were the two instances in which Saskatchewan led the entire world: the first provincewide hospital plan (1947) and the first provincewide medicare plan (1962). But why Saskatchewan? In a province without a large city, there were few rich people or powerful corporations. Rarely did people have surplus cash, but there was an abundance of good will, of trust in one another, of a willingness to help each other, and of a sense that lives could be improved through communal effort. Mutual co-operation among pioneer settlers was more the rule than the exception; it was better to do things together than separately. If a family had to build a barn, neighbours came to help raise the rafters. The entire community would turn out to build a curling rink. Throughout the twentieth century, community co-operation manifested itself in public ways; not only in health concerns, but also in the development of the farmer-owned and -operated Saskatchewan Wheat Pool, and politically through the creation and election of the social-democratic ccf party. Saskatchewan residents had a strong sense of justice and fairness. Honesty was the rule. Municipal politicians were forward-

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thinking and innovative, using and changing the municipal structure to full advantage to meet the needs of local residents. A high priority was given to health matters by the public, especially women. Church women set up hospitals, while farm women, through the Homemakers, the women’s section of the Grain Growers Association, the Red Cross societies, the iode, and the many union hospital auxiliaries (among others) underscored the connection between gender and health. Saskatoon provided an outstanding example when, in 1914, to combat the spread of bovine tuberculosis through milk, it became the first city in the British Empire to forbid the sale of raw milk. We suggest that the co-operative spirit of the predominantly rural Saskatchewan people, most of them immigrants from Europe, had been developed to a higher and more practical degree than in any other jurisdiction in North America. That community spirit was reforged in the fires of the Great Depression. In the face of immense economic, environmental, and social adversity, the world shifted. As the drought receded, war and postwar affluence brought a reordering of priorities. There was a willingness to try new social experiments, to pool the collective economic might for the social stability of all. The advances made in Saskatchewan required two ingredients: the co-operative spirit, as described above, and the individuals whose passion and direction became the catalyst. It is our thesis that without the unique community spirit, coupled with “the right person in the right place at the right time,” some or most of the events recounted here would not have come to pass. These leaders possessed unusual wisdom and prudence. Survivors of the Depression, severe drought, and dust storms (“the Dirty Thirties”), these men and women were more frugal than any group since and not in the least litigious. Much effort went unpaid. Every dollar went a long way. The people of

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Saskatchewan were, to use today’s term, proactive. Whether bureaucrat, politician, or scientist, each leader saw a need, gathered the evidence necessary for an informed decision, and then acted expeditiously. Nearly immediate response by government was then more the rule than the exception. Each visionary’s effort added to the foundation built by a predecessor. These were simple times, without red tape. The time was right. From a historical perspective, we can look back over the Saskatchewan events chronicled in this book and at least dream about returning to our roots. At the local level, think of the grass roots empowerment felt by the pioneers whose municipal taxes paid for innovative municipal doctors and hospital plans and contributed directly to tuberculosis control and the Swift Current Health Plan! Centralized control proved to have some down-sides. The loss of local control was brought home to me on 5 July 2002 when I was the guest speaker at the 100th anniversary of the Yorkton hospital. This hospital had a superb nursing training program from 1903 until 1969;15 the near-overflow crowd at the banquet was composed mainly of nurses who had trained in Yorkton and had gathered from across Canada to demonstrate their undiminished loyalty and esprit-de-corps.16 They still resent the closure of this successful program by centralists. Canada’s present nursing shortage (and the doctor shortage in rural areas!) were the predictable result of bad decisions and poor planning that were not evidence-based. Nurses have always been the backbone of the health care system. Provincially, consider the assumption by both Sigerist and Douglas that the medical school should be the linchpin of the health care system; the unstated corollary would be that it requires commensurate funding. As my father warned T.C. Douglas

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in 1946, medical schools are extremely expensive and a secondrate medical school would be worse than no medical school.17 Federally, funding of medicare would be less of a problem if the federal contribution were restored to the 50 per cent provided to each province in the early years, rather than the current figure, said to be about 14 per cent. Moving medicare forward may ask of us all, at each level, to learn from our history. Can we emulate the co-operative spirit, altruism, and ingenuity shown by Saskatchewan pioneers?

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NOTES

i n t roduc tion 1 Louis Horlick, “Medicare and Canadian Federalism.” In A.M. Herzberg and I. Krupka, eds., Statistics, Science and Public Policy. The Two Cultures? Proceedings of the Fourth Conference on Statistics, Science and Public Policy, Hailsham, UK, 1999 (Kingston: Queen’s University 1999), 153–8. 2 Lewis H. Thomas, The Making of a Socialist: Recollections of T.C. Douglas (Edmonton: University of Alberta Press, 1982), 372–3. 3 Eleanor McKinnon. “Open Door Policy,” in Ed and Pemrose Whelan, Touched by Tommy (Regina: Whelan Publications, 1990), 25. 4 A slightly different version of the story can be found in C.S. Houston and S. Fedoruk, “Radiation Therapy in Saskatchewan,” in J. Aldrich and B. Lentle, eds., A New Kind of Ray: The Radiological Sciences in Canada (Canadian Association of Radiologists, 1995), 153–4; and C.L. Greenstock, “From Szechuan to Saskatchewan,” 247–51.

Notes to pages 4–6

1

2

3

4

5

6 7 8

9 10

c h a pter o ne E.E. Rich, ed., The Publications of the Hudson’s Bay Record Society: Cumberland and Hudson House Journals 1775–82, Second Series, 1779–82 (London: The Hudson’s Bay Record Society, 1952), 228; 232–3. John W.R. McIntyre and C. Stuart Houston, “Smallpox and Its Control in Canada.” Canadian Medical Association Journal 161, 12 (14 Dec. 1999): 1543–7; C. Stuart Houston and Stan Houston, “The First Smallpox Epidemic on the Canadian Plains: In the Fur-Trader’s Words,” Canadian Journal of Infectious Diseases 11, 2 (March/April 2000): 112–15. Sally Clubb, Our Story: 75 Years of Caring (Saskatoon: St Paul’s Hospital, 1982), 2; Marguerite E. Robinson, The First Fifty Years (Regina: Saskatchewan Registered Nurses Association, 1967), 8. John Murray Gibbon and Mary S. Mathewson, Three Centuries of Canadian Nursing (Toronto: Macmillan, 1947), 214. Not until 1927 was a two-storey brick building, St Joseph’s Hospital, built at Ile-à-la-Crosse with government support. H.C. Jamieson, Early Medicine in Alberta (Edmonton: Douglas, 1947), 21; see also Marcel M.C. Dirk, A Healthy Outlook: The Centennial History of the Medicine Hat Regional Hospital (Medicine Hat: Holmes Printing, 1989). R.B. Deane, “Augustus L. Jukes, a Pioneer Surgeon,” Calgary Associate Clinic Historical Bulletin 2, 4 (1938): 1–4. Robinson, First Fifty Years, 8. Joyce Morgan and Barb Straker, “Medical History of Saltcoats,” in Saltcoats Roots and Branches (Saltcoats: Saltcoats and District Historical Society, 1982), 217–23. Robert Lampard, “Medicare: An Alberta Legacy,” Legacy May–July 1998: 34. Lewis Thomas, “Early Territorial Hospitals,” Saskatchewan

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Notes to pages 6–18

11 12 13

14 15 16 17 18 19 20 21

History 2, 2 (1949): 16–20. In the 1891 census the entire Medicine Hat district had a population of only 1,316. The Calgary hospital opened later in 1890 and the Lethbridge hospital in 1894. Gibbon and Mathewson, Three Centuries, 208. In 1901 there were 91,279 people in the area that was to become Saskatchewan in 1905. Personal copies of this large book, owned by each midwifery student in most English-speaking countries, were affectionately named “Maggie.” Robinson, First Fifty Years, 32, 39. Saskatchewan Department of Agriculture, Annual Report 1906 (Regina), 156–8. A. Becker, “The Lake Geneva Mission, Wakaw, Saskatchewan,” Saskatchewan History 29 (1976): 51–64. Clubb, Our Story, 6. Saskatoon City Hospital Golden Anniversary, 1909–1959 (Saskatoon: City Hospital, 1959), 18. Joan Feather and Vincent L. Matthews, “Early Medical Care in Saskatchewan,” Saskatchewan History 37 (1984): 41–54. Sister Yvonne Bezaire, Our Roots: A Promise (Saskatoon: Catholic Health Association of Saskatchewan, 1993), 4. C.S. Houston, “Early Saskatchewan Hospitals,” Annals of the Royal College of Physicians and Surgeons of Canada 23 (1990): 265–70.

c h a pter two 1 C.S. Houston, “Maurice MacDonald Seymour: A Leader in Public Health,” Annals of the Royal College of Physicians and Surgeons of Canada 31 (1998): 41–3, by permission. 2 Evelyn Eager, Saskatchewan Government: Politics and Pragmatism (Saskatoon: Western Producer Prairie Books, 1980), 147.

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Notes to pages 18–22

3 Seymour eventually became the Commissioner of Public Health, among other distinctions. See Statutes of Saskatchewan 1909 C. 8, Sec. 33; see also Robert I. McLaren, The Saskatchewan Practice of Public Administration in Historical Perspective, Studies of Health and Human Services, Canadian Studies Volume 19 (Lewiston, ny: The Edwin Mellen Press, 1998): 12–13. 4 M.M. Seymour, “Public Health Work in Saskatchewan,” Canadian Medical Association Journal 15 (1925): 276. 5 Brief from Society of Obstetricians and Gynecologists via College of Physicians and Surgeons to the Thompson Committee, in the files of C.J. Houston, Saskatchewan Archives Board (sab). 6 Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan, 1944–1964” (Master’s thesis, University of Regina, 1990), 6. 7 Seymour, “Public Health,” 274. 8 Ibid., 275. 9 Ibid., 277. 10 M.M. Seymour, “A Study of Milk Problems in Canada,” [Canadian] Public Health Journal 17 (1926a): 241–4, 295–301, 353–8, 394–404. 11 Ibid., 300. 12 M.M. Seymour, “The Seymour Plan,” [Canadian] Public Health Journal 17 (1926b): 593–6. 13 Seymour, “Public Health,” 275, 277. The Saskatchewan Department of Health Annual Report (1929: 95) again made the claim that Saskatchewan was acknowledged as still having the “lowest death rate in the Dominion and in the Empire.” Presumably the relative youth of newcomers was the main explanation.

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Notes to pages 23–8

14 Lillian Chase, “Maurice MacDonald Seymour,” Canadian Medical Association Journal 30 (1929): 212–13. 15 McLaren, Saskatchewan Practice of Public Administration, 12–13. c h a pter th ree 1 Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan, 1944–1964” (Master’s thesis, University of Regina, 1990), 16. 2 Holdfast History and Heritage Committee, Holdfast, History and Heritage (Author: 1980), 39. 3 Doris Hungle, “Medical Services.” In Holdfast, History and Heritage, 83–5. Dilke was the nearest village on the Regina side of Holdfast. 4 A vacancy was pending at Craik, population 427, about twenty miles west; the doctor there was about to enlist, and hoped that Schmitt could replace him (Mrs J.A. Dunn, “Our First Municipal Doctor,” Western Producer, 1 March 1962). 5 In the 1916 census, the population of Holdfast was 167, Chamberlain 138, Dilke 93, and Penzance 60. Initially, none of the inhabitants of the four villages was covered by the doctor plan. The rural population in rm Sarnia numbered 2,090; payment of taxes earned medical care from Dr Schmitt. 6 C.S. Houston, “Saskatchewan’s Municipal Doctors: A Forerunner of the Medicare System that Developed 50 Years Later,” Canadian Medical Association Journal 151 (1994): 1642–4, by permission. 7 Holdfast, History and Heritage, 83. 8 Arthur E. Childe was the municipal doctor for rm Victory #226 at Beechy. Present for only two years, he was nevertheless

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Notes to pages 28–33

9

10 11

12 13 14 15 16 17 18 19 20 21 22 23

24

remembered fondly thirty years later. He became Winnipeg’s foremost scientific radiologist, with special skills in pediatric radiology (my field) and neuro-radiology. D.S. Johnstone, “Report of the Committee re Municipal Physicians,” Canadian Medical Association Journal 17 (1927): xii–xiv. C. Rufus Rorem, The “Municipal Doctor” System in Rural Saskatchewan (Chicago: University of Chicago Press, 1931). Ibid., 13. Rorem came to Saskatchewan because of information that Alberta had only two municipal doctors and Manitoba, three. They operated under the provincial Rural Municipality Act of 1929, Secs. 168 and 169. Rorem, “Municipal Doctor,” 12, 16. Gordon Ferguson, “Income Tax and the Municipal Physician,” Saskatchewan Medical Quarterly 14, 2 (1950): 407–10. Rorem, “Municipal Doctor,” 61. Ibid., 62–3. Ibid., 61. Ibid., 74. W.W. Wheeler, “Where Doctors Send No Bills,” Reader’s Digest, July 1935: 75–7. Rorem, “Municipal Doctor,” 83–4. G.E. Britnell, “Saskatchewan,” Encyclopedia Canadiana 9 (1958): 205–28. Mombourquette, “A Government and Health Care,” 28–30. Gordon Lawson, “The Co-operative Commonwealth Federation, Health Care Reform, and Physician Remuneration in the Province of Saskatchewan, 1915–1949” (Master’s thesis, University of Regina, 1998), 38. R.G. Ferguson, “Report of [the] Committee on Economics,” Saskatchewan Medical Quarterly 2, 4 (1938): 12–18.

152

Notes to pages 33–6

25 Ibid., 15. 26 J.J. Collins, “Report of the Municipal Doctors’ Questionnaire,” Saskatchewan Medical Quarterly 5, 4 (1941): 11–24. 27 Health Services Board, Saskatchewan Medical Association, “Model Municipal Contract,” Saskatchewan Medical Quarterly 6, 2 (1942): 17–25. 28 Lawson, “Co-operative Commonwealth,” 131, 145; Advisory Planning Committee Special Document 2A, footnote 138 in Gordon Lawson, “The Road Not Taken: The Health Services Planning Commission Proposals and Physician Remuneration in Saskatchewan,” Canadian Bulletin of Medical History 26, 2 (2009): 426. 29 Joan Feather and Vincent L. Matthews, “Early Medical Care in Saskatchewan,” Saskatchewan History 37 (1984): 41–54. 30 Ibid., 47. The ten uhds were at Davidson, Edam, Eston, Kerrobert, Kindersley, Lloydminster, Lampman, Rosetown, Shaunavon, and Wadena. 31 Statutes of Saskatchewan, 1916, C.12; 1917, C.9; Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 71. 32 A.G. MacKay, Municipal Hospitals 1919 (Edmonton: Municipal Hospital Branch, 1919). 33 Arthur K. Whiston, Municipal Hospitals (Edmonton: Hospitals Branch, Department of Public Health, 1922). 34 Later, in 1948, hospital construction was further supported by federal funds from the National Health Grants Programme, the first federal initiative in health care. See chapter 8. 35 F.D. Mott, “Hospital Services in Saskatchewan,” American Journal of Public Health 37 (1947): 1539–44. 36 Feather and Matthews, “Early Medical Care,” 47. 37 Statutes of Saskatchewan: 1918–19, C.100, Sec. 2. The two rural municipalities named in the Saskatchewan legislation, of

153

Notes to pages 36–41

38

39

40 41

42 43

44

45 46

47

course, are both within Saskatchewan; Malcolm G. Taylor, “The Saskatchewan Hospital Services Plan” (PhD dissertation, University of California, Berkeley, 1949, mimeographed), 72. David Tuckwell wrote “Helping to Solve a Prairie Problem” about the Lloydminster experience in 1917, published in the Canadian Medical Association Journal 7: 800–3. Statutes of Saskatchewan: 1927, C.67, The Union Hospital Act, Sec. 2; 1936, C.37, The Village Act, Sec. 236; 1936, C.36, The Town Act, Sec. 8. Statutes of Saskatchewan: 1934–35, C.30, Sec. 245. C. Stuart Houston and Merle Massie, “Four Precursors of Medicare in Saskatchewan,” Canadian Bulletin of Medical History 26 (2009): 379–93. Taylor, Health Insurance, 72. sab files, sarm brief to Sigerist 25 September 1944; Stuart Houston, “Matt Anderson’s 1939 Health Plan: How Effective and How Economical?” Saskatchewan History 57, 2 (2005): 4–14; see also Houston and Massie, “Four Precursors of Medicare.” Merle Massie, “Red Cross Outpost Hospitals,” Encyclopedia of Saskatchewan (Regina: Canadian Plains Research Centre, 2005): 742; Merle Massie, “Ruth Dulmage Shewchuk: A Saskatchewan Red Cross Outpost Nurse,” Saskatchewan History 56, 2 (2004): 35–44. Taylor, Health Insurance, 72. Robin F. Badgley and Samuel Wolfe, Doctors’ Strike: Medical Care and Conflict in Saskatchewan (Toronto: Macmillan, 1967), 24. Taylor, Health Insurance, 72.

c h a pter fo ur 1 C.S. Houston, R.G. Ferguson, Crusader against Tuberculosis

154

Notes to pages 43–53

2

3 4 5 6 7 8 9

10

11

12

13

(Toronto: Hannah Institute and Dundurn Press, 1991), by permission Associated Medical Services Inc. through its Hannah Institute for the History of Medicine Program. A.B. Cook, R.G. Ferguson, J.F. Cairns, and R.H. Brighton, Report of the Saskatchewan Anti-tuberculosis Commission (Regina: J.W. Reid, King’s Printer, 1922). Helen Ferguson, “That a child might live,” Valley Echo 40, 12 (1959): 4–6. H. Boughton, “A.C.T. million dollar story,” Valley Echo 45, 3 (1964): 19–20. Saskatchewan Anti-tuberculosis League. Annual Report, 1942. Conveying formal membership in the prestigious Royal College of Physicians, thus allowing use of the initials mrcp. Houston, R.G. Ferguson, 58. Cook et al., Report … Anti-tuberculosis Commission. R.G. Ferguson, “A Tuberculosis Survey of 1,346 School Children in Saskatchewan,” Canadian Medical Association Journal 12 (1922): 381–3. G.J. Wherrett, The Miracle of the Empty Beds: A History of Tuberculosis in Canada (Toronto: University of Toronto Press, 1977), 35, 187. In 1922, the Canadian Red Cross provided funds for the Canadian Tuberculosis Association to undertake similar representative school surveys in the other provinces. G.J. Wherrett and S. Grzybowski, Report and Recommendations on Tuberculosis Control in Saskatchewan (Ottawa: Department of National Health and Welfare, 1966), 8. Jean B.D. Larmour, A Matter of Life and Breath: The 75-year History of the Saskatchewan Anti-tuberculosis League and the Saskatchewan Lung Association (Saskatoon: Saskatchewan Lung Association, 1987), 18, augmented by Dr Dudley G. Barnett, personal communication, May 2002. Houston, R.G. Ferguson, 81–2.

155

Notes to pages 54–63

14 15 16 17 18

19

20 21 22

23

24

25

26

27

Ibid., 83. Wherrett & Grzybowski, “Report and Recommendations,” 5, 6. Houston, R.G. Ferguson, 83. Ibid., 84. For an important recent look at tuberculosis, First Nations, and Saskatchewan, see Maureen Lux, “Perfect Subjects: Race, Tuberculosis, and the Qu’Appelle bcg Vaccine Trial,” Canadian Bulletin of Medical History 15 (1998): 277–95. R.G. Ferguson, “Tuberculosis Among the Indians of the Great Canadian Plains,” Transactions of the National Association for the Prevention of Tuberculosis 14 (1928): 625–45. C.S. Houston, “Ferguson’s bcg Research: Canada’s First Randomized Clinical Trial?” Investigative Medicine 16 (1983): 89–91. R.G. Ferguson and A.B. Simes, “bcg Vaccination of Indian Infants in Saskatchewan,” Tubercle 30 (1949): 5–11. R.G. Ferguson, “bcg Vaccination in Hospitals and Sanatoria of Saskatchewan,” Canadian Journal of Public Health 37 (1946): 435–51. G.D. Barnett, “Results of Mass Surveys in the Province of Saskatchewan, 1942–1947,” Canadian Tuberculosis Association Annual Papers 50 (1950): 33–6. Wherrett, Miracle, 255. Later, from 1941 through 1955, Ontario had the lowest tb death rate, except for 1944 and 1954, when Saskatchewan briefly regained the lead. Anonymous, Canadian Tuberculosis Association Bulletin 22, 2 (1943): 4; Wherrett and Grzybowski, Report and Recommendations, 7–8. Wherrett and Grzybowski, Report and Recommendations, 4. In Canada, only the Manitoba Sanatorium Board was similarly constituted. Ibid., 10.

156

Notes to pages 63–9

28 Larmour, A Matter of Life, 101–15. 29 Wherret, Miracle, 255. 30 R.G. Ferguson, Studies in Tuberculosis (Toronto: University of Toronto Press, 1955). 31 C. Smith, “Saskatchewan’s ‘Health Hero’ Enshrined in Hearts of People,” Saskatchewan Health Newsletter 15, 3 (1964): 2, 15. 32 V.H. Hoeppner, Life and Breath 1, 3 (August 1989): 4. 33 Houston, R.G. Ferguson, 134–6. 34 V.H. Hoeppner “Tuberculosis in Saskatchewan Treaty Indians,” Prairie Medical Journal 65 (1995): 18–20. 35 Dr Assaad Al-Azem, TB Control Saskatchewan, Public Health Services. 36 Hoeppner “Tuberculosis,” 19–20.

1

2

3

4

c h a pter five E.W. Barootes, “The Role of Saskatchewan in GovernmentSponsored Health Care: A Retrospective Review,” Annals of the Royal College of Physicians and Surgeons of Canada 24, 2 (1991): 117–19. Thomas H. McLeod and Ian McLeod, Tommy Douglas: The Road to Jerusalem (Edmonton: Hurtig, 1987), 112. This is a superb biography of Douglas. Jacalyn Duffin, “The Guru and the Godfather: Henry Sigerist, Hugh Maclean, and the Politics of Health Care Reform in 1940s Canada,” Canadian Bulletin of Medical History 9, 2 (1992): 191–218. During its final fifteen months in office, W.J. Patterson’s Liberal government had appointed two committees to study the possibility of health insurance. The bipartisan Select Special Committee of twenty-five Liberal and ccf mlas, chaired by Bamm Hogarth, a Liberal mla from Regina, had been appointed on

157

Notes to pages 71–3

5

6

7 8 9

10

11

2 March 1943; they gave an interim report on 12 April 1943 and a final report on 31 March 1944. The Saskatchewan Reconstruction Council, established on 20 October 1943, did not give its final report until August 1944, after the election. Sigerist made “extensive use” of the briefs presented to both groups (Gordon S. Lawson, “The Co-operative Commonwealth Federation, Health Reform and Physician Remuneration in the Province of Saskatchewan, 1915–1949” [Master’s thesis, University of Regina, 1998], 50–4). Dr Hugh MacLean, a Regina surgeon from 1913 to 1938, and ccf candidate in the 1935 federal election, advised Douglas to take the health portfolio (Duffin, “The Guru and the Godfather,” 191–218). Douglas phoned Sigerist first on 16 June. (Nora Sigerist Beeson, ed. & trans., Henry E. Sigerist: Autobiographical Writings [Montreal: McGill University Press, 1966], 187). Henry E. Sigerist, Socialized Medicine in the Soviet Union (New York: W.W. Norton, 1937). Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 88, 434. Also assisting Sigerist were Dr Mindel Cherniak Sheps, a family practitioner and Manitoba ccf executive member from Winnipeg, as secretary; Ann Heffel, a nurse; C.C. Gibson, a hospital administrator; and Dr J.L. Connell, a dentist. (Duane John Mombourquette, “A Government and Health Care: the Cooperative Commonwealth Federation in Saskatchewan, 1944–64” [Master’s thesis, University of Regina, 1990], 54.) Stuart Houston, “Matt Anderson’s 1939 Health Plan: How Effective and How Economical?” Saskatchewan History, Fall 2005: 4–14. C. Stuart Houston and Merle Massie, “Four Precursors of Medicare in Saskatchewan,” Canadian Bulletin of Medical History 26, 2 (2009): 379–93.

158

Notes to pages 72–7

12 13 14 15 16 17 18

19 20 21 22

23 24 25

26

27 28

Houston, “Matt Anderson’s 1939 Health Plan,” 10. Chapin, Report to shssc, 6 (sab R251 file 2 no. 21). Beeson, Henry E. Sigerist, 190. H.E. Sigerist, Report of the Commissioner (Regina: Health Services Survey Commission, 1944). Ibid., 5; also cited by Lawson, “Co-operative Commonwealth Federation,” 62. Houston, “Matt Anderson’s 1939 Health Plan,” n62. This figure was unrealistic, given that the average cost of hospitalization per capita in Saskatchewan had that year already reached $5.20, having risen from $1.93 in 1934 (Malcolm G. Taylor, “The Saskatchewan Hospital Services Plan” [PhD dissertation, University of California, Berkeley, 1949, mimeographed], 140.) Sigerist, Report of the Commissioner, 5. Cited by Taylor, Health Insurance, 434. Beeson, Henry E. Sigerist, 231. Lawson’s 1998 thesis explains how fee-for-service payment became entrenched, and why the ccf government chose not to follow the Health Services Planning Commission’s recommendation that doctors be placed on salary. T.C. Douglas to Dr J.L. Brown, letter reprinted in Saskatchewan Medical Quarterly 9, 3 (1945): 31–4. Taylor, Health Insurance, 87. Advisory Committee on Health Insurance, Report (Ottawa: 1942–43). This 558-page report was presented by Chairman J.J. Heagerty to the House of Commons in December 1942. F.B. Roth and R.B. DeFries, “The Saskatchewan Department of Public Health,” Canadian Journal of Public Health 49, 7 (1958): 276–85. Taylor, Health Insurance, 252. See chapter 8, n8. Ibid, 244.

159

Notes to pages 77–81

29 The Social Assistance Plan was administered by the Medical Services Division of the Saskatchewan Department of Public Health (ibid., 252). 30 Ibid., 252. 31 Mombourquette, “A Government and Health Care,” 119. 32 McLeod and McLeod, Tommy Douglas, 312. Thomas H. McLeod was a trusted economic advisor to T.C. Douglas. See A.W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961 (Toronto: University of Toronto Press, 2004), 61. c h apter six 1 Joan Feather, “From Concept to Reality: Formation of the Swift Current Health Region,” Prairie Forum 16 (1991a): 59. 2 Curtis McManus, Happyland: A History of the “Dirty Thirties” in Saskatchewan, 1914–1937 (Calgary: University of Calgary Press, 2011). 3 Hazlet Historical Society, Hazlet and Its Heritage (Hazlet, 1987), 1, 3. 4 Somewhat similar plans that, unlike the municipal doctor plans, allowed free choice of doctor, had begun in Alberta at Cardston in 1932 (Beryl Shaw, “Medicare in Cardston,” in Chief Mountain Country: A History of Cardston and District. [Cardston: Cardston and District Historical Society, 1987], 72–4), and at Lamont in 1933 where, for the first two years, “services exceeded payment five-fold” (Robert Lampard, “Medicare: An Alberta Legacy,” Legacy, May–July 1998: 34–5). The Cardston plan ran until 1968; Shaw failed to claim this as “the longest continuous, voluntary, prepaid medical insurance program in Canada for thirty-seven years” (Robert Lampard, Alberta’s Medical History: “Young and Lusty, and Full of Life” [Red Deer, ab, Published by Robert Lampard; printed by Friesens, 2008], 631–6).

160

Notes to pages 81–4

5 6 7 8 9 10 11 12

13 14

15

16

17

18 19 20 21 22

Houston and Massie, “Four Precursors,” 383. Feather, “From Concept to Reality,” 70. Houston and Massie, “Four Precursors,” 383–5. Webb History Book Committee, Prairie Memories (Webb, 1982), 62. Houston and Massie, “Four Precursors,” 385. Ibid., 386. Swift Current Sun, 25 August 1945. Syd Munt, “How Swift Current Region Was Organized.” (Mimeographed, 3 pages, 1946). As postmaster at Hazlet (Oct. 1943–Sept. 1950: Hazlet and Its Heritage, 61), Munt’s father, John, had handled the voluminous mail sent out by Burak the previous year. Munt, “How Swift Current Region,” 1. Lester Jorgenson, “Rural Municipality of Miry Creek No. 229 and Health Region No. 1,” in Bridging the Centuries (Abbey, sk: Miry Creek Area History Book Committee, 2000), 52–8. F.D. Mott, “Prepaid Medical Care under Governmental Auspices in Saskatchewan,” Canadian Journal of Public Health 41 (1950): 403–10. Munt, “How Swift Current Region,” 1. Burak met in person with Dave Belbeck of the Swift Current Sun, S.H. Gamble of the Gull Lake Advance, and W. Sharpe of the Shaunavon Standard. Burak attended council meetings at rm Grassy Creek #78 at Shaunavon, rm Arlington #79 at Dollard, rm Bone Creek #108 at Instow, rm Carmichael #109, and rm Gull Lake #139. Feather, “From Concept to Reality,” 72–3. Ibid., 74. T.C. Douglas, “The Doctor in Saskatchewan’s Health Plans,” Saskatchewan Medical Quarterly 9, 1 (1945): 24–31. Feather, “From Concept to Reality,” 74. Munt, “How Swift Current Region,” 2.

161

Notes to pages 84–6

23 Burak suffered a crushing personal disappointment when Stewart Robertson was appointed to the job that he had coveted. Burak moved out of the area permanently to become secretarytreasurer in other municipalities at Hafford, Ogema, and lastly rm Aberdeen #373. He died in Saskatoon on 8 June 1976. 24 Feather, “From Concept to Reality,” 74. 25 Pat Cammer, “Some Memories of the Beginnings of Health Region #1” (Typescript of speech given at the final Swift Current Health Region information meeting, Swift Current, 3 June 1993). 26 Feather, “From Concept to Reality,” 75. 27 Sadly, on 5 December 2001, a Ministry of Health bureaucrat in Regina, lacking any sense of history or justice, renumbered Saskatchewan’s health regions, from east to west. Swift Current was stripped of its historical right to continue a hallowed tradition as “Number One” – not only in Saskatchewan, but in all of North America. 28 Gull Lake was at first hesitant to join a health region and opposed the plan. It sought discussion and confirmation regarding financing. Letter, 25 September 1945, Town of Gull Lake to Ministry of Health. Files in Gull Lake town office. 29 Stewart Robertson, “New Horizons for Better Health.” In Winds of Change (Swift Current: Swift Current Health Region, 1966), 23–6. From the beginning the plan provided a dental program for children, although it was not fully implemented during the first two years. 30 The vice-president was Ken Rutherford, a school principal who was also mayor of Swift Current. In 1960, Ken was an unsuccessful ccf candidate in the 1960 provincial election in British Columbia. 31 Drs O.M. Irwin and R.R. Stirrett of Swift Current, Dr J.A. Matheson of Gull Lake, and Dr F.B. Dawson of Maple Creek. 32 Swift Current Sun 30 April 1946.

162

Notes to pages 86–8

33 Dr Lloyd Davey lasted seventeen months, resigning 30 June 1948. Pay was inadequate. Later, Peart was general secretary of the Canadian Medical Association, based in Toronto in 1966. 34 Dr Alan Gregg of the Rockefeller Foundation, when touring western Canada to examine medical services, visited the Health Services Planning Commission in Regina. In answer to the question, “In which countries are health services supplied to residents … under a plan sponsored by the State,” he answered: 1. Russia. 2. Peking [Beijing] China, for 200,000 people. 3. Swift Current Health Region No. 1. This story was related to the first annual meeting of Health Region No. 1 on 25 September 1947 by Carl Kjorven. 35 Apart from one leave, during which he still served part-time. 36 Fred D. Mott, “Prepaid Medical Care,” 403–10. Mott called this unique arrangement a “dual and yet co-ordinated program of community and personal health services.” 37 Vince Matthews was director, Medical and Hospital Services Branch, 1957–62; acting deputy minister, 1962–63; and associate deputy minister, 1963–64, Saskatchewan Department of Health. Thereafter he was professor and head, Department of Social and Preventive Medicine at the University of Saskatchewan. He retired and became professor emeritus in 1987 and died suddenly on 7 October 1988. 38 Swift Current Health Region, Winds of Change, 8. 39 McManus, Happyland. 40 Two surgeons, an obstetrician, and an anaesthetist. 41 J. Lloyd Brown, “Swift Current Health Insurance Scheme,” Saskatchewan Medical Quarterly 14, 2 (1949): 353–67. 42 Cammer, “Some Memories.” In April 1947, when she married Ross Cammer, a farmer west of Webb, Patricia Ditner left her position as Stewart Robertson’s secretary. 43 Dr Orville Hjertaas, interview by Maureen Matthews, “The

163

Notes to pages 88–92

44 45 46

47

48 49 50 51 52 53 54 55 56 57 58 59 60 61

Origins of Medicare,” Ideas, Canadian Broadcasting Corporation, 5 December 1990, transcript, 2. Cammer, “Some Memories.” Brown, “Swift Current Health Insurance,” 357. J.A. Matheson, O.M. Irwin, F.B. Dawson, and G.G. Ferguson, “Report of the Swift Current Health Region No. 1,” Saskatchewan Medical Quarterly 11 (1947): 21–5. E.A. Tollefson, Bitter Medicine: The Saskatchewan Medicare Feud (Saskatoon: Modern Press, 1964); Gordon Lawson, “The Road Not Taken: The 1945 Health Services Planning Commission Proposals and Physician Remuneration in Saskatchewan,” Canadian Bulletin of Medical History 26, 2 (2009): 395–427. Matheson et al., “Report of Health Region No. 1,” 24. Brown, “Swift Current Health Insurance,” 358. J.A. Matheson, “Swift Current Health Service,” Saskatchewan Medical Quarterly 14 (1950): 368–70. Gordon Howden, “General Practice in Health Region No. 1,” Saskatchewan Medical Quarterly 13 (1949): 335–9. Swift Current Health Region, Winds of Change, 55. A.D. Kelly, “The Swift Current Experiment,” Canadian Medical Association Journal 58 (1946): 506–11. V.L. Matthews, “Patterns for Progress Emerge.” In Swift Current Health Region, Winds of Change, 18–21. Maureen Matthews is the daughter of the late Dr Vincent L. Matthews. Maureen Matthews, “The Origins of Medicare,” Ideas, Canadian Broadcasting Corporation, 5 December 1990, transcript, 10. Ibid., 5, 8. V.L. Matthews, Winds of Change, p. 19 Regina Leader Post 19 January 1967. Jorgenson, “Rural Municipality of Miry Creek,” 56. Ibid., 56.

164

Notes to pages 92–4

62 Joan Feather, “Impact of the Swift Current Health Region: Experiment or Model?” Prairie Forum 16 (1991b): 225–48. 63 Swift Current Health Region, “The Swift Current Medical – Dental Program, 1946 to 1962.” (Mimeographed, n.d.). 64 Feather, “Impact,” 243. 65 Jorgenson, “Rural Municipality of Miry Creek,” 57. 66 Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 266. 67 Vince Matthews (Address to annual meeting, Swift Current Health Region Board, 5 June 1985). 68 I was shocked to realize that Saskatchewan lagged behind other provinces in establishing rural health regions. The Swift Current Health Region No. 1 was the only fully functioning health region in Saskatchewan – in one respect a beacon in a land of darkness; by 1943, all other provinces except Saskatchewan had a system of rural public health units for preventive medicine (Feather, “From Concept to Reality,” 66). 69 Jorgenson, “Rural Municipality of Miry Creek,” 55. c h a pter sev en 1 Henry E. Sigerist, Report of the Commissioner (Regina: Health Services Survey Commission, 1944), 11. 2 Gibson went on to become professor of neurological research and of the history of medicine at the University of British Columbia. 3 Douglas J. Buchan, Greenhouse to Medical Centre: Saskatchewan’s Medical School 1926–1978 (Saskatoon: University of Saskatchewan, 1983), 39. 4 On a personal note, my medical class at the University of Manitoba elected Wendell Macleod as our honorary president. As a result, he gave the address, “The Gold-headed Cane” at our graduating banquet in Winnipeg in 1951.

165

Notes to pages 94–7

5 Buchan, Greenhouse, 21–2. 6 Ibid. 7 Louis Horlick, Medical College to Community Resource: Saskatchewan’s Medical School, 1978–1998 (Saskatoon: University of Saskatchewan, 1999). 8 Louis Horlick, They Built Better Than They Knew: Saskatchewan’s Royal University Hospital. A History, 1955–1992 (Saskatoon: Royal University Hospital Foundation, 2001), 16. 9 Ibid., 19. 10 Buchan, Greenhouse, 36. 11 Horlick, They Built Better.

1 2

3 4

5 6

7

c h apter eight W. Douglas Piercey, “Hospitals,” Encyclopedia Canadiana 5 (1958): 161–4. Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan” (Master’s thesis, University of Regina, 1990), 68. Ibid., 103–4. A.W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan 1944–1961 (University of Toronto Press, 2004), 145. H.E. Sigerist, Report of the Commissioner (Regina: Health Services Survey Commission, 1944), 7. Aided by “provincial hospital construction grants … the ratio of hospital beds to population increased from 4.8 per 1,000 in 1946 to 6.5 per 1,000 in 1951.” Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGillQueen’s University Press, 1978), 103–4. Louis Horlick, They Built Better Than They Knew: Saskatchewan’s Royal University Hospital. A History, 1995–1992 (Saskatoon: Royal University Hospital Foundation, 2001), 10.

166

Notes to pages 98–101

8 Johnson, Dream No Little Dreams, 80. See chapter 5, nn26–8. 9 Harley D. Dickinson and Renée Torgerson, “Medicare: Saskatchewan’s Gift to the Nation?” in Jene M. Porter, ed., Perspectives of Saskatchewan (University of Manitoba Press, 2009): 175–96. 10 By 1949, the Paddockwood hospital closed its doors. Merle Massie, “Ruth Dulmage Shewchuk: A Saskatchewan Red Cross Outpost Nurse,” Saskatchewan History 56, 2 (Fall 2004): 35–43. 11 Most doctors were also accepting of Thomas H. McLeod, the brilliant economist seconded to the Health Services Planning Commission, but they were suspicious of Dr Cecil Sheps, Mott’s predecessor, and especially of Cecil’s wife, Mindel, who had served for a longer time as secretary of the hspc. Most physicians thought this couple had too much power, and sensed that they wished to impose their version of socialist ideology on the province. 12 Taylor, Health Insurance, 102–3. 13 Hospitals were graded and paid a per diem rate that varied with the facilities and services provided (ibid., 102). 14 Ibid., 103. 15 Johnson, Dream No Little Dreams, 145. 16 F.D. Mott, “Prepaid Medical Care under Government Auspices in Saskatchewan,” Canadian Journal of Public Health 41 (1950): 407. 17 F.D. Mott, “Hospital Services in Saskatchewan,” American Journal of Public Health 37 (1947): 1542. 18 Taylor, Health Insurance, 104; 167, 435n84. 19 James A. McAllister, The Government of Edward Schreyer (Montreal: McGill-Queen’s University Press, 1984), 43. 20 Christopher J. Rutty, “The Middle–Class Plague: Epidemic Polio and the Canadian State, 1936–1937,” in Canadian Bulletin of Medical History 13, 2 (1996): 277–314; 277.

167

Notes to pages 101–5

21 Janet MacKenzie, “The Saskatchewan Response to Poliomyelitis,” Report for the Saskatchewan Western Development Museum, 2002. 22 Johnson, Dream No Little Dreams, 145. 23 Milton I. Roemer, “‘Socialized’ Health Services in Saskatchewan,” Social Research 25 (1958): 87–101. 24 Privy Council (Canada) 3408. This was followed by Saskatchewan Order-in-Council 74/49 on 11 January 1949. 25 By chance, two other members in addition to my father, Dr C.J. Houston, were from Yorkton, population 5,000. City clerk Howard Jackson represented the Saskatchewan Urban Municipalities Association and newspaper publisher S.N. Wynn represented the Saskatchewan Hospital Association. 26 C.S. Houston, “The Early Years of the Saskatchewan Medical Quarterly,” Canadian Medical Association Journal 118 (1978): 118–19, by permission. 27 Ken McTaggart, The First Decade (Ottawa: Canadian Medical Association, 1973), 43. 28 C.J. Houston, “Report,” Saskatchewan Medical Quarterly 15, 4 (1951), 626. 29 Health Survey Committee, Saskatchewan Health Survey Report (Regina: Government of Saskatchewan, 1951), 225. During these meetings, Malcolm Taylor and C.J. Houston became lifelong friends. Taylor later was in charge of research for the federal Royal Commission on Health Services chaired by Saskatchewan Chief Justice Emmett Hall, 1961–64. 30 Taylor, Health Insurance, 167, 233. c h apter nin e 1 Fannie H. Kahan, Brains and Bricks: The History of the Yorkton Psychiatric Centre (Regina: White Cross Publications, 1965), 13–15.

168

Notes to pages 106–9

2 Ibid., 16. 3 Joe Cherwinski, “The Rise and Incomplete Fall of a Contemporary Legend: Frozen Englishmen in the Canadian Prairies during the Winter of 1906-1907,” Canadian Ethnic Studies/Etudes ethniques au Canada 30, 3 (1999): 20–43. 4 Harley Dickinson, The Two Psychiatries: The Transformation of Psychiatric Work in Saskatchewan, 1905–1984 (Regina: Canadian Plains Research Centre, 1989), 21. 5 Colin M. Smith, “Mental Health Services in Saskatchewan, 1914–1978” (Typescript of talk given to psychiatry rounds, University Hospital, 17 February 1984). 6 D.G. McKerracher, “A New Program in the Training and Employment of Ward Personnel.” American Journal of Psychiatry 106 (1949): 259–64. 7 Colin M. Smith, “A Decade of Psychiatry in Saskatchewan,” Saskatchewan Medical Quarterly 38, 3 (1974): 31–3. 8 Humphry Osmond, “Function as the Basis of Psychiatric Ward Design,” Mental Hospitals 8, 4 (April 1957): 23–9; also paraphrased in Kahan, Brains and Bricks, 25, 83. 9 Colin Smith, “Mental Health Services,” Encyclopedia of Saskatchewan (Canadian Plains Research Centre, 2005): 599–600. 10 Erika Dyck, Psychedelic Psychiatry: LSD from Clinic to Campus (John Hopkins University Press, 2008), 22. 11 Saskatchewan Legislative Records, Legislative Journal, sess. 1945, vol. 44, p. 14; cited in Dyck, Psychedelic Psychiatry, 23, 149. 12 Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961 (University of Toronto Press, 2004), 80 13 Smith, “Mental Health Services,” 600. 14 Dyck, Psychedelic Psychiatry, 23. 15 Smith, “Mental Health Services,” 600.

169

Notes to pages 109–12

16 John Mills, “Lessons from the Periphery: Psychiatry in Saskatchewan, Canada 1944–1968.” History of Psychiatry 18, 2 (2007): 179–201. Mills, a retired psychology professor from the University of Saskatchewan, died 14 March 2012 in Comox, bc. 17 Dyck, Psychedelic Psychiatry, 25. 18 Mills, “Lessons from the Periphery,” 182. 19 Ibid., 181. 20 Angela Martin, “Psychiatric Nursing,” Encyclopedia of Saskatchewan, 729. 21 M.C. Schreder and Colin M. Smith, “La formation des infirmiers psychiatriques,” Information Psychiatrique 50 (1974): 489–94. 22 Instruction for untrained ward attendants had begun in 1930, but they received only sixty hours of lectures over two years. 23 Mills, “Lessons from the Periphery,”195, citing a 1985 presentation by M. Schreder. 24 Dyck, Psychedelic Psychiatry, 24, 149n35. 25 Martin, “Psychiatric Nursing,” 729. See also Chris Dooley, “‘The older staff, myself included, we were pretty institutionalized ourselves’: Authority and Insight in Practitioner Narratives of Psychiatric Deinstitutionalization in Prairie Canada,” Canadian Bulletin of Medical History 29 (2012): 101–23. 26 Smith, “Mental Health Services,” 600. 27 Mills, “Lessons from the Periphery,”182. 28 Dyck, Psychedelic Psychiatry, 26. 29 Ibid., 26; Smith, “Mental Health Services,” 600. 30 Smith, “Mental Health Services,”600. 31 Dyck, Psychedelic Psychiatry, 13, 17–19; Smith, “Mental Health Services,”600. 32 Dyck, Psychedelic Psychiatry, 27.

170

Notes to pages 112–15

33 34 35 36

37

38 39

40 41

42 43

44 45

Ibid., 31. See, e.g., Dyck, Psychedelic Psychiatry, 74. Mills, “Lessons from the Periphery,”184. C.M. Smith and L.L. McKay, “The Open Psychiatric Ward and Its Vicissitudes,” American Journal of Psychiatry 121 (1965): 763–7. C.M. Smith and D.G. McKerracher, “The Comprehensive Psychiatric Unit in the General Hospital,” American Journal of Psychiatry 121 (1964): 52–7. D.G. McKerracher, “Psychiatry in General Practice,” Canadian Medical Association Journal 88 (1963): 1014–16. W.A. Cassell, C.M. Smith, F. Grunberg, J.A. Boan, and R.F. Thomas, “Comparing Costs of Hospital and Community Care,” Hospital and Community Psychiatry 23 (1972): 197–200. F.S. Lawson, “Mental Hospitals: Their Size and Function,” Canadian Journal of Public Health 49 (1958): 186–95. F.S. Lawson and K. Izumi, “The Saskatchewan Plan,” Mental Hospitals 8 (1957): 27–31. Dr Ian McDonald informs me that McKerracher was also at the Denver meeting in 1956, but was watching television – a World Series baseball game famous that day for a no-hitter – while Lawson delivered the paper on the Saskatchewan Plan. Kahan, Brains and Bricks, 27. Saskatchewan’s first and only cottage mental hospital, adjacent to the new 200-bed regional hospital, opened in Yorkton in October 1963, with five cottages of thirty beds each. F.S. Lawson, “Saskatchewan’s First Regional Mental Health Facility,” Mental Hospitals 16 (2) February 1965: 85–6. F.S. Lawson, “The Saskatchewan Plan,” Canadian Nurse 63, 6 (June 1967): 27–9.

171

Notes to pages 116–19

46 Smith, “A Decade of Psychiatry,” 31. 47 D.G. McKerracher, “Psychiatric Care in Transition,” Mental Hygiene 45 (1961): 3–9. 48 D.G. McKerracher, Department of Psychiatry, Annual Report, 1963. University of Saskatchewan Archives. 49 Ibid. 50 W.J. McCorkell and D.G. McKerracher, “The Family Doctor and the Psychiatric Ward,” Mental Hospitals 13 (1962): 300–2. 51 The rural equivalent was at Central Butte, where the three family practitioners received regular twice-monthly support from a visiting psychiatrist for two years. (L.W. Christ, E. Christ, and G.W. Mainprize, “Observations on the Psychiatric Project at Central Butte, Saskatchewan,” Canadian Family Physician 13 [1967]: 35–41). 52 D.G. McKerracher, C.M. Smith, F.E. Coburn, and I.M. McDonald, “General-Practice Psychiatry: Two Canadian Experiments, Lancet 2 (1965): 1005–7. 53 Mills, “Lessons from the Periphery,” 185. c h a pter ten 1 Ellice had been named for his birthplace, Fort Ellice, the Hudson’s Bay Company (hbc) post on the Manitoba-Saskatchewan boundary. 2 The son of Archibald McDonald, an hbc fur trader, Ellice had graduated in medicine from McGill University with his MB and BCh in 1901. 3 Murray to Dunning, 6 October 1922. Premier Dunning papers Y–16–0, pages 25, 918–19 (unpublished letters), Saskatchewan Archives Board (SAB), M6. 4 Dunning to Murray, 11 October 1922, SAB, M6. 5 R.A. Macbeth, “The Origin of the Canadian Cancer Society,” Canadian Bulletin of Medical History 22: 155–73.

172

Notes to pages 119–22

6 B.W. Currie, “Ertle Leslie Harrington, 1887–1956,” Proceedings and Transactions of the Royal Society of Canada 50 (1956): 91. 7 R.O. Davison, “Saskatchewan’s Programme for Cancer Control,” Canadian Public Health Journal 24 (1933): 566–71. 8 A. Becker, “A Sketch of Radiology at St Paul’s Hospital,” Saskatchewan Medical Quarterly 34 (1970): 34–6. 9 J. Hawkes, The Story of Saskatchewan and Its People (Regina: S.J. Clarke, 1924), 1720–1; “Obituary: Dr Clarence Henry,” Canadian Medical Association Journal 70 (1954): 701. 10 Anonymous, “400 K.V. X-ray Therapy Unit Now Available in This Province,” Saskatchewan Medical Quarterly 2 (1938): 22. 11 For a “nominal” fee of $10, an appreciable amount in those times. Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan, 1944–1964” (Master’s thesis, University of Regina, 1990), 25. 12 Charles R. Hayter, “Compromising on Cancer: The Saskatchewan Cancer Commission and the Medical Profession, 1930–1940,” Saskatchewan History 54 (2002): 5–17. 13 Mombourquette, “A Government and Health Care,” 25. 14 D.V. Cormack, “The Saskatchewan Radon Plant, 1931–1962,” Physics in Canada 41 (1985): 3–5. 15 Blair had trained as a surgeon in Winnipeg. Following concentrated cancer training at centres in Great Britain, France, Germany, Belgium and Sweden, he was employed as a cancer specialist at New York Memorial Hospital, the University of Alabama, and then the University of Toronto. 16 Contrary to popular belief in Saskatchewan, Alberta offered free cancer treatment in Calgary and Edmonton, beginning in 1941. Saskatchewan was not first in this regard. 17 M.S. Acker and T.A. Watson, “Saskatchewan’s Experience with

173

Notes to pages 123–6

18 19

20

21

22 23

24

25 26

a Comprehensive Public Cancer Program,” American Journal of Public Health 50 (1960): 65–73. Anonymous, “Portraits in Radiology: Harold Elford Johns, PhD,” Applied Radiology 1978: 25. Lauriston S. Taylor was the founder and chair of the U.S. National Council on Radiation Protection and Measurements (ncrp), 1929–77. He was the guru of radiation protection throughout my radiology career, until he died at age 102 in 1994. He was the leading biographer of other radiation physicists world-wide. Harold Johns, Transcript of interview by Lauriston S. Taylor, Rockville, Maryland, 17 October 1979, cited in C.S. Houston and S.O. Fedoruk, “Radiation Therapy in Saskatchewan,” in J.E. Aldrich and B.C. Lentle, eds., A New Kind of Ray (Vancouver: University of British Columbia, 1995), 141–54. Six years later, in November 1952, the Saskatchewan Division of the Canadian Cancer Society gave Sylvia Fedoruk a $1,000 travelling fellowship to cover a two-month visit to cancer treatment sites in Chicago, Cincinnati, Detroit, New York, Oak Ridge and San Francisco; her expenses came to $996. Houston and Fedoruk, “Radiation Therapy,” 147. McNaughton had been born to a pioneer family at Moosomin, 25 February 1887. Trained as an engineer at McGill University, he was president of the Atomic Energy Control Board of Canada, 1946–48. C.S. Houston and S.O. Fedoruk, “Saskatchewan’s Role in Radiotherapy Research,” Canadian Medical Association Journal 132 (1985): 854–64, by permission. H.E. Johns, “aapm Coolidge Award,” Medical Physics 3 (1976): 375. Houston and Fedoruk, “Saskatchewan’s Role,” 858. The betatron was financed by a joint grant of over $120,000 from

174

Notes to pages 126–9

27

28

29 30 31

32 33

Atomic Energy Control Board and the ccf government, with additional help from the National Cancer Institute Sask Division of the Canadian Cancer Society. Saskatchewan’s application was chosen over several other Canadian universities. Muriel Snider, “Twenty–five Million Volts of Hope.” Saturday Night 18 October 1949. E.L. Harrington, R.N.H. Haslam, H.E. Johns, and L. Katz, “The Betatron Building and Installation at the University of Saskatchewan,” Science 110 (1949): 283–5; H.E. Johns, E.K. Darby, R.N.H. Haslam, L. Katz, and E.L. Harrington, “Depth Dose Data and Isodose Distributions for Radiation from a 22 Mev Betatron,” American Journal of Roentgenology 62 (1949): 257–68; H.E. Johns, E.K. Darby, and R.O. Kornelson, “The Physical Aspects of Treatment of Cancer by 22 Mev X-rays,” British Journal of Radiology 24 (1951): 355–64; S.O. Fedoruk, H.E. Johns, and T.A. Watson, “Isodose Distributions for a 1100 Curie Cobalt 60 unit,” Radiology 60 (1953): 348–54. (Sixteen additional papers concerning radiation dose measurements are cited in Houston and Fedoruk, “Radiation Therapy,” 426). At this time, Dr H. Quastler, with the help of physicist D.W. Kerst, had treated a single patient with a betatron. H. Quastler and G.D. Adams, “Techniques for Application of the Betatron to Medical therapy with Report of One Case,” American Journal of Roentgenology and Radium Therapy 61 (1949): 591–625. M.D. Schulz, “The Supervoltage Story,” American Journal of Roentgenology 124 (1975): 541–59. Houston and Fedoruk, “Radiation Therapy,” 147. Johns, letter to the president, Saskatchewan Division of the Canadian Cancer Society, cited in Houston and Fedoruk, “Saskatchewan’s Role,” 858. Houston and Fedoruk, “Radiation Therapy,” 149. Houston and Fedoruk, “Saskatchewan’s Role,” 859.

175

Notes to pages 130–6

34 Sybil Johns, “At Home with the Atom,” Mayfair Magazine 30 (July 1955): 30–1 and 53–8. 35 Houston and Fedoruk, “Radiation Therapy,” 149. 36 Ibid., 149–50. 37 Ibid., 150. 38 Ibid., 151. 39 Date of death obtained from Medical Records, Saskatoon Cancer Agency. An article by historian Paul Litt, “Photon Finish: The Race to Build the Bomb,” Beaver 82, 2 (April–May 2002): 28–31, fails to mention the drastic difference in the survival of the first two patients treated, nor does it mention that only one of the cobalt-60 machines had been carefully calibrated. 40 W.C. von Röntgen, “Ueber eine neue Art von Strahlen [On a New Kind of Ray],” Sitzungsberichten der Würzburger Physikmedic. Gesellschaft [Proceedings of the Physical-Medical Society of Würzburg], 28 December 1895; second communication in Nature, 1896. Röntgen could have become a very wealthy man, but he deliberately refrained from taking a patent on his invention; he wished to share it with the world. 41 H.E. Johns, L.M. Bates, E.R. Epp, D.V. Cormack, and S.O. Fedoruk, “1,000-Curie Cobalt-60 Units for Radiation Therapy,” Nature 168 (1951): 1035–8. 42 A. Morrison, W.R. Dixon, C. Garrett, H.E. Johns, L.M. Bates, E.R. Epp, D.V. Cormack, and S.O. Fedoruk, “Multicurie Cobalt 60 Units for Radiation Therapy,” Science 115 (1952): 310–12. 43 As isodose curves. 44 S.O. Fedoruk, H.E. Johns and T.A. Watson, “Isodose Distributions for a 1,100-Curie Cobalt60 unit,” Radiology 60 (1960): 348–54. 45 D. Cassels, “Brave New Worlds for Nuclear Medicine,” Ascent 1 (1979): 8–10.

176

Notes to pages 136–9

46 D.A. Fee and S.O. Fedoruk, “Clinical Value of Liver Photoscanning,” New England Journal of Medicine 262 (1960), 123–5. 47 A more complete biography of Sylvia Fedoruk can be found in Stuart Houston and Bill Waiser, Tommy’s Team: The People behind the Douglas Years (Calgary: Fifth House, 2010), 42–8. 48 T.D. Cradduck, “The Design of a Detection and Display System for a Radio-isotope Scanner” (MSc thesis, University of Saskatchewan Department of Physics, 1962). T.D. Cradduck and S.O. Fedoruk, “A Study of Collimators for Use in Radioisotope Scanning Techniques,” Journal of the Canadian Association of Radiologists 13 (1962): 9–13. 49 T. Cradduck, “Flashback, Saskatoon, 1961,” in A New Kind of Ray, edited by J.E. Aldrich and B.C. Lentle (Vancouver, ubc Press, 1995), 386–7. Cradduck’s PhD dissertation in 1965 resulted in two more joint papers with Fedoruk: T.D. Cradduck, S.O. Fedoruk and J.A. MacKay, “A ‘Large Crystal’ Scintillation Scanner,” Journal of Nuclear Medicine 5 (1964): 27–39; T.D. Cradduck and S.O. Fedoruk, “An Experimental Determination of the Overall Spatial Resolution of a Scintillation Camera,” Physics in Medicine and Biology 10 (1965): 67–76. 50 S.J. MacIntyre. S.O. Fedoruk, C.C. Harris, D.E. Kuhl, and J.R. Mallard, “Sensitivity and Resolution in Radioisotope Scanning: A Report to the International Commission on Radiation Units and Measurements,” in Medical Isotope Scintigraphy, vol. 1 (Vienna: International Atomic Energy Agency, 1969): 391–433. 51 Houston and Fedoruk, “Radiation Therapy,” 154. e p i l ogue 1 Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 239–330.

177

Notes to pages 139–41

2 Noel Doig, Setting the Record Straight: A Doctor’s Memoir of the 1962 Medicare Crisis (Saskatoon: Indie Ink Publishing, 2012). 3 A.W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961 (Toronto: University of Toronto Press, 2004), 251. 4 Sargent E. and Mary McGowan, Cordwood and Courage (Paddockwood and District History Committee: Friesen Printers, 1982): 357–9. 5 Five days before the McGowans’ wedding date. They got their blood tests finished in time, and the wedding went forward 28 July 1962. 6 Taylor, Health Insurance, 239–330; E.A. Tollefson, Bitter Medicine: The Saskatchewan Medicare Feud (Saskatoon, Modern Press, 1964) provides a legal viewpoint. Robin F. Badgley and Samuel Wolfe, Doctors’ Strike: Medical Care and Conflict in Saskatchewan (Toronto: Macmillan, 1967) is a third recommended source. A recent example is Noel Doig, Setting the Record Straight. See also Gregory P. Marchildon and Klaartje Schrijvers, “Physician Resistance and the Forging of Public Healthcare: A Comparative Analysis of the Doctors’ Strikes in Canada and Belgium in the 1960s,” Medical History 55, 2 (April 2011): 203–22. 7 Taylor, Health Insurance, 367. 8 Taylor, Health Insurance and Canadian Public Policy, revised edition 2009, 502. 9 Marchildon and Schrijvers, “Physician Resistance,” 222. 10 Two medical doctors, David M. Baltzan of Saskatoon and Arthur van Wart of Fredericton, New Brunswick; Dean Alice Gerard of the University of Montreal School of Nursing; Dr Leslie Strachan, a dentist from London, Ontario; Wallace McCutcheon, an industrialist from Ontario, and Dr O.J.

178

Notes to pages 141–5

11 12 13 14 15

16

17

Firestone, an economist. Dr Malcolm G. Taylor was research consultant and Professor Bernard Blishen was research director. Taylor, Health Insurance, 342. Ibid., 375. Greg Marchildon, ed., The Heavy Hand of History (Regina: Canadian Plains Research Center, 2005): 61. Ibid., 51. As a family practitioner in Yorkton, 1951–60, my assigned role was to teach the student nurses about dermatology and sexually transmitted diseases. Fourteen of the twenty-one members of the nursing class of 1962 returned; that evening they sang two songs as part of the entertainment. When the new medical school was about to open in Newfoundland in 1967, and Lord Stephen Taylor was president of Memorial University, I was offered the headship of diagnostic radiology. I have since admired from afar the funding and stability of that department. Free from the intervening level of bureaucracy of a city-wide health board, which in Saskatoon has yet to develop appreciable priorities for either teaching or research, impoverished Newfoundland, it appears to me, regards its medical school as a provincial resource and treasure.

179

INDEX

Abbey, 37, 81. See also Miry Creek Aberdeen, Scotland, 7 Acme Machine and Electric, 130, 135 Act Respecting the Control and Treatment of Cancer (proposed, 1944), 121 Agnes, Sister, 4 Agriculture, Minister of, 27 air ambulance, 101–2 Alberta, 3; free cancer treatment, 173n16; joined medicare, 141; tuberculosis treatment, 54; Venereal Disease Act (1918), 19; union hospitals, 35–7. Alexander, A.B., 43 Allis-Chalmers Company, 125 American College of Chest Physicians, 66

American Psychiatric Association Mental Hospital Institute, 114 American Public Health Association, 22 Anderson, J.T.M., 119 Anderson, Matt, 38. See also Matt Anderson Plan; McKillop (rm); Municipal Medical and Hospital Services Act; Strasbourg Andrews, C.H., 58 Anglican Sisterhood of St John the Divine, 5 Anna Turnbull Memorial Hospital, 11 Associated Canadian Travelers (act), 46, 61 Assumption College, 18 Atomic Energy Commission, 124–5

Index

Atomic Energy Control Board of Canada, 125 Atomic Energy of Canada Limited (aecl), 133 Atomic Energy Project, 129 Bacille Calmette-Guérin (bcg) vaccination, 55, 59–60 Barnett, G.D., 43 Bassano, ab: municipal union hospital, 35 Bates, L.M. (Lloyd), 130, 134. See also “Saskatchewan mafia” Battleford: hospital, 11; nwmp hospital, 4; population, 11; tuberculosis treatment, 19. See also North Battleford Beechy (municipal doctor), 28 Bell, James, 5 Bentley, T.J., 102, 139 betatron, 124–9, 134 Bethune (municipal doctor), 28 Biggins, nurse, 5 Big River, 58 Big Stick (rm), 84 Birsay (municipal doctor), 28 Blair, Allan, xviii–xix, 121–6 Blakeney, Allan, 55 Boston, ma, 49 Boucher, Sister, 4 Boughton, Harvey, 43, 49, 65 Brandon, mb, 6, 7 Brandon College, xx Britannia (rm), 36

182

British Columbia, 101, 134; hospitalization plan, 103; joined medicare, 141 British Journal of Radiology, 135 Brock (municipal doctor), 28 Brown, J. Lloyd, 71, 75, 86, 89. See also Saskatchewan Health Services Planning Commission Buchan, Douglas J., 94 Buffalo River First Nation reserve, 67 Bureau of Public Health, 18 Cabri, 80, 91 Caldwell, A.L., 80–1 Canadian Cancer Society, 119 Canadian Centre for Nuclear Innovation, 137 Canadian Medical Association, 28, 89 Canadian Pacific Railway, 18 Canadian Public Health Association, 22 Canadian Society for the Control of Cancer, 119 cancer, 22, 43, 61, 98, 118–37 Cancer Control Act, 122 Canora: hospital, 13, 15; tb clinics, 52 Cardston, ab: municipal union hospital, 35 cbc (Canadian Broadcasting Corporation): xxi, 90 “ceiling principle,” 77, 88 Chalk River, on, 129

Index

Chamberlain (municipal doctor), 28 Chapin, Charles H., 72. See also McKillop (rm) Chapman, Roy, 26. See also Dilke charge nurse, 39–40 Charles Mickle Fellowship, 64 Chase, Lillian, 23 Christmas Seal campaign, 46, 61 Churchill River, 4 Cipriani, A.J., 129 Clarke, C.K., 106 Clearwater Sanatorium, 59 cobalt-60, 123–4, 129–37 Collins, John J., 33. See also Ituna Committee on Municipal Physicians, 28. See also D.S. Johnstone Conference of State and Provincial Health Authorities, 22–3. See also Seymour Plan Connell, Robert, 61–2 continuing education, 48–9 Cook, A.B., 51 Coombs, Mother Hannah Grier, 4–5 co-operation (particularly community), 63, 86, 89, 142 Co-operative Commonwealth Federation (ccf), xviii, 66, 69, 75, 82, 84, 88, 122, 138, 142, 157n4, 158n5, 158n9, 159n22, 162n30, 174n26

183

Cormack, D.V., 134, 136. See also “Saskatchewan mafia” cottage hospital, 5, 6, 10, 39, 81, 96; psychiatric cottage hospitals, 105–7, 114–16, 171n43 Craik, 27; municipal doctor, 28; population 151n4 Cumberland House, 3 Cupar: school tb survey, 51 Darling and Pearson (architectural firm), 106 Davey, Lloyd, 86, 163n33 death rate, 22, 54, 56, 64 de Grandmaison, Nicholas, 64 Delco Light Company, 56 Denver, Colo., 114 depth dose, 130, 133–5 Diefenbaker, John G., 141 Dilke, 26, 151n3. See also Chapman, Roy diphtheria, 22, 31, 41 Directly Observed Therapy (dot), 68 Ditner, Pat, 87, 163n42 Dixon, W.R., 134 d-lysergic acid diethylamide (lsd), 112–13. See also psychedelic therapy “doctors’ strike,” xix, 91, 139–41 Doig, Noel, 139 Dominion Health of Animals Branch, 22 “doughnut” or high-energy

Index

betatron tube, 126–8. See also betatron Douglas, Shirley, xxi Douglas, T.C., 63, 66, 69–71; on approving the betatron, xix–xxi; on cancer treatment, 122, 124; as cbc’s “Greatest Canadian,” xxi; promises nonpolitical commission, 75; health policy as Minister of Health, 75–8; on health regions, 81, 84; and medical college and university hospital, 93–5; on mental health, 108–9; on resigning as Minister of Health, 102; role in medicare, 139–40; and Saskatchewan Health Services Planning Commission, 98; epilogue 138–41 Dragan, George, 121 Dr George Ferguson School, 66. See also Regina drought, 32–3, 48, 79, 86, 143 Drumheller, ab: municipal union hospital, 35 Dunning, Charles A., 118 Dyck, Erika, 108–11 dysentery, 20 Echo Lake, 20 Eldorado Mining and Refining, 132 Elkin, Nurse, 5 empowerment, 92, 144

184

Epp, E.R., 34. See also “Saskatchewan mafia” Ewing, James, 119 Feather, Joan, 79, 84 Fedoruk, Sylvia, 134–7. See also Foreword; “Saskatchewan mafia” fee-for-service, xix, 28, 76, 81, 140, 159n22 Ferguson, G. Gordon, 102 Ferguson, Helen, 65 Ferguson Island, 66 Ferguson, Robert George (R.G.), 20, 33, 41–67 File Hills Indian Agency, 56–7 Fines, Clarence, xx First Nations, 3–4, 43, 51, 55–60, 67–8, 156n18 Fort Ellice, 172n1 Fort Qu’Appelle, 43, 118 Fort Qu’Appelle Sanatorium (Fort San), 43, 45, 47, 49, 52, 64–5; nursing course, 49; post office, 43 Fort Walsh: nwmp hospital (and pharmacist), 4 Frappier, Armand, 60 Fraser (Myles), Margaret, 7 Freemont (municipal doctor), 28 Gardiner, James G., 47, 54 Garrett, C., 134 Gibson, Clarence, 77 Gibson, W.C., 93, 165n2

Index

Goderich, on, 19 Golden Prairie, 84 gonorrhea, 19 Grain Growers’ Assocation (women’s section), 143 Grandin, Bishop, 4 Grand Rapids, mb, 5 grassroots, 23, 44, 52, 63, 92 Grey Nuns (Sisters of Charity), 4, 11, 13 Gull Lake, 84, 89, 102 Hall, Emmett M., 141, 168n29 Hanna, ab: municipal union hospital, 35 Harrington, Ertle L., 119–25 Hart, Bob, 65 Hart, F.W., 65 Harvard University, 49 Haslam, R.N.H., 125 Hazlet, 80 Heagerty, J.J., 159n25 Heagerty Interdepartmental Advisory Committee on Health Insurance, 76 Health Insurance District #1, 72. See also McKillop (rm), Chapin, Charles H. Health Services Board, 32–3 Health Services Planning Commission, 77, 81, 98, 159n22 Health Services Survey Commission (Saskatchewan) (shssc), 71

185

Henry, Clarence M., 119 Heward: school tb survey, 51 High River, ab: municipal union hospital, 35 Hingley, E.G., 65 Hitsman, Elden, 73 Hjertaas, Orville, 87 Hoffer, Abram, 112 Hogarth, Bamm, 157n4 Holdfast, 25, 27 Holdfast (municipal doctor), 25–8, 32 Homemakers’ Clubs, 23, 45, 143 Horlick, Louis, 94–5 Houston, C.J. (father of C. Stuart Houston), 102–3; Introduction and Epilogue Howden, Gordon, 89–90 Hudson’s Bay Company (hbc), 3–4; 172n1 Hugh Waddell Memorial Hospital, 15. See also Canora Humboldt: hospital, 16 Ile-à-la-Crosse, 58; first hospital in Saskatchewan, 4 Imperial Order Daughters of the Empire (iode), 46, 143 Indian Head, 19, 65; hospital, 10; nursing training, 10; population, 11 infant mortality rate, 89 Irwin, O.M., 162n31 Islay, ab: municipal union hospital, 35

Index

Ituna, 33 Izumi, Kiyoshi, 114. See also Saskatchewan Plan Johns Hopkins University, 71 Johns, Alfred Edward, xx Johns, Harold, xvii–xx, 122–5, 129–30, 134. See also “Saskatchewan mafia” Johns, Sybil, 129 Johnson, A.W., 160n32 Johnstone, D.S., 28. See also Committee on Municipal Physicians Joliette, nd, 41 Jorgenson, Lester, 83, 85, 92 Journal of the Canadian Association of Radiologists, 134 Jukes, Augustus L., 4 Katz, L., 125 Kelly, Arthur D., 89. See also Canadian Medical Association Kelvington, 121 Kerst, D.W., 124, 126, 175n28 King Edward tuberculosis hospital, 43. See also Winnipeg King George infectious disease hospital, 43. See also Winnipeg Kirkby, R.W., 43 Kirychuk, Mary, 140 Kitchi-Manitou, 58 Kjorven, Carl, 84, 85, 91, 102, 163n34

186

Lady Minto Hospital, 13. See also Melfort La Loche, 58, 67 Langley, George, 27. See also Minister of Agriculture Lashburn: hospital, 15 Latta, S.J., 54 Lawson, F.S. (Sam), 109–10, 113–15. See also Saskatchewan Plan Leader Post, 91 League of Nations, 22–3 Lebret Indian School, 56 Leroy (municipal doctor), 28 Lewis, W.B., 129. See also Atomic Energy Project Lindsay, W.S., 95 Lintlaw (municipal doctor), 28 Lloyd, Woodrow, 139–40 Lloydminster, 36; hospital, 11, 35, 36, 37 Lloydminster Times, 36 London, England, 48, 123, 134 London, on, 132–4 London Free Press, 133 Lorne, Marquis of (governor general), 6 Low, David, 105–7 lsd. See d-lysergic acid diethylamide MacDonald, Maria, 18 MacKay, John, 130, 135–6. See also Acme Machine and Electric

Index

Mackenzie, C.J., 124–5. See also National Research Council MacLean, Hugh, 158n5 Macleod, J. Wendell, 94, 165n4 MacNeill, J.W., 107 Manitoba, 3, 20, 42, 152n11, 158n9; joined medicare, 141; tuberculosis treatment, 54, 59–60, 156n26 Maple Creek, 89, 162n31; hospital and nurse training school, 10; nwmp hospital, 4; population, 11 Marchildon, Gregory, 140 Mary E. Truesdell Nursing Home, 6 maternity grant, 19, 39 Matheson, J.A., 89, 162n31 Matthews, Maureen, 90, 164n65 Matthews, Vincent L., 86–7, 90–1, 163n37 Mayneord, M.V., 123. See Royal Cancer Hospital Matt Anderson Plan, 38–40; 72–3, 81 McAllister, James, 101 McAra, Peter, 65 McCorkell, Wilf, 116–17 McDonald, Ellice, 118–19 McGill University, 19, 94, 121, 174n23, 192n2; medical school, 98 McGowan, Sargent, 140, 178n5 McKerracher, D.G. (Griffith),

187

109–11, 113–16 McKillop (rm), 38, 72–3 McKinnon, Eleanor, ix–xix McLaren, Robert, 23 McLean, C.S., 32 McLeod, Ian, 78 McLeod, Thomas H. (Tommy), 77 McMaster University, 122 McNaughton, A.G.L., 124, 174n23 McTaggart, Ken, 102 Meadow Lake, 67 medical college, 74, 92–3, 130 Medicine Hat, ab: hospital, 6; population, 149n10 medicine men and women, 3–4 Melfort: hospital 13; tb clinics, 52. See also Lady Minto; Victorian Order of Nurses Melrose, Walter, 84 Memorandum on Organization of Health Regions, 81 Mental Health Act, 111 mescaline, 112 milk, 20–1, 44, 143; pasteurization, 22. See also tuberculosis Millar, (nurse), 5 Mills, John, 111, 114, 117, 170n16 Minister of Agriculture, 27 Minto, Lady, 6–7, 10, 13. See also Victorian Order of Nurses (von) Miry Creek (rm), 37, 81, 92

Index

Michi-Manitou, 58 Montreal, qc, 5, 15, 60 Montreal Lake, 66 Moose Jaw: hospital, 4, 11, 12, 16; mental health clinic, 109; polio clinic, 101; population, 11; school tb survey, 51; tb clinic, 52 Moosomin, 19, 124, 174n23; hospital 7, 9; population 11 Morrison, A., 134 Motherwell, W.R., 18 Mott, F.D. (Fred), 98–9, 102, 163n36, 167n11 municipal doctors, 23, 27–35, 72, 144, 152n11; location, 28 municipal hospitals, 23, 36–40; location in ab, 35 Municipal Medical and Hospital Services Act, 38. See also Anderson, Matt; Matt Anderson plan Munroe Wing (Regina General Hospital), 109 Murray, Walter, 118 Muskeke-O-Kemacan (Great White Physician), 28, 58. See also Ferguson, R.G. Myers, G.W., 99 Myles, Margaret Fraser, 7 National Association for the Prevention of Tuberculosis, 57 National Cancer Institute, 127 National Council of Women, 6

188

National Health Grants Program, 96, 153n34 National Health Insurance Plan (Great Britain), 86 National Research Council (nrc), 55, 124, 129, 134 New Brunswick, 178n10; joined medicare, 141 Newfoundland: joined medicare, 141; medical school 179n17 Newton, il, 25 New York City, 20; Memorial Hospital 119, 173n15 Ninette, mb, 20; Sanatorium, 42 Nipawin, 46 Normal School (Teacher’s College), 46, 47, 51 North Battleford, 114: hospital, 16; psychiatric clinic, 109; psychiatric hospital, 107; school tb clinic, 51; tb clinic, 52, 114. See also Saskatchewan Hospital North Dakota, 41 North-West Mounted Police (nwmp), 4; Royal North West Mounted Police, 19 North West Territories: joined medicare, 141 North-West Territories, 6 North-West Territories Medical Council, 22 Nova Scotia: joined medicare, 141 Nuclear Enterprises, 136

Index

nuclear imaging, 136–7 nurses, student, 49, 55, 60, psychiatric nurse training, 109–10 Ogdensburg, ny, 105 Onoway, ab, municipal union hospital, 35 Ontario, 18, 52, 104, 105, 129, 132, 133; joined medicare, 141 Osmond, Humphry, 112, 114–15 Paddockwood, 38–40, 98, 140, 167n10 Paille, Father (Oblate), 11 Palliser Triangle, 80 para-amino-salicyclic acid, 64 Parsons, Phoebe (nurse), 5 Patrick, T.A., 7 Patterson, W.J., 157n4 pavilion-style psychiatric hospital, 107 Peart, Arthur F.W., 86, 163n33 Pennant, 84 Pépin, Sister, 4 peyote cactus, 112 Philadelphia Cancer Institute, 119 photofluorographic surveys, 61–2 photoscanning, liver and whole body, 136–7 Picker Cobalt units, 136 Pierce, S.J.S., 42 “Pile of Bones,” 6. See also Regina

189

Pittville (rm), 38, 71, 80–2 poliomyelitis, 101 Prebble, Peter, xviii Presbyterian Church, 11, 13 preventorium, 46, 50 Prince Albert, 19, 141; hospital, 6, 8, 15; nwmp hospital, 4; population, 11; psychiatric clinic, 109, 115; sanatorium, 43, 47, 58–9, 64 Prince Edward Island: joined medicare, 141 Protestant Hospital for the Insane, 105 Provost, ab: municipal union hospital, 35 psychedelic therapy, 112–13, 138 Psychiatric Services Branch (Saskatchewan), 113 Public Health Act, 18 Qu’Appelle: nwmp hospital, 4 Qu’Appelle Indian agency, 56; reserve, 56 Qu’Appelle Valley, 18, 20 Quebec: joined medicare, 141 Queen Victoria, 6 radium, 118, 120–1, 123–4, 129 radon, 121 Red Cross, 39, 143, 155n10 Red Cross Outpost Hospitals, 38–40, 98 Regina, 6, 7, 8, 18, 19, 21, 28,

Index

38, 47, 56, 65–6, 71, 81, 88–9, 92–3, 99, 104, 106, 114, 121, 124, 157n4, 158n5, 162n27, 163n34; cancer clinic, 121; hospital, 13; nwmp hospital, 4; polio clinic, 101; population, 11; sheriff, 51; school tb survey, 51; tb clinics, 52; vd clinic, 19 Regina College, 21 Regina General Hospital, 109, 119 Regina Leader Post, 91 Registered Nurses, 72, 102, 107; Registered Psychiatric Nurses, 107, 110–11 Riel Rebellion, 4, 18 Riverside (rm), 81, 84–5 Robertson, Stewart, 81, 85, 87, 90–1, 162n23, 163n42 Roemer, Milton, 75 Roman Catholic, 11, 15 Röntgen, Wilhelm Carl von, 134 Rorem, C. Rufus, 28–30, 152n11 Rosthern, 47 Royal Canadian Air Force Clinical Investigation, 93 Royal Canadian Legion, 66 Royal Cancer Hospital, 123 Royal College of Physicians (mrcp), 48 Royal Institute of Public Health, 23

190

Royal North West Mounted Police, 19 Rural Municipal Act, 53 Rush Lake (municipal doctor), 28 St Boniface, mb, 4, 11 salaried doctors, xix, 27–35, 71, 75, 80–1, 159n22; loss of due to medicare, 34 Saltcoats: hospital, 5 Sanatoria Act, 53 sanatorium. See Clearwater; Fort Qu’Appelle (Fort San); Ninette; Prince Albert; Saskatoon; Trudeau Saranac Lake, ny, 20 Sarnia (rm): (municipal doctor), 19, 25–7, 34 Saskatchewan Anti-tuberculosis Commission, 49–50 Saskatchewan Anti-tuberculosis League, 20, 45, 51, 54, 58, 61–6 Saskatchewan Association of Rural Municipalities (sarm), 33, 53, 65, 71 Saskatchewan Cancer Agency, 176n39 Saskatchewan Cancer Commission, 119, 122 Saskatchewan Cancer Commission Act, 119 Saskatchewan College of

Index

Physicians and Surgeons, xix, 33, 38, 76, 102, 103, 139, 140 Saskatchewan Gazette, 82 Saskatchewan Health Service Board, 32–3 Saskatchewan Health Services Planning Commission (hspc), 77, 81, 98, 159n22, 163n34, 167n11 Saskatchewan Health Survey, 96–7 Saskatchewan Hospital: North Battleford, 107, 114, 117; Weyburn, 109, 112, 114, 117 Saskatchewan Hospital Services Plan (shsp), 98–101 Saskatchewan Lung Association (sla), 63–4, 66 “Saskatchewan mafia,” 134 Saskatchewan Medical Association, 22, 33, 47, 65, 66, 76, 102, 119; Cancer Committee, 119 Saskatchewan Medical Care Insurance Commission, 92 Saskatchewan Medical Quarterly, 75, 84 Saskatchewan Plan, 114–16 Saskatchewan Psychiatric Nurses Act, 111 Saskatchewan Psychiatric Nurses Association, 111 Saskatchewan Sanatoria and Hospitals Act, 54

191

Saskatchewan Social Assistance Plan, 75–7, 97, 100, 122, 140 Saskatchewan Tumour Registry, 120 Saskatchewan Urban Municipal Association (Saskatchewan Urban Municipalities Association) (suma), 54, 168n25 Saskatchewan Wheat Pool, 102, 142 Saskatoon, xviii, 21, 47, 73, 89, 93, 94, 113, 116, 124, 126, 143; betatron, 126–9; closure of sanatorium, 64; cobalt-60, 129–36; gamma camera, 136; hospitals, 11, 13, 119, 126; medical college, 115; polio clinic, 101; population, 11; psychiatric clinic, 109; Riel Rebellion base hospital, 5–6; sanatorium, 43, 47, 49; school tb survey, 51; tb clinics, 52; tb survey, 61; typhoid epidemic, 11 Saskatoon Agreement, 140 Saskatoon Star-Phoenix, 130, 133 Schmitt, Henry J., 19, 25–7, 32, 151n4 Schrijvers, Klaartje, 140–1 Schultz, Milford D., 126 Science, 134 Senlac (municipal doctor), 28

Index

Seymour, Maurice Bain, 18 Seymour, Maurice M., 18–24 Seymour Plan for immunization, 22 Sharp-tailed Grouse, 6 Shaunavon, 84, 153n30, 161n17 Shaunavon Standard, 161n16 Shepley, Earle E., 119, 120 Sheps, Cecil, 167n11 Sheps, Mindel Cherniak 77, 81–2, 158n9, 167n11 Shumiatcher, Morris C., xviii Sigerist, Henry, 71–6, 93, 95–7, 100, 144, 157n4, 158n6, 158n9 Sigerist Commission report, 35, 71, 75, 77, 93, 95, 108, 110 Simes, Austin, 59–60 Sinclair, Lister, 90 Sisley, (nurse, nursing home), 11, 13 Sisters of Charity (Grey Nuns), 4, 11, 15 Sisters of Providence, 15, 16 Sisters of St Elizabeth, 16 Skaggs, Lester, 124 smallpox, 3–4; vaccination, 22 Smith, Colin, ix, 109 Smith, Ivan H., 133 Smythies, John, 112 Social Assistance Medical Care Plan, 75–6, 77, 97, 100, 122, 140 Stapleford, E.W., 21

192

St Elizabeth’s Hospital, 16. See also Humboldt sterilization, 74 Stewart, D.A., 20, 42–3 Stirrett, R.R., 162n31 Stoughton: school tb survey, 51 Strasbourg, 38, 73 streptomycin, 64 Swift Current, 11, 79–92, 115, 162n27, 162n30, 162n31; hospital, 16, 17; psychiatric clinic, 109; tb clinic, 52 Swift Current Health Region, x, 72, 79–92, 96, 102, 138, 144, 162n27, 163n34 Swift Current Regional Hospital Council, 90 Swift Current Sun, 86 syphilis, 19 Taché, Father (later Bishop), 4 Taylor, Lauriston, 123, 174n19, 179n17 Taylor, Lord Stephen, 72, 91, 140 Taylor, Malcolm G., ix, 37, 40, 71, 92, 99–100, 102, 140, 168n29, 178n10 Thompson Advisory Planning Committee, xix Thompson, Walter P., 129 Thomson, James S., 124–5 Tisdale tb clinics, 52 Tizley, Richard, 61 Toronto, on, xx, 106, 123

Index

Toronto Asylum, 106 Trudeau Sanatorium, ny, 20 tuberculin test, 51, 56, 60; of cattle 20, 21 tuberculosis, 20–2, 41–68, 101, 118, 138, 143, 144; bovine tuberculosis, 20; epidemic among First Nations graph, 57; and First Nations, 43, 55–9 Tuckwell, David Grieve, 36 typhoid, 11, 20, 22, 42 Uhrich, J.M. (health minister), 47 union hospitals, 35–9, 82, 96–7, 143 United Farmers of Canada (ufc), 32, 54 United Kingdom, 23 United States, 28, 98, 105, 123, 129 United States Air Force, 59 United States Public Health Service, 98 University Hospital, 74, 93–5, 116, 126, 130 University Hospital Act, 94 University of Alabama, 173n15 University of Alberta, 122 University of California, Berkeley, 99 University of California, Los Angeles, 75 University of Chicago, 29

193

University of Illinois, 124 University of Manitoba, 59 University of Ottawa, 23 University of Pennsylvania, 118 University of Saskatchewan, 64, 66, 93–5; college of medicine, 93–4, 113, 118–19, 124 University of Toronto, 22, 64, 122 University of Western Ontario, 129 Vachon, Father (Oblate), 11 venereal disease, 19, 74 Venereal Disease Act, 19 Venice Café, 91 Verdun, qc, 105 Vermilion, ab: municipal union hospital, 35 Victoria, bc, 134 Victoria Hospital: Prince Albert, 6; Regina Victoria, 6–7; Queen Victoria, Yorkton, 7; London, on, 132. See also 7–10 Victorian Order of Nurses (von), 6–7, 13 Victor X-ray Corporation, 56 Voth, Abe, 116–17 Wadena: tb clinics, 52; union hospital district, 153n30 Wakaw: Anna Turnbull Memorial Hospital, 11 Ward Island, 105

Index

Warwick, O.H., 127 Watson, T.A., 127, 130 Webb (rm), 81, 85, 163n42 Wesley College, 41 Weyburn, 112, 114; rm, 53; asylum, 107, 117; hospital, 16; psychiatric clinic, 109; psychiatric nursing, 111 Wherrett, G.J., 52 Wherrett-Grzybowski report, 52 White, Paul, 49 Willoughby, J.H.C. (private hospital), 11, 14 Wilton (rm), 36 Windsor, on, 18

194

Winnipeg, mb, 5, 6, 41–3, 49, 56, 136, 151n8, 158n9, 165n4, 173n15; general hospital, 5 Women’s Missionary Society, 13 Wolan, Casimir, 90–1 Yorkton, 7, 19, 42, 144, 168n25; Yorkton Queen Victoria Hospital, 7, 9, 144, 179n15; population, 11; psychiatric clinics, 109; psychiatric cottage hospital, 115, 171n43; tb clinics, 52 Yukon: joined medicare, 141

36 Steps on the Road to Medicare

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36 STEPS ON THE ROAD TO MEDICARE H o w S a s k a t c h e w a n L e d t h e Way

C. Stuart Houston and Merle Massie

McGill-Queen’s University Press Montreal & Kingston • London • Ithaca

© McGill-Queen’s University Press 2013 isbn isbn isbn isbn

978-0-7735-4285-3 978-0-7735-4286-0 978-0-7735-8957-5 978-0-7735-8958-2

(cloth) (paper) (epdf) (epub)

Legal deposit fourth quarter 2013 Bibliothèque nationale du Québec Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free McGill-Queen’s University Press acknowledges the support of the Canada Council for the Arts for our publishing program. We also acknowledge the financial support of the Government of Canada through the Canada Book Fund for our publishing activities.

Library and Archives Canada Cataloguing in Publication Houston, C. Stuart (Clarence Stuart), 1927–, author 36 steps on the road to medicare : how Saskatchewan led the way / C. Stuart Houston and Merle Massie. Includes bibliographical references and index. Issued in print and electronic formats. isbn 978-0-7735-4285-3 (bound).–isbn 978-0-7735-4286-0 (pbk.).– isbn 978-0-7735-8957-5 (epdf).–isbn 978-0-7735-8958-2 (epub) 1. National health insurance – Saskatchewan – History–20th century. 2. Medical policy – Saskatchewan – History – 20th century. I. Massie, Merle, 1971–, author II. Title. III. Title: Thirty-six steps on the road to medicare. ra412.5.c3h72 2013 c2013-904662-3 c2013-904663-1

368.4'20097124

CONTENTS

Abbreviations vii Acknowledgments ix Foreword xiii Introduction xvii 1 2 3 4 5 6 7 8 9 10

Saskatchewan Hospitals: Off to a Slow Start 3 Dr Seymour and Public Health 18 Municipal Doctors and Municipal Hospitals 25 Dr Ferguson and Tuberculosis 41 Sigerist and Pensioners’ Care 69 Swift Current Health Region 79 Medical College and University Hospital 93 Provincewide Hospitalization 96 Innovations in Psychiatry 105 High-voltage Cancer Treatment 118 Epilogue 138 Notes 147 Index 181

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A B B R E V I AT I O N S

act aecl apha bcg ccf dot hbc hspc iode lsd mb bch mrcp nrc nwmp rm rpn sab

Associated Canadian Travelers Atomic Energy Canada Limited American Public Health Association Bacille Calmette Guérin vaccination (tb) Co-operative Commonwealth Federation Directly Observed Therapy Hudson’s Bay Company Health Services Planning Commission Imperial Order Daughters of the Empire D–lysergic acid diethylamide Bachelor of Medicine, Bachelor of Surgery Member, Royal College of Physicians National Research Council North West Mounted Police Rural Municipality Registered Psychiatric Nurse Saskatchewan Archives Board

Abbreviations

sarm Saskatchewan Association of Rural Municipalities sca Saskatchewan Cancer Agency sdcmh Saskatchewan Division, Canadian Mental Health Association shsp Saskatchewan Hospital Services Plan sla Saskatchewan Lung Association sti Sexually Transmitted Infection uhd Union hospital district von Victorian Order of Nurses

viii

ACKNOWLEDGMENTS

stuart houston I was indebted to many people prior to 2002. Early in the process, Eleanor McKinnon, private secretary to Premier T.C. Douglas; Malcolm Taylor, former secretary to the Health Services Planning Commission; and Hon. Walter Smishek, former minister of health, provided interviews. Hon. Sylvia Fedoruk wrote the foreword and critiqued the chapter on high-voltage radiation. Joan Feather and Lester Jorgenson critiqued the chapter on the Swift Current Health Region, and provided additional information. Dr Colin Smith critiqued the chapter on psychiatry, and Drs Ian McDonald and Frank Coburn provided interviews. Pat Matthews gave me biographical material and a photograph of her late husband; Mrs William Burak provided a small photo of her late husband. The Saskatchewan Archives Board provided most of the photographs. Michael West provided permission to use the copyrighted photograph of Malcolm Taylor. The portrait of Henry Sigerist came from the Alan Mason Chesney Medical Archives at the Johns Hopkins Medical Institutions.

Acknowledgments

Associated Medical Services Inc., through its Hannah Institute for the History of Medicine Program, kindly gave permission to use material from R.G. Ferguson, Crusader against Tuberculosis (1991). The Canadian Medical Association Journal and the Annals of the Royal College of Physicians and Surgeons have each allowed use of portions of four of my articles published in their journals, as cited individually in the references. Dr John W. Aldrich and Dr Brian C. Lentle have allowed extensive use of the Houston and Fedoruk chapter in their 1995 book that marked the centennial of Röntgen’s discovery of xrays. The Canadian Broadcasting Corporation program Ideas kindly allowed use of three excerpts from the radio program of 5 December 1990. Zennon Slowski and Dr Donald S. Houston solved my computer problems. The entire manuscript was read critically in 2002 by Allan E. Blakeney, Mary I. Houston, and J. Frank Roy, and by doctors Ronald M. Bremner, Louis Horlick, Stan Houston, and Robert Lampard. I am grateful for their insightful comments and corrections. With the help of my co-author, Merle Massie, this revised manuscript adds several critical dimensions to the medicare story. The origins and impact of the Swift Current Health Region and Saskatchewan’s psychiatric innovations have received expanded attention. We have reoriented Saskatchewan’s roots in First Nations and fur trade experience. Other additions include coverage of the Red Cross Outpost Hospitals, poliomyelitis, the air ambulance, the Matt Anderson plan, a more in-depth look at Saskatchewan’s advances in cancer treatment, and a tribute to Sylvia Fedoruk. Stuart expresses his personal assessment of the implementation of medicare in 1962, and its continued influence,

x

Acknowledgments

in the epilogue. The revised manuscript was improved by Erika Dyck and Greg Marchildon. Any residual errors or omissions are the responsibility of the authors. merle massie I would like to thank Stuart Houston for allowing me to have a part to play in this revised version of Steps on the Road to Medicare. As a historian, I emphasize the social context behind the remarkable achievements listed here. Stuart is an exceptional collaborator – he kept me fascinated, and often in stitches, with his assessments of Saskatchewan people, places, and events. The revised version holds Stuart’s central narrative voice, but fills out the story of Saskatchewan’s adventures in health care transformation.

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FOREWORD B Y S Y LV I A O . F E D O R U K

Saskatchewan has been a leader in many aspects of health care. These developments arose from the co-operation and mutual help necessary among pioneer settlers, sparsely distributed in a relatively hostile environment. House-raising, barn-raising, and the building of community amenities such as schools and curling rinks made it logical for other co-operative developments also to occur. These accomplishments took place in an atmosphere of community, creativity, and trust. Individuals with foresight such as Drs Seymour, Ferguson, Blair, and Johns helped Saskatchewan to lead the world. In 36 Steps on the Road to Medicare: How Saskatchewan Led the Way, Stuart Houston reviews many of the exciting events in a story that reflects the strengths of Saskatchewan people. Stuart, himself, is truly a part of Saskatchewan history. He served on the executive of the Canadian Society for the History of Medicine from 1979 to 1987, including two years as

Foreword

president. His published works in medicine and the history of medicine number 288, including four books, seventeen chapters in books, and sixty-nine original scientific articles. His published works in ornithology and natural history number 681, including eight books, forty-three forewords or chapters in books, and 292 original papers. His interest in ornithology is legendary, especially in bird-banding – he and his wife, Mary, have banded over 147,000 birds of 211 species, with 3,800 recoveries or encounters. Stuart is professor emeritus of medical imaging at the University of Saskatchewan. Our paths have intertwined over many years. We both took our schooling in the Yorkton area of Saskatchewan in the 1940s. For about twenty years, until my retirement in 1986, Stuart and I collaborated in teaching radiation physics, the “Stuart and Sylvia show,” to first-year medical students at the University of Saskatchewan. When I was chancellor, it was my privilege to present him with a DLitt degree (1997), although he had taken no classes and written no exams. Most of the medical students appreciated him – he is the only medical doctor to have been elected honourary president of the Student Medical Society three times, including in his last full year of teaching and practice. Stuart received Saskatchewan’s highest honour, the Saskatchewan Order of Merit, in 1992, and was made an Officer of the Order of Canada in 1993. In 1997, he was the fourth recipient of the Gold Medal of the Canadian Association of Radiologists. His most recent honourary degree was a DCnL, in 2002. The Honourable Sylvia O. Fedoruk, oc, som, dstj, ba, ma, dsc, lld, dhuml, fccpm

xiv

Foreword

authors’ note Sylvia Fedoruk died, independent to the end, in her home, on 26 September 2012 at age 85. As an undergraduate, Sylvia received the Governor-General’s medal “as the most distinguished graduate of any college,” together with the Spirit of Youth award for her achievements in athletics and student governance. She was both the top academic and the top female athlete: a member of twelve university championship teams in basketball, track and field, golf, volleyball, and hockey. Canada’s first women’s world curling title came later. Sylvia’s entire academic career was spent on the campus of the University of Saskatchewan, where she was director of physics services for the Saskatchewan Cancer Foundation, chief medical physicist for the Saskatoon Cancer Clinic, and professor of oncology. She was the first woman member of the Atomic Energy Control Board of Canada. In 1986, Sylvia Fedoruk was the first female chancellor of the University of Saskatchewan (1986–89). Two years later, she served six years as the first woman Lieutenant Governor of Saskatchewan (1988–94). She received five honourary doctorates, the Queen’s Jubilee Medal (1977), and the Taras Shevchenko Award of the Ukrainian Canadian Congress. In 1986 she was made an Officer of the Order of Canada and was awarded the Saskatchewan Order of Merit. In 2009, she was inducted into the exclusive Canadian Medical Hall of Fame. Rarely if ever has any woman anywhere been such an achiever in so many different fields – and never has that achiever re mained to the end so humble and so modest.

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INTRODUCTION Medicare is considered to be the most valued social programme in Canada today. Canadians have rated it as their most important concern, ahead of programmes in employment and social welfare … medicare is an essential part of Canada’s national identity and part … of what it means to be Canadian.1

Most of the steps that led to medicare were forged in Saskatchewan. The events described in this book changed the course of health care throughout Canada. There is a certain danger in listing all the times Saskatchewan was “first,” leaving us open to charges of hero-worship, bragging, and jingoism. In this revised edition, my co-author Merle Massie and I enumerate these “firsts,” with one caveat: we do not say that all of these firsts are, therefore, key “steps” on the road to medicare that should be followed by other jurisdictions around the world. Some were. Others showcase Saskatchewan’s vivid and path-breaking leadership. Yet we hope those connected with Saskatchewan will be proud of the recurring themes of co-operation, innovation, and rapid response to need throughout Saskatchewan’s ninety-seven year history of health care. But one question must somehow be addressed. Why was Saskatchewan so consistently the leader? Why not Alberta? Manitoba? Nova Scotia?

Introduction

Allow me to begin with a vignette from my own experience. As an amateur medical historian who in most years meets with the men and women of the Canadian Society for the History of Medicine, I understand full well, from the experiences narrated by friends at these meetings, the need to question conventional wisdom, folk legends, and mythology. I had been told many times that Premier Tommy Douglas of Saskatchewan had okayed development of the world’s first betatron to treat cancer after one visit from Allan Blair and Harold Johns, probably in 1946. This story was surely partly legend, and perhaps apocryphal folklore. Or was it? So, when I had the chance to hear the truth first-hand, I seized the opportunity. T.C. Douglas was coming to Saskatoon to give a speech at a major New Democratic Party (ndp) banquet on 18 February 1983. I phoned Peter Prebble, my ndp Member of the Legislative Assembly, and asked whether I could be booked for a short interview with Douglas. Peter phoned back to say that his schedule was full, but that if my wife, Mary, and I would come to the banquet, we would be assigned to drive Douglas back to his lodgings at the Bessborough Hotel. We accepted this unusually innovative offer with alacrity. I had met Douglas only a few times. The first time, when I was a student, he was a guest in my family home in Yorkton, together with his personal advisor and assistant Morris C. Shumiatcher. I have a vivid memory of these two men standing beside the fireplace after supper, my six-foot-four father towering over both. Early in Douglas’s career as Co-operative Commonwealth Federation (ccf) premier of Saskatchewan, my father had been on the committee that negotiated payments to doctors for treating impoverished people receiving social assistance. Later, Dad served as one of three doctors nominat-

xviii

Introduction

ed by the Saskatchewan College of Physicians and Surgeons on the Thompson Advisory Planning Committee on Medical Care. The interim report of the Thompson committee recommended a system of universal health coverage, financed by direct taxation and general revenues, and run by a non-political commission. Doctors would be paid on a fee-for-service basis, rather than by salary as in a state medicine system. Premier Douglas recommended the commission “because it was requested by the doctors, and because it would assure no political interference.”2 This was surely one of many examples of Douglas’s pragmatism. As a high-school student, I had typed some of Dad’s letters and briefs during his time on this commission. As I drove Douglas back to the hotel in 1983, he asked after my parents and spoke well of both, the rancor of the so-called doctors’ strike in 1962 notwithstanding. Time was short and Douglas needed to go to bed. I asked my well-prepared questions, and as I remember it, the conversation went as follows: csh: Do you remember the day that Harold Johns and Allan Blair dropped into your office to ask for permission to buy a betatron to treat cancer? tcd: Yes, clearly, as if it were only yesterday. csh: Is it true they came unannounced, without an appointment? tcd: Probably. I had an open-door policy, guided by my trusted secretary Eleanor McKinnon. [Later an interview with Miss McKinnon in Regina confirmed that unscheduled visits were the rule. Douglas made it a policy to help any Saskatchewan citizen. The system worked best without fixed appointments.]3 csh: Is it true that you listened to their “pitch,” asked for an approximation of the probable cost, and that they then

xix

Introduction

walked out of your office with a virtual carte blanche to proceed? tcd: Yes. csh: Is it true that you made this decision without consulting your treasurer, Clarence Fines, or any member of your cabinet? tcd: Absolutely. csh: Is it true that you made this important decision without consultation with any other medical doctors or physicists, or any outside agency? tcd: I believe that to be true. csh: How did you justify making such a momentous decision on the spur of the moment? tcd: Well, after all, I was both premier and minister of health. csh: How did you have the courage to do this without consultation with anyone at all? tcd: Well, it was easy. I had complete confidence in the knowledge and the integrity possessed by both men. They assured me that highvoltage radiotherapy offered great promise in the treatment of cancer. Dr Allan Blair had come from Toronto to head up the leading cancer agency in North America. And Harold Johns! Why, when I attended Brandon College, Alfred Edward Johns was my mathematics teacher and my favourite professor. He had been a missionary in Chengtu [Chengdu], West China, until 1924. His son, Harold, had been born in China. I was both poor and undernourished. The osteomyelitis in my femur was chronic, would periodically break down and issue pus, and this ran me down. The Johns family took pity on me and often had me over for Sunday supper in a deliberate attempt to put

xx

Introduction

some weight on my frame. It was evident that their son, Harold, showed unusual promise. So, with my close personal knowledge of both men and my complete faith in their integrity, my permission did not seem to me to be a gamble at all. I told this story in March 2002 to Shirley Douglas on a phonein program on cbc radio, and she thanked me for it.4 I don’t think she really believed her father had been that rash, making so important a decision so quickly. But the story as told above is an example of a visionary in action. Douglas was a leader, the “right man in the right place at the right time,” who moved events forward. This helps to explain why, on 29 November 2001, T.C. (Tommy) Douglas easily topped a month-long national cbc television poll as “The Greatest Canadian.” He was one part of the answer to “How Saskatchewan led the way.”

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36 Steps on the Road to Medicare

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CHAPTER 1

S A S K AT C H E WA N H O S P I TA L S Off to a Slow Start

To maintain a little balance in an unabashed book of firsts, it seems only fair to admit that the area that became Saskatchewan in 1905 was slow off the mark – the advent of hospitals was delayed in comparison with adjacent Manitoba and Alberta. Of course, health care, for thousands of years, had been in the hands of medicine men and women in what became Saskatchewan. They had practical knowledge of effective herbal remedies, and a cultural and spiritual connection to community and to the land. When smallpox, that scourge of the North American First Nations, hit Saskatchewan in the winter of 1781–82, traditional medicine was of no use. The fur trade community at Cumberland House organized itself as a de facto field hospital. “Indeed, I have no Medicines to Give him that is fit for that Disorder,” lamented Hudson’s Bay Company (hbc) Master William Tomison on 30 December 1781. Still, Tomison took in the sick, “& they have due attendance Night & Day &

36 Steps on the Road to Medicare

yet there is but little hopes of their recovery, most of them being greatly Starved before they came here.”1 Smallpox returned in 1816. Cowpox vaccinations, developed in Europe, were used in western Canada among the First Nations, stemming what could otherwise have been a severe outbreak. A third epidemic appeared in 1870. The hbc took the lead, through its posts, in providing the vaccine and teaching residents arm-to-arm vaccination techniques.2 It should come as no surprise that, given the fur trade origins, the first hospital established in what is now Saskatchewan was along the fur trade highway of the Churchill River at Ile-àla-Crosse. Three dedicated Sisters of Charity (Grey Nuns), Sisters Agnes, Boucher, and Pépin, arrived there in 1860 with Bishop Grandin after an arduous journey of fifty-seven days in an open barge from St Boniface. This was only fourteen years after Father Taché (later Bishop Taché) set up his mission among the First Nations and a few French-speaking trappers. The three sisters established a convent, a dispensary, and a mission school.3 In 1873 they began the formal operation of a hospital.4 Later, with the construction of each North-West Mounted Police barracks, a building was set aside as a hospital. Fort Walsh in the Cypress Hills was first in 1875, followed by Qu’Appelle in 1881, Regina and Maple Creek in 1883, and Battleford and Prince Albert in 1884.5 When Dr Augustus L. Jukes was appointed senior surgeon to the North-West Mounted Police in 1880,6 and stationed at Fort Walsh, he appointed a pharmacist as hospital steward. In 1885, two temporary military hospitals were created to care for wounded men evacuated from the battles of the Riel Rebellion. The first was a frame building with forty beds erected at Moose Jaw by the government. The head nurse was Hannah Grier Coombs, known as Mother Hannah, who later founded

4

Figure 1.1 Saltcoats cottage hospital (sab r-a23797)

the Anglican Sisterhood of St John the Divine. The second, Saskatoon’s temporary base hospital with up to eighty patients, was staffed by Dr James Bell of Montreal, Miss Millar (head nurse of the Winnipeg General Hospital, on loan), Nurse Phoebe Parsons, and Nurse Elkin. When the last Saskatoon patients were evacuated to Winnipeg by river barge and steamer, via Grand Rapids, the southern half of present-day Saskatchewan was again without a hospital.7 The first public hospital, at Saltcoats, was too far ahead of its time. Built in 1896, it opened in 1897 with a resident medical superintendent, a matron, and three trained nurses (figure 1.1). An early tragedy sullied its record on 4 January 1898. Nurse Biggins went to the basement carrying a coal oil lamp, which hit an overhead beam, broke, and set her clothes on fire. She died the next day. By year’s end, only forty-nine in-patients

5

36 Steps on the Road to Medicare

had been treated, but 374 days of free treatment had been provided. With its record of bad luck, and so many patients unable to pay, the hospital was closed in 1899.8 When the railroad reached “Pile of Bones” in 1882, it became the capital city of the North-West Territories. Canada’s governor general, the Marquis of Lorne, was asked to give the new village a more suitable name. Since he was married to Queen Victoria’s daughter, he christened it Regina in honour of his mother-in-law. Despite their town’s designation as a capital city, Regina citizens requiring hospital care were forced to take the train east to Brandon or Winnipeg until late in 1889. That year the first general hospital in the North-West Territories opened in Medicine Hat, with forty beds and a $5 hospitalization (insurance) option as part of their 1889 fundraising project.9 Regina patients alone accounted for 1,623 days of in-patient care in the Medicine Hat hospital in 1895.10 For nine years, Regina had only the Mary E. Truesdell Nursing Home, founded in August 1889. In 1896 the Regina branch of the National Council of Women began to raise money for a cottage hospital, with nurses supplied by the Victorian Order of Nurses (von). The cottage hospital opened in 1898 (figure 1.2). Meanwhile, in Prince Albert, the Victoria Hospital began with a small building in 1899 (figure 1.3). Its Ladies’ Aid, among other contributions for the hospital, received nightshirts and a tablecloth, as well as a brace of Sharp-tailed Grouse, two dozen eggs, and six cakes to feed the patients.11 At the end of 1899 there were two hospitals, each with seven beds, to serve about 90,000 people in fast-growing Saskatchewan.12 In 1899, the foundation was laid for a new twenty-five-bed hospital on Hamilton Street, just south of 14th Avenue in Regina. The von contributed $1,500, with the proviso that the new hospital be named the Regina Victoria. Lady Minto, wife

6

Off to a Slow Start

Figure 1.2 Victorian Order of Nurses Hospital, Regina (sab r-b535)

of the governor general, formally opened it in September 1901 (figure 1.4). A nursing training school began at once, with three students in the first class. The hospital continued to expand and was taken over by the City of Regina in 1907. It has been the largest hospital in Saskatchewan ever since. The third permanent hospital in southern Saskatchewan, the Queen Victoria Hospital (figure 1.5), opened in my hometown of Yorkton in 1902; the drive for $1,800 was sparked by one of my heroes, Dr T.A. Patrick. The von contributed $3,000. Here began the second school of nursing. One of the graduates of this unaccredited school in 1917 was Margaret Fraser. After her husband died, Margaret Fraser Myles took upgrading and returned to be matron of the Yorkton hospital in the late 1920s. She then moved to Aberdeen, Scotland, where she became the author of the world’s best-selling Textbook of Midwifery, ten editions of which appeared between 1952 and 1985.13 The Moosomin hospital, the first between Brandon and Regina, also opened in 1902 (figure 1.6).

7

Figure 1.3 Victoria Hospital, Prince Albert (sab r-a1679)

Figure 1.4 Regina Victoria Hospital, Regina (sab r-b386)

Figure 1.5 Queen Victoria Hospital, Yorkton (Howard M. Jackson)

Figure 1.6 Moosomin Hospital (sab r-a218)

36 Steps on the Road to Medicare

Figure 1.7 Lady Minto Hospital, Indian Head (sab r-b10943)

The fifth and sixth hospitals opened in Maple Creek in 1904 and Indian Head (figure 1.7) in 1905. Both had nursing training schools. Maple Creek began as an eight-bed cottage hospital, but moved into a twenty-bed brick building in 1908. Nursing training continued until 1925 at Indian Head and 1935 at Maple Creek.14 When Saskatchewan was proclaimed a province in 1905, there were six hospitals in operation, four of them with nursing schools. Their seventy-five beds served over 250,000 peo-

10

Off to a Slow Start

ple. In the 1901 census, populations of the main towns were as follows: Regina 2,249, Prince Albert 1,785, Moose Jaw 1,558, Moosomin 868, Yorkton 700, Battleford 609, and Maple Creek 382. By 1906 two more centres had grown to more than 1,000 in population: Saskatoon with 3,011 and Indian Head with 1,545 inhabitants. Two of the eleven new towns with between 500 and 918 people in 1906 (Battleford 824 and Swift Current 554) soon built hospitals. Thus each centre with a population of 500 in 1900 or of 1,000 in 1906 had a hospital by 1912. In 1906, a twenty-eight-bed, four-storey general hospital opened in Moose Jaw (figure 1.8), just in time to care for victims of a typhoid epidemic. The building was steam-heated, but it had no elevator. That year a small rented building opened as a hospital in Lloydminster,15 and the Presbyterian Church opened the Anna Turnbull Memorial Hospital (figure 1.9) near their mission house in the hamlet of Wakaw.16 With the 1906 typhoid epidemic in the rapidly growing town of Saskatoon (which grew from 2,000 to 3,000 during the year), the eight beds in Nurse Sisley’s nursing home (figure 1.10) were quickly filled; cots were set up in surrounding buildings and even in the open grounds. The overflow of typhoid patients was taken to the new Roman Catholic rectory on Fifth Avenue, where Oblate Fathers Vachon and Paille cared for them around the clock. Propitiously, two Sisters of Charity from St Boniface came through Saskatoon in September. Although on a fundraising mission, they were pressed into service. In temporary quarters they cared for thirty-four severely ill typhoid patients, four of whom died. On 22 February 1907, the Grey Nuns purchased Dr J.H.C. Willoughby’s private home on Pleasant Hill, just west of the Saskatoon city limits. They opened it with seventeen patient beds on 10 March 1907 (figure 1.11).17 A three-storey

11

Figure 1.8 General Hospital, Moose Jaw (sab r-a7260)

Figure 1.9 Anna Turnbull Memorial Hospital, Wakaw (sab r-a12696)

Figure 1.10 Nurse Sisley’s Nursing Home, Saskatoon (A. Becker)

brick building was added in 1913 (figure 1.12). A new Saskatoon City Hospital opened with fifty-six beds in April 1909; its official history claims it as the first municipal hospital in western Canada (figure 1.13).18 In 1907 the Grey Nuns Hospital was founded in Regina and the twenty-three-bed Lady Minto Hospital, operated by the von, opened in Melfort. The Women’s Missionary Society of the Presbyterian Church established a small hospital in Canora, which

13

Figure 1.11 Dr J.H.C. Willoughby’s home, Saskatoon (A. Becker)

Figure 1.12 St Paul’s Hospital, Saskatoon (sab r-b1358)

Off to a Slow Start

Figure 1.13 City Hospital, Saskatoon (sab r-a3511)

expanded to become the thirty-bed Hugh Waddell Memorial Hospital in 1914. The Lashburn Hospital was built with a $10,000 bequest. In 1909, it offered the first hospital insurance scheme: a $5 ticket entitled one person to three weeks of hospitalization.19 The growing need for hospitals in other cities and towns was filled by Roman Catholic sisters. Sisters of Charity came from the Maritimes to open the twenty-five-bed Holy Family Hospital in Prince Albert in 1910, and Sisters of Providence came from Montreal to found Notre Dame Hospital in North

15

Figure 1.14 Notre Dame Hospital, North Battleford (sab r-b5148)

Battleford in 1911 (figure 1.14). In 1912, Sisters of St Elizabeth came from Austria to launch St Elizabeth’s Hospital in Humboldt and Sisters of Providence from Kingston opened the thirty-bed Moose Jaw Providence Hospital in 1912.20 That year, general hospitals opened in Swift Current (figure 1.15) and Weyburn (figure 1.16).21 By 1912, in terms of availability of hospitals, Saskatchewan was beginning to catch up with its two neighbouring provinces.

16

Figure 1.15 Swift Current Hospital (sab r-a3351)

Figure 1.16 Municipal Hospital, Weyburn (sab r-b129)

CHAPTER 2

DR SEYMOUR A N D P U B L I C H E A LT H

Maurice M. Seymour is the pacesetter in our story. Born 7 July 1857, in Goderich, Ontario, Seymour was one of three children of Captain Maurice Bain Seymour, who hailed from Ireland, and Maria MacDonald, who came from Scotland. He began his studies at Assumption College, Windsor, Ontario, in 1873 and then obtained his medical degree from McGill University in 1879. Rather unusually for those times, he took two years of postgraduate study before he went into practice.1 After employment with the Canadian Pacific Railway during its construction in 1881–83 and service in the Riel Rebellion in 1885, Seymour practised in the beautiful Qu’Appelle Valley, forty-five miles northeast of Regina. He moved to Regina one year before Saskatchewan’s formal birth and was appointed Provincial Medical Health Officer on 10 April 1906.2 He spent the rest of his professional life in charge of public health in the new province. For his first seventeen years, public health had a low profile, as a mere branch within the large and powerful Department of Agriculture (under Hon. W.R. Motherwell), and then within Municipal Affairs. In 1909, Seymour was instrumental in preparing the Public Health Act, which established a Bureau of Public Health.3

Dr Seymour and Public Health

Whatever his title and whichever government department he worked within, Seymour laid a solid, achievement-filled, and logical foundation for public health. His enforcement arm was the Royal Northwest Mounted Police. In the new province in 1905, Seymour saw that financial aid, 50 cents per patient day, was needed for the six hospitals – in Prince Albert (1899), Regina (1901), Yorkton and Moosomin (1902), and Battleford and Indian Head (1905). One of Seymour’s strengths was his ability to react rapidly to provincial needs by drafting forward-looking legislation that would receive support from members of both political parties. Some of his actions were firsts for Canada. Responding quickly to the needs of the Rural Municipality (rm) of Sarnia #221, which had used $1,500 of tax money in 1915 to retain Dr Schmitt in that community (see chapter 3), the legislature the very next year amended the Municipalities Act to allow use of municipal taxes to build a hospital, hire a nurse, or expend up to $1,500 to hire a doctor – a first in North America. Seymour also drafted Saskatchewan’s Venereal Disease Act in 1920, with a revision in 1923. This was not a first in Canada, for Alberta had passed its own act and had begun offering free treatment in 1918. Venereal disease (vd, now known as sexually transmitted infection or sti) was relatively common, particularly syphilis. Saskatchewan offered free diagnosis and treatment. On a single day in 1924, in Regina, the vd clinic treated 100 adults, half of them for syphilis and half for gonorrhea, and five children for congenital syphilis.4 In 1912, only one birth in twenty occurred in hospital. By 1923 this figure had risen to one in six. Sadly, childbirth continued to take a toll on mothers. In 1926, Saskatchewan had the highest maternal mortality rate in Canada.5 Nevertheless, to help with the financial costs of hospital births, Seymour designed a “Maternity Grant” of $25 in 1914 as a boon to farm 19

36 Steps on the Road to Medicare

women in particular, providing $15 for the attending physician and $10 for clothes and bedclothes for the baby.6 In 1920, seventeen mothers applied; in 1921, 125; in 1922, 253; in 1923, 286; and in 1924, 427.7 By 1923, there were 2,253 hospital beds in a province of 770,000, or 3.4 beds per thousand population. Since people were often quite sick before they entered hospital, it is not surprising that the average stay was 12.7 days.8 One of the biggest public health problems was tuberculosis (tb). Soon after Seymour’s son was treated at the famous Trudeau Sanatorium at Saranac Lake, New York, Seymour organized the public meeting on 17 February 1911 that formed the Saskatchewan Anti-tuberculosis League. He persuaded the league to build its first sanatorium in an attractive coulee nestled in the Qu’Appelle Valley, facing Echo Lake and protected from north winds. At that time, bovine tuberculosis caused 25 per cent of tb deaths among Saskatchewan children; 18 per cent of 456,000 cattle tested were positive for tb.9 Eventually, Seymour achieved uniform, free tuberculin testing of cattle. On the advice of Dr D.A. Stewart of Ninette, Manitoba, Seymour hired Dr R.G. Ferguson to run the province’s tuberculosis program (see chapter 4). With typhoid fever, bovine tuberculosis, and summer dysentery all taking a toll, the Canadian Public Health Association appointed Seymour chairman of a countrywide study of milk problems in Canada from 1924 through 1926. Seymour’s group sent fifty-two questions to every Canadian city with a population over 20,000 and published the results.10 They reported that Canada’s per capita milk consumption was 0.4 litres/day (compared to New York City at 0.3). More deaths in Canada were due to milk than to any other food. For example, there were 42 deaths from 619 instances of typhoid

20

Dr Seymour and Public Health

Figure 2.1 Dr Maurice M. Seymour (sla)

and scarlet fever and an unknown number due to tuberculosis, all presumed to have been transmitted by milk. Dr E.W. Staple ford, president of Regina College, told a hearing about the deaths of 8 of his 204 students and 1 of his teachers from raw milk delivered daily from a farm a few miles outside Regina. Stapleford described “nine coffins being carried out.”11 Saskatchewan led in the tuberculin testing of cattle. In April 1917, the City of Saskatoon was the first in Canada to inspect

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36 Steps on the Road to Medicare

and license all dairy herds supplying the city; cows were tested by the Dominion Health of Animals Branch. Five other Saskatchewan cities and four towns followed. An additional thirty-one towns and seventy villages had organized preliminary inspection and licensing. Seymour recommended pasteurization of milk (heating to 142–145°f for thirty minutes, then cooling until delivered), but his suggestion was difficult to implement during hot summer days. Diphtheria was another serious problem; in 1917, Seymour began giving out free antitoxin to be dispensed by the medical profession. Seymour was not an unduly modest man (figure 2.1). In 1926 he published his Atlantic City presidential address to the Conference of State and Provincial Health Authorities under the title “The Seymour Plan.” He asked general practitioners to immunize against diphtheria in September and October, smallpox during November and December, and typhoid during January and February.12 He tried to make public health simple and easy to understand, with such slogans as “Do not spit” and “Swat the fly.” Cancer increased steadily during his tenure, until it edged out tuberculosis by exactly one death in 1924. That year, however, Saskatchewan had the lowest general death rate of any portion of the British Empire.13 Seymour was a member of the North-West Territories Med ical Council from 1885 to 1905 and served twice as president. He organized the Saskatchewan Medical Association in 1906. He was one of the first in Canada to obtain a diploma in public health from the University of Toronto. In 1915 he served as president of the Canadian Public Health Association and as vice-president of the American Public Health Association (apha). In 1923 he represented Canada at the Health Section, League of

22

Dr Seymour and Public Health

Nations. In 1925 he was elected president of the Conference of State and Provincial Health Authorities. He was honoured as a fellow of the Royal Institute of Public Health in the United Kingdom, a fellow of apha, and a recipient of an honourary lld degree from the University of Ottawa in 1925. Dr Lillian Chase described him as “a great organizer, a man of varied gifts and charming personality, [who] enjoyed the esteem of all.”14 Why was Seymour so successful? In part the answer is personal: he was a capable administrator, with unceasing energy. His greatest strength was his ability to harness Saskatchewan’s highly developed co-operative spirit. He could achieve support from municipal councils (in enforcing health laws for the common good, even when this might seem elsewhere to impinge too much on personal freedom); teachers (one year he sent a letter to each teacher in the province); clergymen (when launching a vaccination campaign, he would ask that an announcement be read from the pulpit on the preceding Sunday); rural Homemakers’ Clubs (who assisted, gratis, the doctors and nurses during his vaccination campaigns), and weekly newspapers (which published his weekly article on health). Seymour’s success was also based on the province’s strength: while he was in charge of public health, Saskatchewan grew to be the third most populous province in Canada, flowing with investment, agricultural wealth, and new people. Seymour was not superannuated until 1 November 1927, at age seventy, when he became medical advisor to the government on public health matters. His greatest gift to the people of Saskatchewan was his unbelievably rapid response to the grassroots development of municipal doctors and municipal hospitals. He also laid a sound foundation for Saskatchewan’s future leadership in health. Policy analyst Robert McLaren declared that Seymour, in serving Saskatchewan so long and so well in

23

36 Steps on the Road to Medicare

his specialty of public health on the provincial, national, and international stages, serves as the prototype of a proactive public servant fostering services to enhance the well-being of the citizenry.15 He died on 16 January 1929, at seventy-one, fifteen days after Saskatchewan initiated the first universal free treatment for tuberculosis, the next stepping stone on the road to medicare.

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CHAPTER 3

MUNICIPAL DOCTORS AND MUNICIPAL HOSPITALS

Saskatchewan’s early population growth required new innovations in municipal medical services, and from 1915, laid the foundation for modern medicare. Both municipal doctor plans and municipal hospital schemes found traction first in Saskatchewan.

1. The first municipal doctor in North America: Dr Henry Schmitt of Holdfast, 1915 One major step on the road to medicare occurred in the Rural Municipality of Sarnia. The Holdfast history book, History and Heritage, quotes the motion passed by the council of the rm of Sarnia #221 in January 1914: “That Council advertise for a doctor … Also first correspond with Dr Schmitt of Newton, Illinois, in regard to locating here.” Perhaps Schmitt wrote to Holdfast in response to advertisements, which talked of “The Last Great West” and the “Beautiful Last Mountain Valley

36 Steps on the Road to Medicare

Figure 3.1 Dr H.J. Schmitt, graduation photo (Mary Bradshaw)

where crop failures are unknown,”1 or the contact may have been made by a farmer who had moved from Illinois, lured by the promise of free land in Saskatchewan. In the Sarnia Council minutes of 25 June 1914 it is recorded that Dr Schmitt was “appointed Medical Health Officer for the village [of Holdfast] to take effect on 1 July and that Dr Chapman of Dilke [should] be notified to that effect.”2

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Municipal Doctors and Municipal Hospitals

According to the Holdfast history, “Dr Schmitt covered great distances to minister to the sick” (figure 3.1). Since the rm of Sarnia included nine townships and most roads were prairie trails, his early mode of travel was horse and gig in summer, and horse and cutter in winter. In 1915, he bought a Model T Ford for summer travel when roads permitted.3 That year Dr Schmitt had difficulty collecting enough money from the impoverished farmers and considered moving on to the larger and more prosperous community of Craik.4 Because the people of the municipality were much concerned, the Sarnia council agreed to vote funds from tax money to pay a retainer to Dr Schmitt. This agreement was the first municipal doctor arrangement in North America.5 To keep Schmitt in the community, the rural municipality paid him a stipend of $1,500 in 1915 and $2,500 in 1916.6 Minister of Agriculture the Honourable George Langley, in charge of health matters, wrote to rm Sarnia, “We watch your experiment hopefully but skeptically.” But as the Holdfast history recorded, Langley “need not have worried. Every settler in the area would soon attest to the fact that Dr Schmitt’s services far outweighed the remuneration he received.”7

2. The first municipal doctor legislation in North America, 1916 In 1916 the Saskatchewan Legislature, influenced by provincial Commissioner of Health Maurice Seymour, enacted the Municipal Hospital Act, permitting rural municipalities to make a grant to physicians to supplement their income, such grants not to exceed $1,500. This made legal what rm Sarnia had already done. In 1919, legislation was enacted whereby a rural municipality might engage a physician on a salary – not to

27

36 Steps on the Road to Medicare

exceed $5,000 – to provide medical care to the residents of the municipality. In 1932, provision was made whereby portions of municipalities might engage the services of a physician, or two or more municipalities could co-operate. By 1935, provision was made in the Town and Village acts for an assessment of up to $2 per head of population, according to the last Dominion census, to engage a physician. In 1937, a further change permitted the raising of a sum of $5,000 for a surgeon. Finally, in 1941, the Rural Municipality Act was amended to permit physicians to be paid on a fee-for-service basis from public funds. how successful were the municipal doctor plans?

The report of the Committee on Municipal Physicians, presented by Dr D.S. Johnstone, a Regina surgeon, to the Canadian Medical Association annual meeting in Regina in 1927 provides a snapshot of Saskatchewan’s success. That year there were thirteen municipal doctors in Saskatchewan, practising in twelve localities: Holdfast, Craik, Beechy,8 Bethune, Birsay, Brock, Chamberlain, Freemont, Leroy, Lintlaw, Rush Lake, and Senlac. Most municipal doctors were paid between $3,500 and $5,000. All medical needs of ratepayers and their hired help were covered. The Johnstone committee stated that Craik and Holdfast were “old and well settled municipalities, where the practice was quite able to sustain one or more doctors in each municipality – it was apparently a straight case of going out to hire a doctor in the hope of saving money [and] attendance fees.”9 The municipal doctor system attracted the interest of the Committee on the Costs of Medical Care in the United States. They sent C. Rufus Rorem, an economist, to study the situation in 1929 and 1930. His studies resulted in an eighty-fourpage book in 1931.10 Rorem’s map (figure 3.2) showed the

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Municipal Doctors and Municipal Hospitals

Figure 3.2 Rorem’s map of where municipal doctors were located in Saskatchewan (courtesy University of Chicago Press)

location of the thirty-two municipalities with municipal doctors in Saskatchewan.11 Twenty employed a total of twenty-one fulltime doctors; twelve other municipalities had part-time agreements with sixteen physicians.12 Seven municipalities engaged municipal doctors for the first time in 1929, while another four did so in 1930. In 1930, Saskatchewan had 558 licensed practitioners and a total hospital bed capacity of 3,357, but only one of the municipal doctors had a hospital to work in. Of

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36 Steps on the Road to Medicare

Saskatchewan’s inhabitants, 69 per cent lived on farms, 9 per cent in 377 villages, 7 per cent in 80 towns, and 15 per cent in eight cities with a population of 5,000 people or more.13 Rorem found that most doctors were pleased with the system because their incomes were assured. Annual salaries ranged from $2,800 to $5,000, but the doctors were responsible for paying automobile and office upkeep. The statistics collected by Rorem, who did not name any of his informants, showed that one doctor made 426 country calls in a year, necessitating travel of 5,580 miles by automobile. Most municipal doctors pocketed an initial charge of $1 to $3 for the first call; they were allowed to charge mileage for such visits and an extra $7 for obstetrical care. One municipality allowed a doctor to charge $7 for simple fractures, and another allowed a fixed fee of $5 for minor operations. One insurmountable difficulty facing municipal doctors was the complete rigidity of the Federal Income Tax Division, which insisted on treating the entire income as salary. Even though each doctor had to maintain an office, equipment, and an automobile, these costs could not be deducted as expenses because the Income Tax Division viewed municipal doctors as salaried employees. The medical profession was unable to obtain any redress of this unfair practice, except for a few municipalities, which reimbursed expenses separately from the stipend.14 Despite this, most doctors who had previously been in private practice reported that bad debts had so reduced their cash incomes that they were better off with the annual salary of the municipal scheme, although they worked harder after the impediment of the patient’s financial status was removed. One doctor told Rorem, “I am lucky to be on a salary.” Several stated that freedom from financial worries improved the quality of their service to patients and that patients co-operated by

30

Municipal Doctors and Municipal Hospitals

seeking services earlier in an illness. On the other hand, some doctors felt insecure because they could be dismissed on three months’ notice. Several felt that state medicine would not be appropriate outside the special rural situation. One doctor mentioned three families who tended to abuse the scheme, but admitted that they would have been a nuisance to a doctor under any payment system. Physicians agreed that the plan did not interfere with the doctor-patient relationship, and that they could spend more time on prevention, such as vaccination programs. Each municipal doctor served as medical health officer for the municipality and the villages within it. One reported that this was the first year in which there were no cases of diphtheria in his municipality, a situation he attributed to his intensive vaccination program. Municipal officials were even more enthusiastic; one of them said, “If you get a good man who is interested in his work and the health of the municipality, the system cannot be beat.” Another said, “The municipal physician’s system is here to stay, for the simple reason that it works out to the benefit of both parties concerned.” One official reported that this was the first time he had seen all taxpayers satisfied over a rise in taxes.15 In one municipality the candidate for reeve (the rural equivalent of mayor), who ran for office in 1928 on a platform of discontinuing the municipal doctor plan, was defeated by 231 to 30 votes. In another municipality, at the annual ratepayers’ meeting, a taxpayer moved that the council dismiss the present municipal doctor, but no one seconded his motion.16 No individual patient was heavily burdened, yet the taxation basis recognized the difference in financial ability to pay, since the more land one held, the more one paid. Only a few large landowners complained.17 Once the municipal doctor system had been adopted, no community returned to a private practice basis. The

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36 Steps on the Road to Medicare

only downside was that the presence of municipal physicians had unfavourable economic effects upon the practice of independent physicians in adjoining towns and cities.18 Municipal doctors worked hard. Dr Schmitt’s successor at Holdfast in the early 1930s was Dr C.S. McLean. Each year in the early 1930s McLean drove 14,000 miles to make 1,400 house calls, saw another 1,500 patients in his office, and attended fifty to seventy maternity cases.19 A circular sent by the United Farmers of Canada, Local Council, to taxpayers of one municipality before a vote on introducing the municipal doctor system there stated: At present we are committing to pooling our wheat and other farm products. The municipal doctor scheme is in reality a pooling of our doctor’s bills … an insurance against unduly high doctor bills in any one year – an equalization scheme. Are you willing to invest $4.50 per quarter section in the health of our section of the nation? A nation’s first wealth is health, and levies to protect our first wealth should have priority over all others.20 Things got worse during the “dirty thirties” for those doctors not under a municipal plan. The minister of health reported that the “average cash earnings of 130 doctors in the drought area, over a period of two years,” was $27 a month.21 In order to retain these doctors in the province, the Saskatchewan government provided a monthly stipend of $75 to those in the most drought-stricken areas, a program that continued for five years.22 To oversee and regulate the municipal doctor system, the Health Services Board was set up, with equal representation from the province, the Saskatchewan Association of Rural

32

Municipal Doctors and Municipal Hospitals

Municipalities (sarm), and the College of Physicians and Surgeons.23 By October 1938, at the time of Dr R.G. Ferguson’s report on municipal doctor schemes to the Saskatchewan Medical Association, 121 of the 546 provincial doctors were under remarkably varied types of municipal contract. For example, 28 received the $1,500 retainer grant, 36 received a salary of up to $5,000 for regular medical services, and 13 had a contract to supply surgery within the competence of the doctor. In only 15 instances was a physician permitted to charge a flat $2 deterrent fee for the first call, and a reduced fee for maternity cases, fractures, and surgery. Of 546 private family practitioners in the province, 121 cared for ninety-two municipalities, two towns and forty-two villages, a total of 116,421 persons in a Saskatchewan population of 930,893 (12.5%).24 In 1937, the average amount owing the doctor by the municipality was $2,503, while one drought-stricken municipality owed its doctor $13,387.60 in unpaid salary.25 In 1941 Dr John J. Collins, a municipal doctor at Ituna, sent a questionnaire to Saskatchewan rural doctors; ninety replied. They were almost unanimous in declaring that private practice was no longer feasible. One replied, “Any system is to be preferred to the present. Collections appear hopeless. I do not know how medical men can hope to carry on out here [all year] under present and future conditions.” In 1941, municipal doctors reported a mean net income of $3,290, after expenses of $2,012, for serving, on average, 1,998 people (roughly $2 per capita). Thirty per cent of income was privately earned, mainly from treating patients from outside the municipality.26 By 1942, a model contract was drawn up by the Health Services Board of the Saskatchewan College of Physicians and

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36 Steps on the Road to Medicare

Surgeons. Each municipal doctor was to be paid at the rate of one cent per day per quarter section, $432 per township, or $3,888 for a nine-township municipality. This payment was to be for 300 days in any calendar year, the doctor to have all Sundays and statutory holidays off. This was a striking departure from tradition, whereby rural doctors were on call twenty-four hours a day, seven days a week. For country calls, the model contract suggested that doctors be paid ten cents per mile each way by car in summer, fifteen cents from 1 November to 31 March, twenty cents for snowmobile travel and thirty cents per mile each way for a horse-drawn vehicle.27 In 1944, there were at least 101 municipal doctors in Saskatchewan. By the peak year of 1947, they cared for 210,000 people, nearly a quarter of the population.28 In 1950, there were still 173 municipal doctors in Saskatchewan.29 Since the municipal doctor system offered immediate guaranteed payment, it was often preferred by young doctors in their first few years of practice. They saw it as an alternative to “starving” in a city while they built up a practice against competition, and waited months or years for patients to pay their bills. The municipal doctor system was beneficial for patients as well, since it encouraged doctors to practice in rural areas. When medicare was introduced in Saskatchewan on 1 July 1962, the need for salaried municipal doctor schemes vanished. With immediate payment from the provincial government, new doctors could begin practice in a city; as a result, totally unplanned and unforeseen by government, many a village, especially one without a hospital, soon lost its doctor. The trend for doctors to cluster in the cities accelerated. Municipal doctor schemes were developed locally in response to need. The councillors of the rural municipality of Sarnia

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Municipal Doctors and Municipal Hospitals

deserve much credit for an innovative idea quickly put into practice; Seymour merits recognition for his rapid response in making it legal. Municipal doctors were another step on the road to medicare.

3. The first legislation in North America to allow Union Hospital Districts, 1916 Municipal hospital programs paralleled those for municipal doctors, but require separate mention. In 1916, legislative provision was made “for the combining of towns, villages and rural municipalities in union hospital districts” (uhds) to erect and maintain a hospital. By 1920, there were ten uhds in Saskatchewan;30 by 1930, twenty; by the early 1940s, twenty-six.31 Alberta was not far behind Saskatchewan in this respect, with its first municipal hospital in the village of Mannville in 1919, followed quickly by hospitals in Bassano, Cardston, Drumheller, Islay, Onoway, Vermilion, and Lloydminster, the last shared with Saskatchewan.32 By 1922, hospitals were added in Hanna, High River, and Provost. Capital, maintenance, and operation costs were provided by the people in the district: the only revenue received from the Alberta government was a grant of fifty cents per day per patient.33 In Saskatchewan, the Sigerist Report in 1944 (chapter 5) gave sudden impetus to building new hospitals and to forming new Union Hospital Districts34 – forty-four new uhds were created in three years. By 1947, the seventy-eight uhds “covered more than one-third of the settled area of the province, included approximately one-third of the population, and provided about three-eighths of the … hospital beds.”35

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36 Steps on the Road to Medicare

4. The first municipal hospital legislation in Canada, 1916 As an exception to the long lists of other Saskatchewan “firsts,” priority in municipal hospital legislation was shared between Alberta and Saskatchewan in the border town of Lloydminster. Here the local hospital, opened in 1906, closed for financial reasons in 1912. David Grieve Tuckwell, editor of the Lloydminster Times, later mayor of Lloydminster 1913–15 and a new arrival from Australia, promoted the idea of a union hospital, supported by the town and six surrounding municipalities. The hospital reopened in October 1913 (figure 3.3). Rural municipality residents contributed one cent per acre; Tuckwell proudly noted that the homesteader, and his wife, family, and dependents, gained hospital accommodation for $1.60 per year, the “very maximum of protection for the very minimum of cost.”36 In 1916, Saskatchewan (first) and Alberta (second), each passed appropriate legislation. In Saskatchewan it read: “The Council of the Town of Lloydminster, the Rural Municipality of Britannia and the Rural Municipality of Wilton may enter into agreement with each other to provide money for the maintenance and extension of the said hospital and for the payment of the [hospital] expenses of their respective ratepayers and residents.”37 The legislation served as an example for other areas.38 Saskatchewan passed a more general Union Hospital Act in 1917. To improve and streamline administration, the Rural Municipality Act was amended in 1927, 1928, 1929, and 1934. The Village Act and the Town Act were amended in 1936.39 As a result of legislation, there were ten Union Hospital districts in 1920; by 1938, there were twenty.

36

Figure 3.3 Lloydminster Union Hospital (sab s-b150)

5. The first legislation in Canada to allow personal taxation for health purposes, 1934 Although Saskatchewan citizens were willing to work together to improve local medical and hospital service delivery, financing these initiatives required creativity and innovation. Previously, health service could be financed only by a tax on property. In 1934, the Rural Municipality Act40 “was amended to empower the council to fix an annual tax for non-ratepayers. This appears to be the first instance in which statutory authority was granted for the levying of a personal tax for health services … in Canada,” asserted medical historian Malcolm Taylor. This legislation made sense: why should rural ratepayers with a land base carry all the costs? Villages and towns had many citizens who did not own a farm, but needed medical and hospital care. Some municipalities began to “break the mould” on munic ipal hospital plans. The rm of Miry Creek, for example, began a hospital plan in 1937 that allowed their residents to

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36 Steps on the Road to Medicare

be hospitalized anywhere in Saskatchewan, not just at the local hospital in Abbey. By 1943 the rm of Pittville used its medical services levy to pay for residents’ medical bills with any doctor, anywhere. Both moves ran contrary to the Rural Municipality Act, but continued nonetheless (for more on these plans, see chapter 6).41 municipal medical and hospital services act: the matt anderson plan, 1939

In 1939, the forward-thinking reeve of rm McKillop at Strasbourg, Norwegian-born Matt Anderson, initiated the Municipal Medical and Hospital Services Act.42 Known as the “Matt Anderson Act,” the plan permitted payment of both hospital (up to a 21 day stay) and medical services through a $5 personal taxation, limited to $50 per family. It combined municipal and hospital plans under one act. The core of the Anderson plan involved choice of doctor: patients were not limited to the local municipal doctor, but could visit one of several doctors in Regina connected to the scheme through medical service agreements. Under these agreements, the doctors would accept 50 per cent of the Saskatchewan College of Physicians and Surgeons schedule of fees as payment in full, when visited by patients under the health plan. By 1944, thirteen rms operated under the “Matt Anderson Act,” 92 had salaried doctors under the Rural Municipality Act, and 118 rms provided hospitalization.43

6. The first Red Cross Outpost Hospital in the British Empire, 1920 A separate initiative, related to municipal hospital plans, was the Red Cross Outpost Hospital program, which started at Pad-

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Municipal Doctors and Municipal Hospitals

dockwood, Saskatchewan in 1920 – a first in the entire British Empire. Following the First World War, the Red Cross (using funds left over from the war effort) designed cottage hospitals in conjunction with soldier settlement communities. These communities, often in remote rural areas, needed local medical services but were unable to support municipal hospitals through land taxation. Pioneer homesteaders without patent on their land did not pay municipal taxes. Land taxes require ownership. In this scheme, the community would provide the building and look after its maintenance; the Red Cross would find and pay for the staff and supplies. A resident charge nurse, not a doctor, triaged the patients and planned care. Patients with serious illness or injuries were transferred to a hospital or doctor in the nearest large centre. Other patients were capably and routinely stitched, set, delivered, or dispensed by the charge nurse. Patients were expected to pay if they could, but often paid through barter, or fees were waived. Most maternity patients took advantage of the provincial Maternity Grant. Over time, twenty-four outpost hospitals operated in Saskatchewan. By 1946, over 37,000 inpatients and 27,000 outpatients, as well as 8,800 births, had been recorded in Red Cross hospitals. As communities matured and roads improved, outpost hospitals either transformed into municipal hospitals, or closed (see figure 3.4). The outpost hospital initiative allowed poor pioneer and remote communities with a limited taxation base access to medical care, which in essence placed medical care as a right, not a privilege of local wealth.44 By 1948, eighty-eight municipalities provided their residents with hospital service at municipal expense. Sixty-six financed this through a property tax and twelve utilized the Municipal Medical and Hospital Services Act, which allowed a personal tax.45 By 1954, there were 104 union hospital districts.46 As

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36 Steps on the Road to Medicare

Figure 3.4 Paddockwood Red Cross Outpost Hospital, 1948, with nurse Ruth Dulmage Shewchuk in front. (sab Ruth Shewchuk collection)

historian Malcolm Taylor noted, “the construction and maintenance of hospital facilities and the prepayment of medical and hospital services through municipal tax levies – are a tribute to local initiative and the understanding of the importance of health services … a remarkable development not duplicated on such a scale elsewhere in Canada.”47 Once again, Saskatchewan residents worked together to give health a top priority, to a degree not seen in the rest of the country.

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CHAPTER 4

DR FERGUSON AND TUBERCULOSIS

In fighting the disease that for many years took the greatest toll on health and productivity, Robert George Ferguson was one of the most consistent and effective leaders in North America. Sixth in a family of sixteen, he was born 12 September 1883 near the Red River at Joliette, North Dakota, only seventeen miles south of the forty-ninth parallel. At age nineteen he was delegated by his family to choose a farm in Saskatchewan, of similar size to the one being vacated in North Dakota. He selected one at the south edge of Yorkton and moved his parents, brothers, and sisters there. Four years later his father died. George managed the farm in summer and attended Wesley College in Winnipeg in winter, obtaining his ba in 1910, intending a career in the ministry. When his husky voice, the result of childhood diphtheria, did not allow him to preach three sermons each Sunday, he chose medicine as next best, graduating with his md in 1916 (Figure 4.1).1

Figure 4.1 Dr R.G. Ferguson, graduation photo (sla)

Ferguson’s interest in research stemmed from his student experience in Dr S.J.S. Pierce’s laboratory in Winnipeg, making typhoid vaccine for Canadian troops in the First World War. His interest in tuberculosis had been stimulated by his work, while still a medical student, with Dr D.A. Stewart, medical superintendent at the Ninette Sanatorium in Manitoba. Stewart had so much faith in Ferguson’s integrity and ability that he left him, still a final-year medical student, in administrative charge of the sanatorium for a few weeks to go on his honeymoon.

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Dr Ferguson and Tuberculosis

Ferguson’s first year in medical practice in Winnipeg under Dr A.B. Alexander was the best possible preparation for his later career, with first-hand responsibility at the King George, the infectious disease hospital, and the King Edward, the city’s tuberculosis hospital. During 1916–17 he developed his three postulates of tuberculosis control: 1 Early discovery means early recovery 2 Reduce the level of infection in the community 3 Interrupt the transmission of the tubercle bacillus As Dr G.D. Barnett later commented, these three postulates became the foundation on which the Saskatchewan program was built. In July 1917, Ferguson was appointed acting superintendent of the new sanatorium at Fort Qu’Appelle, Saskatchewan (Figure 4.2), on the recommendation of Dr Stewart. Almost immediately the site became known as Fort San; a full post office by that name existed in the administration building from 1926 to 1966. As the only doctor, Ferguson was on call twenty-four hours a day; he was known to sit up all night holding the hand of a dying patient. In 1919, he attracted two equally dedicated assistants, Dr Harvey Boughton and Dr R.W. Kirkby, whom Ferguson later promoted to direct the new sanatoria in Sask atoon (15 April 1925) and Prince Albert (7 January 1930), respectively. At that time, tuberculosis was epidemic among the First Nations population. It was also much the commonest cause of death in white adults between the ages of twenty and forty-five,2 killing or disabling more able-bodied wage earners and homemakers than did heart disease, cancer, or other infections. Before the widespread advent of x-ray machines, symptoms were insid-

43

ious and non-specific; many patients were in the advanced stage before a correct diagnosis was made. Poverty, overcrowding of large families in small prairie shacks, and malnutrition favoured tuberculosis and in turn led to more poverty. The disease spread through coughing and by the unregulated sale of milk from infected cows.

7. The first grassroots public support for an anti-tuberculosis campaign, 1917–48 Nowhere else in North America did the attack on tuberculosis, or perhaps any other single disease, have as much grassroots support. In spite of the apparently unpromising outlook, Ferguson galvanized, educated, and cajoled an entire province.

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Figure 4.2 Fort Qu’Appelle Sanatorium, 1918 (sla)

He harnessed the co-operative spirit needed for survival in a new province with poor roads and harsh winters. Rural communities were fertile ground for his persuasive talents. Under his guidance, schoolchildren, teachers, nurses, doctors, service clubs, municipalities, and the provincial government co-operated in a costly but seemingly effective effort, unequalled anywhere else on the continent. The aims were to raise money for the Antituberculosis League and to keep public concern alive. Often the responses were simple, but symbolic. Groups of farmers’ wives, scattered throughout the province and organized as Homemakers’ Clubs, would each donate dozens of eggs or chickens

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36 Steps on the Road to Medicare

to feed patients. The Imperial Order Daughters of the Empire, better known as the iode, made tuberculosis its main concern; members raised money to build the children’s pavilion, furnish the schoolroom, buy books for the library, pay the bills of indigent children, and build and staff a preventorium, where mothers could be isolated from their infants from birth.3 Radio announcers donated their time to put on weekly amateur shows. There was an annual tuberculosis essay contest for schoolchildren. Prospective teachers were taught about tuberculosis at the Normal School, the name then given to the Teachers’ College. Twice, snowstorms led to important, long-term fundraising activities. Ferguson’s timing in each instance was impeccable. In 1934, his car was stuck in the snow and he walked to a railroad car on the track nearby. In it were members of the newly formed Associated Canadian Travelers (act), a group searching for a public service project. When they heard Ferguson’s needs, they agreed to help in the annual Christmas Seal campaign. On another occasion, other act members, stormbound with Ferguson in Nipawin, agreed to try amateur radio broadcasts as a means of raising money, and eventually broadcast these over six stations for more than thirty years. The act raised $813,000 to combat tb between 1934 and 1955.4 In a predominantly rural province, Ferguson, as a son of the farm, understood farmers and spoke their language. He represented the anti-tuberculosis campaign by means of an agrarian metaphor in his 1942 annual report: The people of Saskatchewan know that tuberculosis is a bad weed. In the language of the farmer, it is a perennial which, if not uprooted, will shed its seeds from year to year. When these weeds or cases are sparse the best practice is to find them and remove them before the seeds are shed.

46

Dr Ferguson and Tuberculosis

To do this everyone must learn to identify tuberculosis in the seed, in the sprout, in the leaf, in the flower, or in the ripe shelling. That is why the educational campaign for the prevention of tuberculosis goes on in schools, Normal Schools, families, communities, and throughout the province generally. From past results our people have the faith, confidence and will to eradicate this disease. Come peace, come war, prosperity or depression, this life-saving campaign goes on, resulting in less infection, less new cases, and in the end less deaths.5 In the early years Ferguson made certain that both legislators and doctors were familiar with the sanatorium and its work. On 26 November 1920, he gave a tour of the sanatorium to thirty members of the legislative assembly, and in June 1922 the Saskatchewan Medical Association held its annual meeting at the Fort Qu’Appelle Sanatorium. After I published Ferguson’s biography, I learned of another method he used to ensure legislative awareness. As superintendent, based at Fort Qu’Appelle, he was required to pay a monthly visit to the other two sanatoria, in Saskatoon and Prince Albert. Depending on whether he felt the premier (J.G. Gardiner, 1926–29 and 1934–35) or the minister of health (Dr J.M. Uhrich of Rosthern, 1923–29 and 1934–44) most required some gentle prodding, Ferguson would have his secretary telephone that person’s secretary in Regina to learn when the dignitary was travelling north and on which train (there were four each day to Saskatoon). Ferguson would then be sure he was in Regina in time to catch the same train. This would give him three hours (four-and-a-half hours in the case of Health Minister Uhrich, if he was destined for his home constituency at Rosthern) to chat. Thus, those in authority, the decision-makers,

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36 Steps on the Road to Medicare

knew all about the problems and needs of all three sanatoria, the monthly field clinics in each major city and town, and so on. No person in a position such as Ferguson’s in our faster, busier age has the slightest hope for such close personal contact with those in authority. Ferguson was a rare person, superb in every aspect of his work. He had skills in teaching, clinical work, and research, and was also talented in administration and public relations. He knew exactly how to comfort the suffering, homesick, and lonesome. In his quiet way, by example and conviction, he taught everyone who came in contact with him and his work: doctors, nurses, medical students, patients and their families, and the general public. Ferguson was one of the first sanatorium administrators in Canada to give a high priority to continuing education for his medical staff. Even when the San was hopelessly in debt during years of drought and depression, even when short-handed during wartime, he sent his staff away to learn. In spite of the time and expense to get there, London, England, was one of the most popular destinations because of its renowned teachers and the wealth of clinical experience available. Members of the medical staff often took an entire year of postgraduate training at the sanatorium’s expense; each year at least one sanatorium physician went away for special studies. Training was sometimes rewarded by success in the Royal College of Physicians (mrcp) examination.6 Over the years, this education proved to be a good investment. Radiographers, nurses, and dietitians were regularly sent away for short courses and practical experience in another institution. There was no requirement of years of service to become eligible for further education. If the sanatorium needed someone trained in a new technique and a young staff member was

48

Dr Ferguson and Tuberculosis

eager to learn, an educational opportunity was available after only one or two years of employment. Dr Harvey Boughton was the first to take educational leave; he spent two weeks in Winnipeg in 1920. Next, Ferguson went to Boston for two months in 1920; he spent one month studying heart disease with Dr Paul White, a world-renowned cardiologist, and three weeks taking a $100 course in internal medicine at Harvard University. Ferguson believed that the physician who is limited to treating one disease is “apt to develop a blind side, and to lose his true perspective in the interpretation of symptoms which are the common stock of widely different diseases.”7 To recognize early tuberculosis, one had to keep in touch with the whole field of internal medicine. In Boston, one of the first centres to provide courses for graduates in medicine, alongside a splendid medical library, a doctor’s medical experience and perspectives could be broadened. Later, Ferguson arranged for every student nurse in Saskatchewan to attend an eight-week affiliation course at a sanatorium. Between 1 June 1945 and May 1964, 3,774 student nurses had this practical experience at either the Fort Qu’Appelle or the Saskatoon sanatorium. Transportation and sickness expenses were paid by the sanatoria. The affiliate nursing course ended at Fort San in October 1962 and at the Saskatoon San in May 1964.

8. The first province to determine the prevalence of tuberculosis, 1921–22 After only four years as head of the tuberculosis program, Ferguson convinced the powers-that-be that little was known about the disease anywhere in North America. He persuaded the government to form the Saskatchewan Anti-tuberculosis Commission

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36 Steps on the Road to Medicare

to determine the prevalence of tuberculosis in the Saskatchewan population and to plan future sanatorium beds on the basis of the findings. Not only was his wish granted, but he was made secretary of the commission when it was appointed by Orderin-Council on 22 July 1921, thereby gaining the staff and funds to research the extent of the tb problem in Saskatchewan. Thus, he was able to write his own ticket. The recommendations of the final report of the commission did not gather dust on a shelf, as do many government reports today, but instead formulated Ferguson’s lifelong objectives. Few medical men have had, early in their careers, an opportunity to document the extent of a target disease and in doing so, to plan for ways to combat it, setting the direction of their life work. Of the commission’s recommendations, published in October 1922, the first four were considered mandatory:8 1 Hospital and sanatorium accommodation must be increased to care for those who are spreaders of the disease. The Commission recommended the construction of two new sanatoria of at least one hundred beds each, to allow the average patient twelve months of treatment. 2 There must be provision for the care of children from homes where open tuberculosis is found. A preventorium should be established to prevent the newborn infant from contracting tuberculosis from its mother. Children should be separated from actively tuberculous parents. 3 The system of financing the cost of treatment must enable all those who need treatment to obtain it with the least delay. 4 Diagnostic facilities must be improved and extended to all parts of the province, along with a nursing service and follow-up of all ex-tuberculous patients.

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Dr Ferguson and Tuberculosis

As an additional bonus, when the commission disbanded, Ferguson co-opted its chairman, A.B. Cook, Regina’s sheriff, to become managing director of the Saskatchewan Anti-tuberculosis League and thus ensured its success.

9. The first representative cross-sectional school studies of tuberculosis, 1921 As part of the research necessary for the commission report, arrangements were made with school boards to examine about 200 children between the ages of six and fourteen in each of seven representative communities: Regina, Saskatoon, Moose Jaw, North Battleford, Cupar, Stoughton, and Heward. Each child received a physical examination by a chest specialist; an ear, nose, and throat specialist; and a dentist. Eighty of these children were selected, on the basis of physical findings, for a chest radiograph.9 Of the 1,184 children examined, ten had active tuberculosis; another fifteen were found to have tuberculosis on the followup chest radiograph. A positive tuberculin test in 56.6 per cent of children indicated they had been exposed to tuberculosis (44% by age six and 61% by age fourteen). Of an additional 162 First Nations children examined in residential schools, 93.1 per cent had a positive tuberculin test. Normal School students had a 75.6 per cent positive tuberculin test rate, and 0.9 per cent had active tuberculosis. They were followed up annually throughout Ferguson’s career; he watched with satisfaction the steady drop in the rate of positive tests. Of 185 dairy cows in the same communities, 18.5 per cent tested positive.

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36 Steps on the Road to Medicare

These baseline studies were, for their era, unusually sophisticated proportional samplings of representative communities. In his history of tuberculosis in Canada, Wherrett confirms that these studies were the first in Canada.10

10. The first traveling tuberculosis clinics, 1923 The Wherrett-Grzybowski report in May 1966 acknowledged that the credit for sponsoring Canada’s first traveling clinics was shared between Saskatchewan and Ontario.11 Clinics began in Regina in September 1923 and in Moose Jaw in May 1928, and for some years were held one day per week. Follow-up clinics were also offered in two Saskatoon hospitals and at Fort San. Once-a-month clinics, chiefly for patients referred by general practitioners for diagnosis of lung disease, were held in North Battleford and Swift Current (beginning in 1930), Yorkton and Canora (1933), Tisdale and Melfort (1934), and Wadena (1940).12

11. The first universal free diagnosis and treatment of tuberculosis, 1 January 1929 Ferguson worked systematically to gain grassroots support for free treatment of tuberculosis, advocated in the commission report in 1922. It took seven years. Few could afford to pay for a year or more of treatment in a sanatorium. But from 1917 until 1928 it was Saskatchewan’s policy that “all who were able to pay were required to pay.” In 1924, twenty-nine of 295 patients (9.8%) paid part of the costs for their treatment, even though some were bankrupted and returned home penniless. By 1928, only 2.5 per cent could pay for their treatment. The other 97.5 per cent required at least

52

Dr Ferguson and Tuberculosis

partial financial help from their urban or rural municipal government. Saskatchewan’s Rural Municipal Act of 1920 required each rm to contribute $100 annually to the sanatorium. In 1921, the $30,100 from 301 rural municipalities was set aside as the nucleus of a pool to pay for the treatment of indigent rural patients. Rural municipalities in this way got a four-year head start on their urban counterparts, on the path towards “free treatment.” The Saskatchewan Association of Rural Municipalities (sarm), then the most influential organization in the province, complained at its annual meeting in March 1921 that the urban municipalities were exempt from this levy. In 1925, an urban pool was formed. Without both rural and urban municipal contributions, the sanatoria would have been insolvent. The first resolution to advocate totally free treatment for tuberculosis was introduced at the sarm annual meeting in 1925. Only six of the 600 representatives voted for it. Yet the seed had been planted and the idea grew. In 1926, there were twenty votes in favour. In 1927, a different motion, that the provincial government take over direct control of the sanatoria, carried by a small majority. The government, normally very responsive to resolutions from sarm, countered that they could not afford it. At the annual meeting of sarm in March 1928, a momentous resolution was moved by rm Weyburn #67 to petition Saskatchewan legislators “to amend the Sanatoria Act so that all classes of T.B. patients shall have free treatment available at the public expense … paid partly by the [provincial] government [and] partly by all rural and urban municipalities.”13 In the midst of the discussion, an ex-patient of Fort Qu’Appelle Sanatorium, now cured and employed as secretary of his

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36 Steps on the Road to Medicare

municipality for nine years, stood up. There, before the eyes of all doubting Thomases, as was remarked later, stood a living example of what could be and was being done through efficient and timely treatment of tuberculosis. This time the motion passed unanimously. A similar resolution was later passed by the Saskatchewan Urban Municipal Association and by the United Farmers. Times were good just before the stock market crash and the depression. As soon as the legislature next met, early in December 1928, the Liberal government of James G. Gardiner presented the Saskatchewan Sanatoria and Hospitals Act. As a government bill, it passed readily. What was amazing was the speed of implementation. The new system of free treatment came into effect in less than a month, on 1 January 1929. The Honourable Sam J. Latta, minister of municipal affairs, characterized the new act as “a great social experiment – and a costly one at that.”14 Roughly half of the league’s operating funds came directly from the rural and urban municipalities, a greater participation than in any other province, “a distinctly Saskatchewan approach.”15 The municipal funding, of course, was not subject to competition from highways and welfare in annual government budgets. It was not unusual for a rural municipality in a given year to spend more money on one disease, tuberculosis, than on roads! There were immediate benefits. As Ferguson reported, “the effect of removing the financial barrier is earlier treatment, earlier isolation, and an [initial] increase in the number of days treatment and the gross cost, but the end result will be more cures and a shorter period of disability, lessened spread of the disease, a lower death rate, and eventually [fewer] new cases.”16 It was seven years before the next province, Alberta, offered free treatment in 1936. Manitoba followed in 1946.

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Dr Ferguson and Tuberculosis

Saskatchewan’s health minister, Allan Blakeney, said in 1964, “the introduction of diagnosis and treatment of tuberculosis at public expense was one of the early and essential steps in developing a program of health services available to all.”17 To have Saskatchewan lead all other jurisdictions in North America, the first to provide free treatment of tuberculosis, the most expensive disease that took longest to cure, was one of Ferguson’s greatest accomplishments. Saskatchewan’s success with universal availability of tuberculosis diagnosis and treatment became an important stepping stone toward universal hospitalization insurance and medicare.

12. The first epidemiologic study of susceptible First Nations people exposed to tuberculosis, 1928 Ferguson’s landmark study of the prevalence of tuberculosis as it reached “fertile ground,” a population with no previous history of exposure to the disease, is one of the best of a very few epidemiologic accounts of such a process anywhere in the world. A new infection, arriving for the first time, hits with great severity, affects almost any body organ at any age, and has a high mortality. Then, as the most susceptible die off and only the more resistant individuals survive, there is a natural and inevitable drop in the number of new cases of that disease. It is more humane and more efficient to prevent disease than to cure it. With his deep concern for First Nations people, Ferguson obtained annual research grants from Canada’s National Research Council (nrc), from 1926 until his retirement in 1948. These grants financed his studies of tb prevalence on adjacent Indian reserves, the first Bacille Calmette-Guérin (bcg) vaccination of First Nations infants, and the first in student nurses. The nrc had been formed on 29 November 1916, and

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36 Steps on the Road to Medicare

its eleventh committee was formed in 1925 to study tuberculosis, initially in cattle. Ferguson graphed the rapid increase in deaths from tuberculosis among First Nations at the Qu’Appelle and File Hills agencies (figure 4.3) as they settled in small houses in close proximity to each other on reserves. Under the new conditions of stationary life, intermittent hunger, and cultural demoralization, the annual death rate from tuberculosis among First Nations was roughly 1,000 per 100,000 population in 1881. It quickly increased to reach the proportions of a serious epidemic by 1884, and became maximal in 1886 at 9,000 per 100,000 per year, about double the birth rate and accounting for two-thirds of all First Nations deaths. By 1895 the rate had dropped to 3,000, by 1901 to 2,000, and by 1907 was back to 1,000 per 100,000. Changes in living or sanitary conditions did not explain the drop. Ferguson recognized that this was the inevitable and natural course of a new epidemic on what researchers call “virgin soil” or a new population. Virtually all Indian children were “tuberculized”; by the age of eleven to fifteen, over 96 per cent had a positive tuberculin test.18 His field work began in 1926 with a thorough examination of children on the File Hills and Qu’Appelle reserves and those attending the Lebret and File Hills Indian schools. Such surveys became annual events. Ferguson recognized the need to determine the prevalence of tuberculosis in First Nations adults as well. How was he to get them together for chest radiographs in rural areas far from electrical sources? He had the brilliant inspiration to join the annual treaty party, when First Nations congregated to receive treaty money of $5 each. He persuaded the Victor X-ray Corporation of Winnipeg to supply a portable x-ray machine and the Delco Light Company of Regina to supply a portable generator. In the

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Dr Ferguson and Tuberculosis

second week of July 1927, all this equipment accompanied the treaty party to the File Hills Reserve, where full compliance was achieved and 130 adults were x-rayed. In 1928, Ferguson presented his landmark report at the prestigious meeting of the National Association for the Prevention of Tuberculosis in Great Britain: The moral and physical weakening of the Indian has to do with the introduction of the horse … firearms … liquor, the exchange of their fur tunics for the blanket, the exchange of the clothes necessary for warmth for alcohol, the extermination of the buffalo and the beaver, the concentrations upon reserves, the change of housing, the change of food, the exclusion of sun … by the clothing of the children; the compulsory concentration of children in

Figure 4.3 Graph of tuberculosis epidemic among First Nations (sla)

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schools, the change of occupation from hunting and warring to agricultural pursuits, and, on the mental side, the psychical depression of conquest by the whites, dependence on Government rations for food, visible ravages of white man’s diseases, desertion by, or incompetency of, their Michi-Manitou and triumph of Kitchi-Manitou, and failure of even the white man’s religion to protect them … The nudity of the Indian children in summer … was ended abruptly … The agents, in their zeal … instructed the parents to clothe their children. Thus for the first time in the history of the race the bountiful summer sun’s rays were largely excluded … a lowering of resistance to disease developed.19 Ferguson’s dedication to First Nations is exemplified by the four-week canoe trip he took in 1927, departing from the end of steel at Big River, to inspect those with tuberculosis at Ile-àla-Crosse and La Loche. Six years later, Dr Andrews from the Prince Albert Sanatorium made the first airplane flight to Ile-àla-Crosse. Ferguson treated First Nations patients as equals, as any compassionate doctor would. They in turn respected him. In 1935, they gave him what he considered the greatest honour of his life, a ceremony naming him as an honourary chief – MuskekeO-Kemacan (figure 4.4). First Nations people were not legally a responsibility of the Saskatchewan Anti-tuberculosis League, a provincial organization, but of the Government of Canada. In spite of this, one of Ferguson’s top priorities throughout his life was to reduce the ravages of the disease among that population. He engineered an agreement with the federal government in 1924 whereby forty beds were allocated for First Nations at the San as a means

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Dr Ferguson and Tuberculosis

of paying off some of the capital advanced by the province near the end of the First World War. Once the Prince Albert Sanatorium opened on 7 January 1930, there were adequate beds for Saskatchewan’s First Nations population, both adults and children. In striking contrast, Manitoba First Nations gained access to sanatorium treatment only in 1946 when the Clearwater Sanatorium opened in wartime United States Air Force buildings.

13. The first statistically controlled BCG vaccination among newborn First Nations infants, 1932–49 Between 1933 and 1943, Ferguson and his former University of Manitoba medical school classmate Dr Austin Simes, of the

Figure 4.4 Muskeke-O-Kemacan, Great White Physician (sla)

36 Steps on the Road to Medicare

Indian Health Unit, vaccinated 306 First Nations infants at birth. Another 303 infants served as controls. Their study was statistically sophisticated for its time – although through imperfect randomization by Dr Simes (tossing a coin for each subject would have been sufficient!), the bcg study lost the opportunity to be the world’s first fully randomized clinical trial.20 Ferguson and Simes’ joint paper showed that the incidence of tuberculosis was nearly five times greater in the unvaccinated, whose disease was more severe and more widespread than in the vaccinated group.21 The bcg studies were carried out in the face of frank hostility to bcg throughout the English-speaking world, apart from the strong support of the Canadian bcg pioneer, Armand Frappier in Montreal. Other North American doctors mistrusted live-bacteria vaccines in general and bcg in particular.

14. The first 1934–43

BCG

vaccination among student nurses,

Because 5 per cent of student nurses and nurses in western Canadian hospitals “broke down” (the term used in standard medical parlance) with tuberculosis, all tuberculin-negative student nurses in Saskatchewan hospitals and all tuberculin-negative sanatorium and mental hospital employees were given bcg vaccination. Ferguson reported in 1946 that this measure reduced the number of cases of manifest tuberculosis to less than a quarter of the previous rate for nurses, to one-fifth of the previous rate for sanatorium employees, and to one-fifth of the rate among student nurses in adjoining Manitoba.22 In subsequent years, this vaccination was extended to tuberculin-negative members of families in which tuberculosis had occurred.

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Dr Ferguson and Tuberculosis

15. The first provincewide photofluorographic surveys, 1942–47 Ferguson organized the first provincewide photofluorographic survey in North America, 1942–47. Since no machines were available commercially, he encouraged his radiographer, Robert Connell (figure 4.5), to develop a method of photographing a fluoroscopic screen with a 35-mm camera (figure 4.6). Connell was aided by Richard Tizley, a welder hired on the day the Second World War began. A second-hand van was purchased for $250 and trial mobile community surveys began in 1941. The aim was to achieve early diagnosis, when the disease would respond most readily to the simple measures then available – bed rest, fresh air, and good food. During the second Saskatoon survey in 1948, 41,082 of the 43,016 residents were radio graphed – the highest rate of participation ever reached (95.5%). About one new, active case of tuberculosis was found per thousand people.23 The survey was staffed by unpaid local volunteers in each village or town, all vying for a higher turnout than in the neighbouring town. Other expenses were met through funds raised by the act amateur hours on all Saskatchewan radio stations and by the annual Christmas Seal campaign. The survey of the entire province was completed in 1947; a second survey began immediately. In 1948, the Anti-tuberculosis League began to pay for a chest radiograph of every patient admitted to hospital. This program was fully operative in every one of 109 Saskatchewan hospitals by 1950. Since people admitted to hospital were more apt to be ill, this became one of the most effective means of detecting new cases of tuberculosis and, as a side effect, detected a roughly equal number of unsuspected lung cancers.

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Figure 4.5 Robert G. Connell (Mrs. G. Connell)

Figure 4.6 Photofluorograph machine used for mass tb surveys (sla)

Dr Ferguson and Tuberculosis

16. The first province with sufficient beds for tuberculosis patients, 1942 From 1921 through 1940, Saskatchewan had a lower tuberculosis mortality rate than any other province.24 Saskatchewan was the first province “to provide sufficient sanatorium beds to treat all tuberculous patients,” the aimed-for ratio being three beds for every tuberculosis death.25 The necessary facilities were disproportionate in size and cost considering the up-and-down finances of an agrarian province. High capital costs were combined with high costs of identifying patients with the disease. why was saskatchewan a leader?

The answer relates, in part, to the calibre of Ferguson, the strong support his own conviction generated, and the administration of the entire program by a “semi-official body, mainly lay and voluntary in its operation.”26 Where else could Ferguson have reached out to every farmer? Where else could he have garnered such solid grassroots support? Where else was such a highly developed social conscience and community co-operation the basis of everyday life? As Premier T.C. Douglas said at the fiftieth anniversary of the founding of the Anti-tuberculosis League, Saskatchewan people had developed “a special capacity to meet and solve problems that by far excels more fortunate places.” Douglas was right. The league had obtained “the support and co-operation of the public to a greater degree than [in] any other province.”27 This public- spirited group has continued its work in preventive medicine since 1981 as the Saskatchewan Lung Association, now the Lung Association of Saskatchewan.28

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lowest tuberculosis death rate in canada

Ferguson’s work bore fruit. He witnessed the decline of case rates from 98 per 100,000 population in 1925 to 51 per 100,000 in 1948. However, incidence and death rates also declined in regions that lacked sanatoria, representing the natural course of any epidemic. Then, with the advent of streptomycin and para-amino-salicyclic acid in 1948, tuberculosis death rates fell sharply. The Prince Albert Sanatorium was closed in 1961, Fort San in 1972, and the Saskatoon San in stages: it stopped taking inpatients in 1978 and outpatients in 1982, and its lab closed in 1986. Overall, though, Saskatchewan had the lowest tuberculosis death rates in Canada from 1921 through 1944 and again in 1954, 1957, 1958, and 1966.29 ferguson in later life

Ferguson was made a Member of the Order of the British Empire (mbe) on the king’s birthday in 1935. He received an honourary lld from the University of Saskatchewan in 1946. He retired on his sixty-fifth birthday, 12 September 1948. His next six years were spent in researching and writing his highly acclaimed book, Studies in Tuberculosis, published by the University of Toronto Press in 1955.30 He received the prestigious Charles Mickle Fellowship in 1961. His portrait, by artist Nicholas de Grandmaison, was commissioned by his friends in 1962. Ferguson died on 1 March 1964. some reasons for ferguson’s success

Ferguson was an unassuming, soft-spoken, compassionate doctor. His personal charm, vision, strength of purpose, and scientific methodology were to make him a leader in North America’s fight against tuberculosis. His quiet influence with the premier and the Department of Health and his compelling per-

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Dr Ferguson and Tuberculosis

suasiveness worked wonders. He had a lifelong knack for getting what he wanted from governments. Ferguson had the full support of the Anti-tuberculosis League’s dedicated board of directors. Peter McAra was mayor of Regina when he became the founding president of the league; McAra continued on the board of directors after he stepped down as first president, and he served again as president from 1930 to 1941. E.G. Hingley represented sarm for forty years and was president of the league from 1945 until his death in 1958. Dr F.W. Hart of Indian Head, an original trustee from 1911 to 1918, returned to the board as representative of the Saskatchewan Medical Association from 1932 to 1946. His son, Bob, married Ferguson’s daughter, Helen. Ferguson’s timing throughout the first thirteen years of his campaign was perfect. The return of veterans after the First World War caused the federal government to pour needed money into new buildings at Fort San; the higher federal per diem rate also helped augment the league’s bank balance. Free tuberculosis treatment passed the legislature in 1928, in part because the farm economy was buoyant in the late 1920s. The First World War had also changed public attitudes more than anyone realized; few other “charities” had as much appeal. All three Saskatchewan sanatoria took great care to maintain good relationships with all practising doctors. As Boughton said later of Ferguson, “One of his long suits was to play hand-inglove with the doctors who referred patients.” Ferguson consistently gained maximum government support, yet he kept a tight rein on management. There was no patronage and no featherbedding. The league provided a marvellous bargain to Saskatchewan in terms of service per patient day per dollar. Whether the Liberals or Conservatives were in power, Ferguson had immediate access to the premier and the minister

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of public health. (When the ccf gained power, Tommy Douglas confided to my father that the province’s recommendation to Ottawa that Ferguson be named Saskatchewan’s lieutenantgovernor had not been successful.) The league, followed by the Saskatchewan Lung Association, operated the sanatoria and clinics – the entire tuberculosis program – until 1987. Members of each successive government realized, sometimes contrary to dogma, that the arrangement was mutually beneficial. The various levels of government put up the money, and the league ran the incredibly cost-efficient organization, with a great deal of help from many volunteers and private organizations. At the same time the league attracted exceptionally dedicated people and provided a high standard of care. Ferguson’s other appointments and awards included: president of the Saskatchewan Medical Association (1922); fellow of the American College of Chest Physicians; member of the Senate of the University of Saskatchewan (1923–28); life member of the Royal Canadian Legion. R.G. Ferguson, mbe, ba, md, lld, 1883–1964, is remembered with respect and affection. His name is commemorated by the R.G. Ferguson professorship at the University of Saskatchewan, by the Dr George Ferguson School in Regina, and by one of Saskatchewan’s largest islands, Ferguson Island in Montreal Lake. “His resting place is in the valley he loved, but his shrine is in the hearts of the people of Saskatchewan.”31 George Ferguson! You should be here today. Saskatchewan needs you: she believes that tuberculosis Is controlled, That public health is no longer at risk,

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Dr Ferguson and Tuberculosis

That the province’s wealth should be used to acquire luxury. Wake us up; show us again with your towering wisdom How to walk the common path of man; And perform the lowliest task with cheer.32 postscript

The number of new cases of tuberculosis among the non-First Nations population in Saskatchewan decreased from 931 in 1926 to 43 in 1990. In 1962 the mobile x-ray took chest radiographs of 3,462 Aboriginal people in northern Saskatchewan, those in the highest risk area, and found not one new case of tuberculosis. But the apparent defeat of the disease, especially in northern Saskatchewan, was short-lived. Sadly, the optimism so evident in 1964, the year Ferguson died, has since palled. Saskatchewan is no longer a leader. In 1987, its largest census area, the northern half of the province, had the highest rate of active new cases of tuberculosis (248.6 per 100,000) of any complete census region in Canada, and the Meadow Lake census division had the eighth-worst record in the country. Two reserves, Buffalo River and Portage la Loche, had rates of 1,000 per 100,000, 400 times that of Caucasians in southern Saskatchewan.33 In 1965, treaty Indians comprised 3 per cent of the Saskatchewan population, yet they had 75 new (not previously reported) cases of tuberculosis. These accounted for 34 per cent of the provincial total, a rate of 260 per thousand. In 1990, First Nations comprised 6 per cent of the population; their 156 new cases of tuberculosis accounted for 75 per cent of the total, at a rate of 267 per thousand.34 In 2012 the rates of new and relapsed cases of tuberculosis in Saskatchewan had dropped to 8.2 per 100,000. That year there were 55 new First Nations

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cases of tuberculosis, a rate of 49 per 100,000, and only 8 of those had primary tuberculosis, a marked improvement.35 Directly Observed Therapy (dot) was introduced into Saskatchewan in the autumn of 1989, to diminish the frequency of treatment failure and of very costly drug resistance. With another person identified to watch patients swallow their pills twice a week, selective breeding of resistant tb bacilli has greatly diminished. In the first four years with dot, compliance rose to over 85 per cent, drug resistance diminished from 13 per cent to 2 per cent, costs decreased to one-fifth the amount for self-administered treatment, and there were fewer hospital admissions.36

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CHAPTER 5

SIGERIST AND PENSIONERS’ CARE

Saskatchewan took a bold step toward medicare in 1944, not through health research or policy or management, but through politics. The province elected:

17. North America’s first social democratic government, 1944 “No person has had as profound an effect on the restructuring of health services in Canada as Tommy Douglas, that doughty little Scottish socialist fighter and orator”1 (figure 5.1). Douglas was “among the greatest political campaigners Canada has known.”2 His Co-operative Commonwealth Federation (ccf) party won a landslide victory, forty-three of the fifty-two seats, in the Saskatchewan election of 15 June 1944 and took office 10 July 1944. The ccf had a triumphant convention following this victory on 13 July 1944.3 Health was Tommy’s number one priority then and throughout his tenure as premier.4 To be certain that health matters were

Figure 5.1 Premier T.C. Douglas (sab r-a3421)

Sigerist and Pensioners’ Care

front and centre, Douglas assumed the health portfolio himself.5 For his first four-year term of office and into his second term, he carried this heavy burden in addition to his responsibilities as premier.

18. The Sigerist Commission, 1944: The first forward-looking provincewide survey to plan for future health needs One of Douglas’s very first priorities, the day after the election, was to contact Dr Henry Sigerist (figure 5.2), professor of the history of medicine at Johns Hopkins University,6 and author of a book that took a rosy view of Soviet medicine,7 to head a health study commission. Although Sigerist was a “physician of international reputation,” as Malcolm Taylor wrote, “there was a great deal of criticism later that a professor of the history of medicine … had been chosen rather than an expert in health services organization and administration.”8 Dr J. Lloyd Brown of Regina was the representative of the medical profession.9 The working group was known as the Saskatchewan Health Services Survey Commission (shssc). Sigerist and the other members began work on 6 September 1944. The commission visited various points across the province and conducted hearings to allow rural health advocates a place to present their initiatives. The files for the survey are held in the Saskatchewan Archives Board, and provide a snapshot of health ideas and concerns brewing in that moment. Several briefs stand out. sarm presented a ten-page brief that outlined various municipal hospital and salaried doctor schemes operating successfully in the province (see chapter 3).10 William J. Burak, reeve of the rm of Pittville, provided details of Pittville’s plan, which paid for hospitalization and doctor visits

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anywhere, for any length of time. His brief emphasized comprehensive coverage, freedom of choice, and local control.11 Matt Anderson, who spearheaded the “Matt Anderson Act” passed in 1939, emphasized the importance of free choice of doctor by the patient.12 Charles H. Chapin, secretary of rm McKillop, presented the full financial statements of what was known as Health Insurance District #1 (which was different from Swift Current Health Region #1; see chapter 6). Chapin pointed out that the health insurance scheme devised in his area of the province “relieved our residents of the financial worry of sickness and taught them to take early actions when any illness or symptoms appear.”13 Sigerist completed visits and hearings by 23 September, finished the report at five minutes after midnight on 1 October,14 and presented his formal report on 4 October 1944.15 As was the case with Lord Stephen Taylor, a medical doctor who gained the confidence of the profession and resolved the medicare dispute in 1962, Sigerist served without pay. His stay in Saskatchewan was too short, yet he accomplished a great deal. He recommended establishment of district health regions for preventive medicine, each centred on a district hospital equipped with an x-ray machine, a medical laboratory, and an ambulance. He advocated rural health centres with eight to ten maternity beds, staffed by a registered nurse and one or more municipal doctors. The municipal doctor plans, he wrote, should be “main tained and developed.”16 He noted that the public must be educated to seek medical advice at the centres, so that each doctor would no longer “spend a large part of his time driving around the country.” Patients were slowly becoming accustomed to seeking medical care in a centralized location. Recognizing that municipal doctors were overworked and underpaid, Sigerist suggested that they receive annual vacations

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Sigerist and Pensioners’ Care

Figure 5.2 Henry Sigerist at desk

with pay. Dr Elden Hitsman of Strasbourg in the rm of McKillop, which operated under the Matt Anderson plan, regularly took vacations while the health district paid a locum (replacement).17 Sigerist proposed “free hospitalization,” which he estimated would cost $3.60 per person per annum,18 and would require another 1,000 to 1,500 hospital beds in Saskatchewan,

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including a 500-bed university hospital attached to a new medical college in Saskatoon. He analyzed succinctly the thencurrent situation and offered solutions. It is easy, with hindsight, to realize that Sigerist’s crystal ball left much to be desired. His recommendation to build or improve many small village hospitals would have been appropriate in the 1930s but not as forward planning for the 1950s and 1960s. By following his report, Saskatchewan was saddled with too many small, one-doctor hospitals. Sigerist did not foresee that, farther down the road, the larger hospitals with better facilities and two or more doctors could, with improved highways, be reached more quickly in subsequent decades. Nor did he realize that doctors would desire relief from being on call twenty-four hours a day, seven days a week. Sigerist, a historian of medicine and not a futurist, also failed to foresee the rapidity of technological change that was already on the horizon. He overlooked the fact that larger farm machinery and highway improvement would contribute to rapid decline in the population of rural municipalities and villages and to increasing use by rural people of business and professional services in the cities. In the hospitals, rather than suggesting there be training of more x-ray technicians, or of combined laboratory and x-ray technologists appropriate for one-doctor hospitals, he recommended that “one nurse in every hospital be trained to handle the x-ray machine and the routine clinical laboratory work.”19 When he advocated consideration of sterilization for mental defectives, then popular in many jurisdictions, he failed to appreciate the ethical considerations involved. He demonstrated incredible naïveté when he prophesied that the complete eradication of venereal disease could be achieved in the near future.

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Sigerist and Pensioners’ Care

Professor Milton Roemer of the University of California, Los Angeles, nonetheless described the Sigerist report as “one of the most advanced health services reports of its time.”20 It provided the “blueprint” for medical care in Saskatchewan for half a century. Sigerist, in looking back on his life in 1950, admitted that he had rarely experienced “a warm feeling of having accomplished a job well,” but that one of these occasions was in 1944, on returning from Saskatchewan.21 douglas’s promises to doctors

At no time did Douglas make a salaried medical service a ccf platform plank.22 Indeed, his letter to J. Lloyd Brown dated 19 September 1945, published in the Saskatchewan Medical Quarterly that December, promised the medical profession that: (1) “a health insurance scheme shall be administered by a Commission which shall be free from political interference and influence”; (2) this commission “shall be representative of the public, those giving the service, and the Government”; (3) the commission “shall have sufficient power and jurisdiction to establish and to administer a plan”; (4) the chairman “shall be a physician”; (5) “no commissioner, representing a profession, shall be appointed except with the approval of the profession concerned”; and (6) “the professional committees shall have unrestricted jurisdiction over all scientific, technical, and professional matters.”23

19. The first comprehensive Social Assistance Plan for pensioners and widows, 1945 Douglas’s next urgent health priority was to provide comprehensive health care for those requiring social assistance, “old

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age and blind pensioners, widows on mother’s allowance, and their dependents.” There were 28,000 such people on the government rolls.24 On average, each doctor would have about fifty of these people as patients. Douglas met with the council of the College of Physicians and Surgeons of Saskatchewan on 23 August 1944 at Hotel Saskatchewan, two weeks before the arrival of Sigerist. The profession co-operated to the fullest. My father came home from the meeting bemused by the course of events. Douglas had asked the council for their estimate of what such a program would cost. The doctors did not know. They asked Douglas for his best guess. He didn’t know. Both sides recognized that these patients required an above-average amount of medical care. Nevertheless, they amicably agreed to use the figure suggested as the cost of medical care by the federal Heagerty Interdepartmental Advisory Committee on Health Insurance in December 1942 – $9.50 per person per year.25 At the annual meeting of the Saskatchewan Medical Association in September 1944, doctors agreed to monitor and police the plan for the agreed-upon fixed lump sum, on a one-year experimental basis. Final agreement was concluded on 1 October 1944, for implementation on 1 January 1945 of what was named the Saskatchewan Social Assistance Plan. By 1957 this plan had over 30,000 beneficiaries.26 This cordial agreement, reached “with extraordinary speed,”27 was welcome to everyone – what we would call today a win-win decision. The patients gained the right to health care without incurring a debt they had little hope of paying. Their families were relieved of responsibility. Municipalities were freed from any obligation to pay for indigents’ care. The doctors were paid for caring for individuals who had rarely been able to pay them in the past. The profession’s cornerstone method of payment – fee-for-service – had not been challenged.

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Sigerist and Pensioners’ Care

The key benefit for the government side, lost in all subsequent financing of health care, was that it could budget for an exact sum, the “ceiling principle,” without risk of over-expenditure. The doctors agreed to accept a fixed sum for any given year. Further, the government’s right to fund a major medical care program had been acknowledged with the new Saskatchewan Social Assistance Plan.28 Douglas had achieved his first health goal and his government had scored on the public opinion front. This scenario was as close to perfection as was ever possible in an imperfect world. The scheme was a success. The doctors themselves policed this scheme to ensure an equitable division of earnings. They could be much tougher on an over-billing member than any government agency. A doctor submitting an account was paid fifty cents on the dollar. The residual was divided proportionately at the end of the year, depending on the number of dollars unexpended in the fund. In 1945, the final payment brought that year’s earnings to 77.5 per cent of the fee schedule, and then in 1946, with increased utilization by patients, earnings dropped to 59 per cent. That year each doctor received a cheque at the end of the year for the final 9 per cent.29 In 1949, the profession negotiated a raise to $12 per capita,30 then to $15, and finally to $21 in 1958.31 Following the Sigerist report, the government moved to create the Health Services Planning Commission (hspc) in November 1944. Its mandate was to shepherd the report recommendations and other briefs and ideas relating to medical needs into policy. Dr Mindel Sheps acted as secretary, alongside Clarence Gibson (an experienced hospital administrator) and Tommy McLeod (Douglas’ financial wizard). The Sigerist report and the Social Assistance Plan were solid achievements in the first six months of North America’s first social-democratic government. The Sigerist report laid out a

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blueprint for change and created a forum for innovative discussion and ideas, and paved the way for Saskatchewan municipalities to band together to establish health districts. Douglas deserves full credit for giving health a higher priority than any political leader before or since. His dedication was coupled with charisma, a legendary sense of humour, and a remarkable adaptability which made the best of any situation. McLeod and McLeod note that Douglas had “brought to the political life of the country a civility that enriched the Canadian scene,” while carrying “a remarkably light load of ideological dogma.”32

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CHAPTER 6

S W I F T C U R R E N T H E A LT H R E G I O N

Joan Feather opens her two landmark articles on the history of the Swift Current Health Region with the following statement: Southwestern Saskatchewan seems an unlikely place for a major experiment in universal, prepaid health services. Rolling grassland, short, hardy crops struggling against drought and wind, vast expanses without signs of human dwelling – how can such a place give rise to a sophisticated service structure? The explanation is to be found in the unique combination of past experience, local leadership, and government policy, skillfully merged into an experiment with remarkable staying power.1 What was the “past experience and local leadership” that contributed to the creation and success of the Swift Current Health Region? Four rural municipalities within Saskatchewan’s southwest drybelt led the way (see map, figure 6.1). Anchoring

36 Steps on the Road to Medicare

Figure 6.1 Map of Health District #1 (Carol Beaulieu)

the old “Palliser Triangle” region of western Canada, these communities were particularly hard-hit by the dual whammy of dust and depression between 1914 and 1937.2 Residents were eager to think of new, collective solutions to reform the care system. In 1937, rm Pittville #169 at Hazlet paid Dr A.L. Caldwell of Cabri a municipal doctor salary of $2,700 per year even though Pittville constituted less than half of his practice area.3

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Swift Current Health Region

When Caldwell joined the army in November 1941, the ar rangement evolved so that residents paid a personal tax and carried an insurance card that paid any doctor, anywhere in Saskatchewan, 50 per cent of the fee schedule as payment in full, and paid any hospital $2.75 per day.4 Pittville residents thus were not restricted to the services of a single salaried doctor, as was the case with municipal doctor plans. This freedom of choice was popular. The plan, though, was contrary to the Rural Municipality Act and in fact, not legal – but legality did not stop the rm from continuing.5 In 1943, 1,200 Pittville residents were covered for a total cost of $13,031, or $10.91 per capita, a bargain for medical and hospital insurance combined.6 A similar renegade plan, which disregarded some of the conditions of the Rural Municipality Act controlling taxation and health, evolved in rm Miry Creek, directly north of rm Pittville. In 1937, the Abbey Cottage Hospital closed. In that same year, Miry Creek began a hospital plan. Funded through an additional land tax levy, Miry Creek residents could seek hospitalization in any hospital in Saskatchewan. They added a medical plan in July 1943, which paid for visits to any Saskatchewan doctor.7 Under guidance of its secretary-treasurer, Stewart Robertson, rm Webb #138, south and east of rm Pittville, operated its medical insurance scheme under the “Matt Anderson Plan” (see chapter 3). Fee-for-service payments were made to doctors visited by rm Webb patients both locally and in larger centres. It cost $7 per person or up to $50 per family.8 North of rm Webb, rm Riverside set out its plan in late 1944, modeled largely on the rm Pittville’s any-doctor, anywhere plan.9 Dr Mindel C. Sheps of the newly created Health Services Planning Commission in Regina presented a Memorandum on Organization of Health Regions to Premier Douglas on 20 April 1945. Any ten

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municipal councils could provide resolutions to form a health district, which would break open local health schemes to consider and provide for medical and hospital needs on a regional basis.10 The memorandum paved the way for what was to come. While the small rural municipalities in Saskatchewan’s southwest corner experimented with medical insurance plans, Swift Current, the pivot city of the region, needed a new hospital. In August 1945, Sheps arrived in Swift Current to discuss the possible formation of a union hospital district.11 She found a local advocate with a much larger agenda: Pittville’s secretary-treasurer, William J. Burak (figure 6.2). Burak was convinced that his Pittville plan should be extended throughout Saskatchewan’s southwest region. In January 1945, before the memorandum on health regions was formulated, Burak wrote to each municipality, proposing that they organize to form a health region to offer not just preventive medicine but a full health plan. The council of rm Pittville was the first to ask the government to establish a health region after the provincial government set out the regulations concerning the creation of health regions, published in the Saskatchewan Gazette on 31 July 1945.12 Rather than have separate meetings to discuss both a new hospital and a health region, Sheps suggested to Burak that “the question of organizing a health region could be discussed” when Sheps visited Swift Current on 18 August 1945.13 The ccf government, uncharacteristically, was dragging its feet. Douglas had given Sheps license to discuss public health, to steer the Swift Current region to set up a union hospital, which would become the central hospital in a district that would emphasize preventative medicine. Burak offered a complete health service plan instead. As a spinoff from that meeting, Burak was appointed a committee of one “to sound out the surrounding municipalities.”

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Swift Current Health Region

Figure 6.2 William J. Burak (Mrs Pola Burak)

A veritable whirlwind, a “mover and shaker,” as Lester Jorgenson called him,14 Burak lost no time. He sent a four-page single-spaced mimeographed letter on 23 August and a followup three-page letter on 30 August to thirty-one rural municipalities, thirty-six villages, six towns, and the City of Swift Current,15 offering his vision of a much larger enterprise, the formation of a region that would offer “complete medical, surgical and hospital services.” Burak also took his personal crusade to the regional weekly newspapers16 and attended regular council meetings of five rural municipalities to advance his proposals.17 He then called a meeting, which he chaired on 15 Sep tember 1945; forty-eight of the invited municipal governments sent delegates. The other two members of Burak’s organizing

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committee were Walter Melrose of rm Big Stick #141 at Golden Prairie and Carl Kjorven of rm Riverside #168 at Pennant.18 Premier Douglas had expressed doubt about the Swift Current priorities; he thought it prudent to have a slower evolution to full medical care. In a radio broadcast Douglas downplayed the necessity of a full regional plan.19 In an article in the Saskatchewan Medical Quarterly in December 1945, Douglas wrote that he wished to introduce a health program, “step by step.” He wrote of regional public health districts and hoped that “at least one public health district [would] be organized as soon as possible” – intending to begin with preventive services.20 Joan Feather confirms this; the government had planned an experimental health region “with a focus on public health services and diagnostic and specialized facilities. But … popular pressures forced a commitment to complete health services at public expense for the region.”21 Burak, who had given a lot of his time and spent his own money, never reimbursed, for “stamps, stationery, telephones, travelling and all other expenses,”22 won out with his grandiose plan.23 By 1 November 1945, the requisite petitions from ten municipalities had been collected, and a vote was held in these municipalities on 26 November 1945.24 The ballot read: “Do you want a comprehensive system of health insurance, hospital and medical care and preventative services?”25 By a 71 per cent vote (Shaunavon’s voters were barely in favour, 137 to 136),26 the residents of southwestern Saskatchewan voted to establish a health region. The Douglas ccf government, to its credit, responded promptly to regional wishes. It passed an Order-in-Council on 11 December 1945 authorizing formation of Swift Current Health Region No. 1.27 On 17 January 1946, the organizational meeting at Gull Lake,28 attended by sixty of the eligible eighty delegates, passed

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Swift Current Health Region

Figure 6.3 Carl Kjorven (Lester Jorgenson)

Figure 6.4 Stewart Robertson (Leah Robertson Koldingnes)

a simple resolution: “That the Regional Board of Health be instructed to provide hospital, medical, and limited dental care as soon as possible and that the funds required be raised by 25 per cent from a land tax and 75 per cent from a personal tax.”29 Carl Kjorven from rm Riverside was selected as chair (figure 6.3), and Stewart Robertson from rm Webb as secretary-treasurer (figure 6.4), bringing their experience to the table.30 The representatives from the district medical society31 met with the executive of the regional board on 3 May 1946. They accepted payment at 75 per cent of the Saskatchewan medical fee schedule, and agreed to have a meeting once a year between themselves and the board. Each side trusted the other. The meeting lasted only fifteen minutes.

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20. The first comprehensive regional health care and the first comprehensive hospital plan in North America, 1946; first region in Canada to combine public health with medical care, 1946 Dr Arthur F.W. Peart, the district medical health officer, arrived in January 1946 and the full-blown preventive program began on 1 May. The Swift Current Sun boldly announced the story as winds of change.32 The new board established an office in Swift Current 7 May 1946. Peart moved on after only nine months and was replaced by Dr Lloyd Davey.33 Universal medical and hospital care came into force throughout Health Region No. 1 on 1 July 1946, two years ahead of Great Britain’s National Health Insurance Plan, which began on 1 July 1948.34 Dr Vincent L. Matthews (Figure 6.5), the third medical health officer, from 1 July 1948 through February 1957,35 provided seamless integration of preventive work with medical care36 and acted as accounts assessor and statistician for the regional board. A man of integrity, Matthews quietly earned the respect of both the medical profession in the area and the general public.37 The drought-stricken Swift Current Health Region comprised an area of 13,932 square miles and a 1946 population of 53,597.38 From the time the region was opened for homestead settlement in 1908, only one year in approximately seven had provided a sound financial return to farmers.39 When the scheme began, only nineteen medical doctors resided in the region, including four specialists in Swift Current.40 With assured payment and, as doctors returned from service in the armed forces, increased availability, the number of doctors jumped to thirty-four in 1947 and thirty-six in 1948. As Lloyd Brown reported: “a fine spirit of co-operation between the doctors and laymen on the Board was evident … and a very evi-

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Swift Current Health Region

Figure 6.5 Dr Vince Matthews (Pat Matthews)

dent desire … to run their own affairs with a minimum of interference or control from the outside.”41 The region’s staff, all paid by the Saskatchewan government, consisted of the medical health officer, seven public health nurses, a health educator, and three sanitary inspectors. Stewart Robertson, functioning as a chief executive officer, held this position until he retired at the end of 1966. Robertson was a frugal Scot who had left Scotland in 1920 at age twenty. Not only did he obtain full value for each dollar spent, but his own office was small, with second-hand furniture, bare wood floors, and no drapes. His first secretary, Pat Ditner, describes him as “caring, kind, sensitive, even-tempered, compassionate, patient … hard working and willing.”42 Nothing flustered him. Each rural municipality and the City of Swift Current had an elected representative; all were laymen. Dr Orville Hjertaas of the Department of Health, assigned to organize health regions,

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remembered the “outstanding board of bright and caring people … basically farmers.”43 The board contained “staunch Liberals and Conservatives and hard line C.C.F.ers, but they all left their politics on the doorstep.”44 The regional health scheme was financed by a personal tax – $15 for one person, $24 for two, $30 for three, and $35 for a family of four or more – and a property tax, calculated to raise 25 per cent of the total, set at 2.2 mills. The provincial government contributed twenty-five cents per capita and paid one-half the cost of x-ray, children’s dental, and out-patient services. The provincial contribution to the Swift Current plan in 1948 came to $63,691.45 For the first six months of the scheme, hospitalization costs were 42 per cent of total expenditures, having been underestimated by about $75,000.46 Fortunately, the advent of provincewide universal hospitalization on 1 January 1947 removed hospital expenses from the six-month-old region’s budget and thus saved the Swift Current plan from bankruptcy. Other measures which brought the budget under better control included: reducing specialist fees from 75 per cent to 50 per cent of the provincial rates in 1948; introducing utilization fees, which controlled “double doctoring” and “shopping around” for medical services, as well as overuse for minor ailments; and the “ceiling principle,” which introduced a budget ceiling in the expectation that the health region as a group had to adhere to strict guidelines.47 Expenditure for medical services within the region, on a feefor-service basis, was $410,453 in 1947 and $453,925 in 1948. In 1948, doctors received an average gross revenue of $12,880 – a net income averaging $8,114, since the overhead for a doctor in the area was estimated at 37 per cent.48 Referrals to specialists outside the region, mainly Regina, came to $58,547 in

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Swift Current Health Region

1947 and $67,909 in 1948. The per capita cost for medical service in 1947 was only $9.83 and in 1948, $10.23.49 For the first time, as Dr J. Lloyd Brown pointed out, statisticians had access to reliable figures concerning the cost of medical care, a valuable side benefit from the operation of the Swift Current plan. The region’s doctors were aware that specialists in Regina and Saskatoon looked askance at this experiment in “socialized medicine.” Dr J.A. Matheson of Gull Lake said, “there have been times when we in the Swift Current area felt like black sheep … We have been trying out some ideas that have not been approved.” He went on to tell of the benefits of the scheme: “security and stability … better incomes … The patients are getting a better service … partly due to an increase in the number of physicians.”50 Payment was in cash from the provincial government, no longer in chickens or sides of beef. Dr Gordon Howden, a family practitioner in Maple Creek before he left to specialize in ophthalmology, gave a well-reasoned account of his experience. He found the scheme did not affect the doctor-patient relationship, but the doctor’s work increased considerably and “many have acquired a taste for xrays … because of the good feeling and spirit of co-operation between ourselves and the Regional Board, we have had an excellent opportunity to present our case under favourable circumstances.”51 One measure of success: the infant mortality rate is reputed to have fallen from a high level (before 1946) to the lowest rate in Saskatchewan in 1965 – 14.4 per thousand live births.52 Dr Arthur D. Kelly, deputy secretary of the Canadian Medical Association, visited the area in 1946. He found that the regional board enjoyed “a large measure of local autonomy.”

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He characterized the region as “a successful experiment in the large-scale provision of medical care, courageously applied, efficiently managed and remarkably free from attempts to make the facts fit preconceived ideas, financial or otherwise.”53

21. The first regional hospital board in Canada, 1951 Vince Matthews’ reminiscences include the information that the Swift Current Regional Hospital Council, formed in 1951, was the first regional hospital organization in Canada, an early precursor of a system that came into vogue, for better or for worse, in most Canadian provinces only in the 1980s and 1990s.54 As Maureen Matthews55 said on her superlative cbc Ideas program with Lister Sinclair, 5 December 1990, “The basic idea was that every citizen deserved equal access to adequate medical care.”56 The following comments excerpted from that cbc program, provide the inside experience of two doctors in the scheme. dr gordon howden: The one thing that doctors and the municipal people felt … that it was our plan. It was a local plan, we could change things, we could communicate, there wasn’t a political overtone at all. It was purely for the benefit of the people in the plan … the fact that it was on a small scale, the fact that it was a give-and-take situation with the municipalities and the doctors, both willing to learn, and being able to change the plans … the doctors did feel that they had input. dr cas wolan: the Health Region trusted the doctors and the doctors trusted the Health Region … after one of these meetings with Stewart Robertson for a few hours, we decided that for the balance of the year we’d go on fifty-one percent of our

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Swift Current Health Region

usual payments … it was kind of a hard deal to take but I agreed to this thing, Stewart agreed to it, and I went back to the physicians and told them why and they accepted it.57 The secret of the success of the Swift Current Health Region was the integrity, pragmatism, and openness of all concerned. Dr Vince Matthews, Stewart Robertson, and Dr Cas Wolan, the doctors’ representative for financial matters, would have coffee together most mornings at the Venice Café in Swift Current. It was, Matthews recorded, “the best buzz group in which I have ever been involved.”58 If a doctor new to the area was overservicing his patients or wanting to install an x-ray machine as a money-maker in his private office, the three would reach an amicable agreement to resolve the problem. Carl Kjorven, a farmer from near Cabri, was a skillful chairman. When Robertson retired on 31 December 1966 after twenty-one years of service, the Regina Leader Post argued that he had achieved greater “closeness of the operating between the doctors and the health region board, and between the patients and the health region board.”59 Before the withdrawal of services of most Saskatchewan physicians in the still-remembered “doctors’ strike” between 1 and 23 July 1962, the Swift Current Health Region “asked to remain autonomous and carry on with their own successful plan.”60 But events became so emotional and so polarized that on 1 July the doctors within the region closed their office doors in concert with those elsewhere in Saskatchewan. After Lord Stephen Taylor’s negotiated compromise on 23 July 1962, many doctors returned to work throughout Saskatch ewan. The Swift Current area continued to operate separately from the provincial health plan, offering advantages over the

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rest of the province: no extra billing and no hospital privilege problems.61 An extra fee of $14 was added to pay for a children’s dental plan. Collection of taxes and doctors’ billings remained separate from the provincial plan.62 In 1953, short of revenue, the Swift Current board added deterrent fees ($1 for an office visit and $2 for a house call).63 By 1972, as part of a new federal-provincial agreement, the province assumed direct responsibility for medical services to those over 65, relieving the board of responsibility for this age group. By 1974, the region ceased levying its own personal taxes. Until 1980, regional cards continued to be issued annually by each rm and town office, but in 1981 the province moved the region medical accounts into Regina.64 Only in 1988 was the region fully merged into the Saskatchewan Medical Care Insurance Commission, and the Swift Current office closed. The last regional information meeting was held on 3 June 1993, the final vestige of local involvement.65 The Swift Current Health Region was unique. It was a success. It was thoroughly tested. It was made to work. As Taylor says, “It had attracted a higher ratio of doctors-to-population than any other rural part of Saskatchewan.”66 The public, the doctors, and the inordinately small administrative staff felt a sense of ownership, of empowerment.67 Swift Current became a major stepping stone on the road to medicare.68 Lester Jorgenson of rm Miry Creek #229 emphasizes that this was a local, grassroots phenomenon. Although supported by the province, “the widely held concept that the Swift Current plan was a provincially directed pilot project does not fit the recorded facts.”69

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CHAPTER 7

MEDICAL COLLEGE AND UNIVERSITY HOSPITAL

The success of any future medicare program in Saskatchewan required a first-rate medical school. Although a two-year medical course had been offered at the University of Saskatchewan since 1926, Saskatchewan medical students had to move to other provinces for their clinical training. Sigerist’s report in 1944 recommended construction of a full, five-year medical school and a 500-bed university hospital in Saskatoon. Sigerist predicted the building and equipping of the hospital and medical school would cost $2 million,1 with annual operating costs of $150,000. university of saskatchewan college of medicine, 1955

Even before the 1944 election, T.C. Douglas was planning for a five-year medical college if and when he took power. In thinking of possible candidates for a dean of medicine, he took advice from Dr W.C. Gibson, then serving at the Royal Canadian Air Force Clinical Investigation unit in Regina.2 Gibson suggested

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his former teacher at McGill University, Dr J. Wendell Macleod.3 However, it was not until July 1951 that the provincial budget and Macleod’s personal circumstances allowed him to accept the position. Macleod was a man of vision; he spent a year studying medical education and recruiting department heads before settling in Saskatoon.4 Meanwhile, in the spring of 1945, the legislature voted $100,000 to begin construction of the medical college; the cornerstone was laid by T.C. Douglas on 26 August 1946. The official opening took place on 8 May 1950.5 The first medical class was admitted in the fall of 1953 and graduated in 1958. There are benefits from a small class size. In spite of usually inadequate funding for the medical college, Saskatchewan medical graduates have done well. The history of the medical college has been chronicled through 1976 by Dr Douglas J. Buchan,6 and from 1976 through 1998 by Dr Louis Horlick.7 university hospital

Premier Douglas established the Board of Governors for the university hospital in September 1946. In December 1946, he agreed to an expenditure of $7 million for a 550-bed hospital, to be connected to the medical building.8 The legislature passed the University Hospital Act in 1947. Construction of three wings of the hospital began in 1948, but due to worrisome delays for financial reasons, the cornerstone was not laid by Premier Douglas until 19 September 1952. In his address, he wisely said, “we wanted no medical school at all unless we could have the best possible.”9 The hospital opening ceremony took place on 14 May 1955. Delays and inflation caused the price of the university hospital to rise far above the “ballpark estimate” of $1,500,000 given

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Medical College and University Hospital

by Dr W.S. Lindsay, dean of the two-year basic science course in medicine, and adopted by Sigerist in his report. The final cost of the hospital was seven times higher – $10,589,703.10 The university hospital brought top-notch specialists and subspecialists and greatly raised the standards of medical care in Saskatchewan, as recorded by Louis Horlick.11 The medical college and university hospital were necessary ingredients in the preparation for medicare.

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CHAPTER 8

PROVINCEWIDE H O S P I TA L I Z AT I O N

Hospital services are costly. They require support from municipal and provincial governments to provide funding and sound policies. Above all, the primary concern should be for the patient. With momentum gained from experience with cottage and union hospitals and the Swift Current Health Region No. 1, Saskatchewan moved toward provincewide hospitalization.

22. The first province to provide capital grants for widespread hospital construction, 1945 Saskatchewan took Sigerist’s advice to heart in becoming the first province to provide funds for capital construction of hospitals, a major step on the road to medicare.1 Between 16 March 1945 and 1 March 1949, the government provided $653,714 in outright construction grants and $173,500 in loans.2 The National Health Grants Programme in 1948 added substantial federal funds to support hospital construction; Saskatchewan,

Provincewide Hospitalization

sadly, having been too quick off the mark, was ineligible for matching federal funds for new construction since most of its hospitals had already been built. The province was in double jeopardy because some of the operational health programs had also been launched in anticipation of federal support; it was learned only too late that, because they were already underway, they were disqualified from receiving federal assistance.3 Nonetheless, the Saskatchewan program moved hospital construction costs out of tight municipal budgets, allowing larger, better equipped hospitals to be built. Larger centralized hospitals could incorporate modern conveniences and technologies, from plumbing and heating infrastructure to power, which led to specialized laboratory and x-ray rooms. Twenty-one new hospitals were established over four years, and forty-one union hospital districts formed.4

23. The first universal hospitalization insurance program in North America, 1 January 1947 Introduction of the first provincewide, compulsory hospitalization insurance program in North America was achieved in Saskatchewan with remarkable speed and efficiency. Hospitalization was expected to cost even more than physician services and thus be the more expensive “half” of the medicare equation. Sigerist estimated that universal, provincewide hospitalization insurance would cost $3.60 per person (about $3.5 million)5 per year and would require another 1,000 to 1,500 hospital beds in Saskatchewan,6 including a university hospital of at least 500 beds.7 The first steps toward provincewide hospitalization insurance included: the Saskatchewan Social Assistance Plan (1 January 1945; see chapter 5), which paid for both medical and hospital services for the province’s most

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needy; free hospitalization and treatment for cancer patients; and full coverage for hospitalization and treatment for mental illness.8 The move to provincewide hospitalization insurance would spread the cost of hospital care across all citizens and ease financial pressure on smaller municipalities. It would also be least likely to disrupt the balance between the doctors’ professional considerations and provincial or regional purse strings.9 The doctors in Saskatchewan enthusiastically and almost unanimously supported the introduction of provincewide hospitalization insurance on 1 January 1947. Doctors could now admit patients to hospital whenever necessary, without concern for cost. Patients could be treated in whichever hospital was best for their care, for the time needed to recover, whether that was a few days or many months. Small hospitals rejoiced, for a time. The Red Cross Outpost Hospital at Paddockwood, for example, no longer needed to rely on intermittent and sporadic local upkeep or payment – hospital costs were covered by the new plan. Still, consolidation and construction in larger centres with provincial support led to rural hospital closures.10 dr mott and the saskatchewan hospital services plan (shsp), 1 january 1947

Dr Fred D. Mott (figure 8.1), a graduate of the McGill Medical School and a senior officer with the United States Public Health Service, became chairman of the Saskatchewan Health Services Planning Commission on 1 September 1946. Tommy Douglas deserves credit for making such a wise choice. Mott’s appointment was welcomed by the medical profession.11 Mott, a man of integrity and a good listener, as well as a man of action, moved the plans for the Saskatchewan Hospital Services Plan (shsp) “into high gear.”12

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Figure 8.1 Dr Fred D. Mott (sab r-a7994)

The provincial hospital plan broke new ground. The administrative machinery had to be invented “from scratch,” and became the model for all subsequent plans. Malcolm Taylor, an interested graduate student of health administration from the University of California, passing through Regina, describes the unprecedented pioneering effort as follows: The new uniform hospital accounting system was finalized under G.W. Myers; the point system was completed,13 the tax collection procedures agreed upon with the municipalities; and the organization of shsp decided upon; scores of clerical, secretarial, and tabulating personnel were appointed and trained, and a massive publicity program was mounted to encourage early registration and tax payment.

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It was a period of feverish activity, reminiscent of mobilization in 1939. The only office space available was in an ancient, vacated store building; clerical desks were long rows of plywood-on-trestles, with clerks sitting elbow-toelbow, processing the registration and tax collection payments.14 The annual hospital premium was $5 for each adult and child, with a maximum of $30 per family. Each municipality received a 5 per cent commission for collecting the premium. The plan provided “complete hospital benefits to all residents of the province. It included public ward care, X-ray and laboratory services, common drugs, and other hospital services. It also provided for the payment of a flat per diem amount toward the cost of out-of-province hospitalization for any Saskatchewan resident.”15 Each resident received a hospitalization card with a number. The shsp was administratively separate from the Department of Health but was not the “independent, nonpolitical commission” the doctors had desired. The deputy minister of health sat on the commission, which oversaw both the shsp and the Medical Services Division, which administered the Social Assistance Medical Care program (see chapter 5). Sigerist’s financial projections were wildly short of reality. The hospitalization costs for the first year were almost exactly twice his forecast – $7,560,763, a per capita cost of roughly $9.69. In subsequent years that $7.5 million seemed a bargain. Per capita costs of hospitalization rose rapidly, to $11.42 in 1948 and $13.59 in 1949. The most economical component in the early years was administration, which consumed only about 5 per cent of total expenditures.16 The $5 per person hospital tax initially covered 60 per cent of the cost of provincewide hospitalization.17 As Taylor says, “The tax collection system was

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Provincewide Hospitalization

successful to a degree unexpected for a regressive ‘poll’ tax.” He adds, “In Saskatchewan, the plan became popular before it was expensive; in B.C., it was expensive before it was popular … a main issue defeating the [British Columbia] government in 1952.”18 Historian James McAllister noted that until 1944, health spending comprised only 1.4 per cent of the Saskatchewan provincial budget. Within four years of implementing the hospitalization plan, health’s portion of the provincial budget rose to 13.1 per cent.19 poliomyelitis treatment

The hospital plan was put to an early test in its first year: 277 polio cases were reported in Saskatchewan, with twelve deaths. Poliomyelitis “was one of the most feared diseases” of the twentieth century.20 The polio clinic in Saskatoon was augmented by the addition of polio clinics in Regina and Moose Jaw. Unlimited free hospital, medical, and nursing services were financed through shsp. In 1952, Saskatchewan was the epicentre of the Canadian polio epidemic. The government took the threat seriously. By the end of 1960, 99 per cent of Saskatchewan children had been immunized.21 Polio joined tuberculosis, cancer, and mental illness as special diseases requiring full provincial medical support. saskatchewan air ambulance

The move toward health regions and centralized hospitals gave support to an innovative initiative. On 3 February 1946, an air ambulance service was put in place. The service speeded up the transfer of residents from remote or rural areas for treatment at the larger regional centres and offset rural hospital closures.22 New hospital construction, universal hospitalization insurance, and a vigorous response to special diseases broadened

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health care in Saskatchewan. By 1958, “the volume of hospital service received by Saskatchewan residents (2,100 days per 1,000 persons per year) was “the highest in North America … their needs are being met.”23 the saskatchewan health survey, 1949–51

On 28 July 1948, the government of Canada announced that it would make funds available for each province to survey “present health services and facilities.”24 Saskatchewan was allotted $43,506 for the provincial survey. A committee of twelve had one representative each from registered nurses, dentists, urban municipalities, rural municipalities, labour, the hospital association, the farmers’ union, the Swift Current Health Region (Carl Kjorven), and two from the medical association (C.J. Houston and G.G. Ferguson, registrar of the Saskatchewan College of Physicians and Surgeons). Dr Mott was chair and Malcolm G. Taylor (figure 8.2) was research director and secretary. In the middle of the health survey, on 14 November 1949, Douglas turned over the Ministry of Health to T.J. Bentley, the member from Gull Lake. It was probably more than simple coincidence that Bentley, a farmer, and later on the field staff of the Saskatchewan Wheat Pool, represented a riding within the Swift Current Health Region. The diverse group met amicably.25 Mott listened to each viewpoint and then asked for overall consensus. As each question came up, it was hammered out to the point of agreement. No minority report was submitted, nor were interim reports supplied to the organizations that each member represented. After more than two years’ work and twenty-five meetings, the twovolume report contained a full catalogue of Saskatchewan’s health resources and an estimate of needs in future.26 Ken McTaggart, in The First Decade, wrote that the Saskatchewan

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Provincewide Hospitalization

Figure 8.2 Malcolm G. Taylor (sab rws-a11567, by permission of Michael West)

Health Survey report surpassed that for any other province; he described it as “the classic of such projects.”27 In addition, as C.J. Houston reported to the College of Physicians and Surgeons, the Saskatchewan committee “established a precedent in working out health matters. It has proved that a widely representative type of Commission can work.”28 Of 115 recommendations, the first was that “a comprehensive health insurance program should be undertaken at the earliest possible date.”29 hospitalization universal throughout canada, 1961

British Columbia’s hospitalization plan, the second in Canada, followed in 1949 but, lacking Saskatchewan’s superb organization, was an administrative nightmare that suffered horrendous problems. Federal funding for hospitalization, on a cost-sharing

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basis of 45 per cent, started 1 July 1958.30 On 1 January 1959, Ontario’s plan went into effect. By 1961, all provinces were participating, with Quebec the last to join. Each province, watching the Saskatchewan example, sent administrators to Regina to learn how to do it right. Federal funds through the cost-sharing agreement to support the hospital plan eased Saskatchewan’s purse strings. The money provided the Saskatchewan government with the funds it needed to undertake its long-sought goal of universal medicare, covering both hospital and medical services.

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CHAPTER 9

I N N O VAT I O N S I N P S Y C H I AT RY

When Saskatchewan became a province in 1905, psychiatry and mental hospitals across Canada were in a backwater compared to the rest of medicine. The first opportunity to show leadership was scuttled by unfortunate advice from Ontario. a missed opportunity to pioneer small, humane psychiatric cottage hospitals, 1908

Dr David Low of Regina, the provincial health officer (figure 9.1), was sent in 1907 to visit mental hospitals in eastern Canada and the United States. He was asked to consult widely and to make recommendations for construction of a mental hospital in the new province. He visited two up-to-date mental hospitals in New York State, at Ogdensburg and Ward Island, and the Protestant Hospital for the Insane at Verdun, Quebec. At these three hospitals, “instead of measures of restraint such as padded cells and straight-jackets,” there was sufficient staff and patients were allowed their freedom and even were allowed to use the libraries that were provided.1

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Figure 9.1 Dr David Low (sab r-a3569)

Low recommended “a cottage system.” However, Dr C.K. Clarke, superintendent of the Toronto Asylum, was asked to be a consultant to the Toronto architectural firm of Darling and Pearson, who were concerned about “scattered plumbing and heating lines” if a cottage plan were chosen. Clarke admitted that the cottage system is “ideal for the patients themselves, and provides means for breaking up the patients into smaller distinct groups,” yet he advised against it on economic and climatic grounds.2 With the devastating winter of 1906–07 firmly in the rear-view mirror in Saskatchewan, it is perhaps not sur-

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Innovations in Psychiatry

prising that heating issues at public institutions carried weight. With coal and wood prices factored into maintenance costs, the Canadian climate would indeed have an impact.3 It is nonetheless a pity that the government chose to follow “expert advice” from Toronto and ignored Dr Low’s recommendations. In retrospect, a series of cottages with closed-in connections between them, suitable for a cold climate, would have made Saskatchewan a leader, giving mentally ill patients more humane treatment. Sadly, the government opted for a pavilion-style institution at North Battleford,4 which opened on 4 February 1914 with 314 patients. The patient population increased to 853 in 1920 and 985 in 1930. A second pavilion institution opened in Weyburn in 1921; it had 1,058 patients in 1930 and about 1,500 in 1963.5 By 1948, including those in the “training school for mental defectives,” 4,500 mental patients were institutionalized in Saskatchewan, “the highest institutionalized rate per capita” in Canada, with “not more than ten Registered Nurses in the three institutions.”6 Weyburn’s hospital has been cited as the last asylum-styled psychiatric care facility, and the largest in the British Commonwealth. Large mental hospitals were inherently counterproductive. “Patients came from long distances, tended to stay a long time and fairly often were not discharged. Deaths were high.”7 “The huge corridors and indefinite spaces would clearly be extremely damaging to people whose perceptual apparatus was already out of gear … the large overcrowded institution not only did not help patients, it hurt them.”8 Yet, the Saskatchewan mental hospitals and their managers deserve credit for some unusually fine care. J.W. MacNeill, first medical superintendent at the Saskatchewan Hospital North Battleford, abolished restraints, removed bars from windows, and changed the use of the term “asylum” to “hospital.” Farm

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and irrigation projects, including extensive gardens, supported the value of beautiful surroundings and meaningful work in helping patients live more fully. Those at the hospital were not inmates but patients, humans with illnesses in need of care.9

24. The first province to provide free psychiatric treatment, 1 January 1946 Medical historian Erika Dyck noted that Douglas “deplored the tradition of placing people with mental illnesses in custodial institutions.”10 Instead, he advocated community care as much as possible, with an emphasis on intervention and preventative medicine. By 1945, Douglas was publicly advocating early diagnosis and treatment, as well as an aggressive public awareness campaign in an attempt to remove the stigma of mental illness: “to get the public to know that there is no more disgrace for one member of the family to get mentally ill than there is for any other member of the family to [get] pneumonia.”11 The Sigerist Commission, as well as Douglas’s own thoughts on mental health and his position as health minister, no doubt combined to push forward the move, in the throne speech of 1945, to full hospitalization and treatment coverage for mental health patients.12 As a result, the government considered the patients and took steps to differentiate those who had mental or physical handicaps from others who experienced mental illnesses or drug and alcohol addictions. Treatment paths diverged.13 Mental health reforms, as well as a new emphasis on treatment, research, and care, placed Saskatchewan at the forefront in the postwar period. Dyck contends that the “delicate and complicated set of historical and psychological factors gave

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rise to a new vision” of mental health innovation.14 Medical historian Colin Smith went further, declaring that the Douglas government initiated a “halcyon period” of mental health services.15

25. The first free outpatient service for mental health patients in Canada, beginning 1947–51 On 1 November 1946, Dr D.G. (Griff) McKerracher became Commissioner of Psychiatric Services for Saskatchewan. Described as a “man of immense charm,” McKerracher was enthusiastic about his role and sympathetic to both the needs of mental health and the innovations required to change how things had been done.16 He “strongly urged a reconceptualization of mental health as an area indistinguishable from general medicine, meaning that its treatment would take place in a general hospital.”17 He moved quickly, establishing an outpatient clinic, the Munroe Wing, of the Regina General Hospital in 1947. Part-time or full-time clinics were operating in Weyburn, North Battleford, Saskatoon, Moose Jaw, Assiniboia, Swift Current, Yorkton, and Prince Albert by 1951.18 Saskatche wan’s per capita expenditures on mental health patients were the highest in Canada.19

26. The first 500-hour psychiatric nurse training program in Canada, 1947 Psychiatric nurses had traditionally trained “on the job.” In 1930, a more formalized “ward attendant” training program began in Saskatchewan.20 Dr F.S. (Sam) Lawson, director of the Saskatchewan Hospital, Weyburn (figure 9.2) wished to upgrade

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Figure 9.2 Dr F.S. Lawson (sdcmh)

the training of attendants to support more expert and humane care for the patients. Supported by McKerracher (and following recommendations in the Sigerist report), Lawson in 1947 devised a three-year (500-hour) program, one or two hours of lectures each day from October to June, to upgrade the training and status of the caregivers.21 Those who completed the course successfully earned a Registered Psychiatric Nurse (rpn) diploma.22 The graduates from this program eventually formed “about 90% of the psychiatric nursing staff” in the two large mental hospitals and tended to be “the most stable members of the community psychiatric team,” remaining for longer periods. Registered Psychiatric Nurses throughout the province provided continuity of patient care, made regular home visits, demon-

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Innovations in Psychiatry

strated a genuine concern, and fulfilled “the traditional helping role.”23 Dyck recorded instances of women coming to Weyburn to take the course, drawn by both the expanded role of women as psychiatric nurses and the provincial system of loans and bursaries to support the training.24

27. The first Psychiatric Nurses Act in North America, 25 March 1948; first Psychiatric Nurses Association in North America, 1948 On the heels of the move to formalize psychiatric nurse training, Saskatchewan enjoyed two more firsts: it shepherded the creation of the Psychiatric Nurses Act, a North American first, in 1948, which led to the first Psychiatric Nurses Association, which registered psychiatric nurses.25

28. The first provincial government to emphasize and fund psychiatric research, 1950s The change toward improving psychiatric care and mental health led to Saskatchewan’s revised Mental Health Act, passed in 1950. It classed mental health as a medical function,26 giving doctors a supportive base for medical intervention. The 1950s spawned a new era of experimentation and research, with Saskatchewan in the lead. Medical historian Dr John Mills asserted that Saskatchewan was the first jurisdiction to commit to a fully funded, provincewide program of psychiatric research, which was comprehensive in humane treatment of mental illness.27 Dyck notes that the 1950s were a period of “unbounded optimism” toward psychiatric research, where McKerracher “nurtured novel perspectives in mental health.”28

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the first province to explore psychedelic therapy, 1953–63

Two of the most innovative researchers facing the challenge of treating mental illness on an equal basis with other medical concerns were Dr Abram Hoffer and Dr Humphry Osmond. Hoffer, a native of Saskatchewan, came to medicine by way of agriculture, through biochemistry. He became the director of the provincial psychiatric research program.29 Hoffer, “an outstanding physician and researcher,” supported “adventurous, questioning, experimental, and optimistic attitudes at a time when they had been lacking.”30 Osmond, a Brit, was baptized as a physician during the Second World War. The war taught him that mental illness could be just as damaging, and sometimes more so, than physical stressors. He began, with his colleague John Smythies, to research mescaline, a chemical substance derived from the peyote cactus plant. The two of them also began working with d-lysergic acid diethylamide (lsd) to induce hallucinations not unlike those suffered by schizophrenic psychotic patients. Osmond came to Weyburn, Saskatchewan, in 1951, first as clinical director and then as medical superintendent at the Saskatchewan Hospital. He pursued his research studies in the bold Saskatchewan medical environment.31 By explaining mental illness as a metabolic dysfunction,32 Osmond and Hoffer were among an elite group of psychiatric researchers intent on researching drug therapies to alleviate psychotic symptoms. But the Saskatchewan experiments underscored more than a simple biochemical connection: mental illness and mental health involved both biological and social considerations. The lsd experiments fused the two.33 The “psychedelic” experience as therapy, as it became known, was

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Figure 9.3 Dr D. Griffith McKerracher (McKerracher Centre, Saskatoon Health Region)

a Saskatchewan first, but has failed to achieve acceptance by psychiatrists.34 29. The first open psychiatric ward that included psychotic patients in a general teaching hospital in Canada, 1955 On 1 July 1955, Dr McKerracher took the post of Head of the Department of Psychiatry, University of Saskatchewan and Dr Lawson took over as Director of the Psychiatric Services Branch of Saskatchewan.35 When the university hospital opened its doors in 1955 in Saskatoon, psychiatric patients were treated almost exactly as were those on medical and surgical wards, being free to visit the cafeteria and obtain passes to visit outside the hospital. Windows were not barred. No one was re strained. From 660 admissions, psychiatric patients left the

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ward without permission on seventy-seven occasions; forty-four returned of their own accord, fifteen were returned by relatives, eight by police, and six by hospital staff.36 McKerracher (figure 9.3), admitted ninety unselected patients who had been committed to the Saskatchewan Hospital at North Battleford and concluded that almost all mentally ill patients could be treated in a general hospital.37 Family practitioners could visit their patients and some could take part in their care. The average length of stay was twenty-one days,38 much shorter than the average stay (18.2 years, often until death!) at North Battleford.39

30. The Saskatchewan Plan, a first in Canada, 1956 Despite advances, the situation at the Saskatchewan Hospital, Weyburn, was appalling. Overcrowded and unclean, it was symbolic of the old institution-style incarceration methods. To address these conditions and find new solutions, in 1956, Dr Sam Lawson and Regina architect Kiyoshi Izumi boldly presented their theoretical and unproven plan, named “The Saskatchewan Plan.” The Saskatchewan Plan hoped to keep patients closer to their families through building eight or more small regional cottage hospitals designed by Izumi. Sam Lawson wrote in 1958: “The older concept of the mental hospital as an asylum where the mentally ill could be stored out of harm’s way is no longer acceptable.”40 Lawson and Izumi presented their plan to a meeting of the American Psychiatric Association Mental Hospital Institute in Denver, Colorado.41 Dr John Mills believes that Sam Lawson, Griffith McKerracher, and Humphry Osmond (figure 9.4), the three senior psychiatrists at Weyburn, developed the plan through study and many long discussions,

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Figure 9.4 Dr Humphry Osmond (sdcmh)

during the year or two before McKerracher accepted the headship of psychiatry at the new medical college in Saskatoon. Lawson expected that construction of the first regional cottage hospital, a radical departure in function and architecture and designed to “give the patients living conditions that are as near those of domestic living as possible,”42 would begin in Swift Current in 1957, but it was delayed by four years and was then built in Yorkton instead.43 At the Yorkton facility, Lawson explained, “all patients from one district are seen by the same team,” thus providing “continuity of care.”44 The cottagestyle Yorkton unit with 148 beds proved to be larger than required. It was the only one of the planned eight hospitals that was built; although the second was authorized for Prince Albert in 1965, that promise was never kept.45 In many ways, the Saskatchewan Plan hoped to reverse the missed opportunity

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to develop humane regional cottage hospitals first proposed by Dr Low in 1908. In striking contrast to the jail-like treatment in North American mental hospitals with large wards, where some patients were naked and others were kept in restraint, cottage hospital operation would be governed by the following six principles: 1 No human being should be incarcerated in an institution when any better solution can be found. 2 The mentally ill should have an equal standard of care to that given to the physically ill. 3 The continuity of care which is provided to the physically ill should also be provided to the mentally ill. 4 There should be integration of psychiatric care with general medical and surgical care. 5 Comprehensive care in the patient’s home area should be made available. 6 In-patient facilities should be designed in such a way that they assist the patient’s recovery.46 The key to the Saskatchewan Plan, as enunciated by McKerracher, was “community service, especially follow-up … through a home-care program.”47 the first psychiatric ward to invite a general practitioner to treat mentally ill patients, 1957

Dr Abe Voth was the first (1957) and Dr Wilf McCorkell (1958 through 1 July 1961) the second family practitioner allotted two beds on the psychiatric ward of the new university hospital in Saskatoon.48 Each had an interest in mental illness, attended psychiatric teaching rounds, and was asked by other family prac titioners to see their patients. McKerracher said that McCorkell

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“participates in teaching with unusual success.”49 McCorkell published his experiences in treating sixty-four psychiatric patients.50 His patients were discharged in an average of twenty-one days, although twenty-one of the sixty-four returned for further treatment.51 Both Voth and McCorkell, from their contact and training, became more confident in dealing with mental patients in subsequent office practice.52 The innovative advances in psychiatric care and clinical research in Saskatchewan had dramatic results. The numbers of in-patients at both Saskatchewan Hospitals declined. Between 1963 and 1966, psychiatric residents at Weyburn declined from 1,519 to 421, a 72 per cent reduction. Dr John Mills contends that it was “the highest rate of de-institutionalization ever recorded in any mental institution anywhere in the world.” Many of the discharged patients were initially “placed in approved homes under the overall supervision of psychiatric nurses.”53 Such de-institutionalization is the hallmark of contemporary psychiatric care.

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CHAPTER 10

H I G H - V O LTA G E C A N C E R T R E AT M E N T

Saskatchewan was slow off the mark in using radiation to treat cancer but, once up to speed, it led the world. As with the initial provision of radium in 1932, high-voltage treatment could be available only with government support. In 1922, Dr Ellice McDonald,1 a Saskatchewan man who had been raised at Fort Qu’Appelle2 and later specialized in cancer research at the University of Pennsylvania, visited University of Saskatchewan president Dr Walter Murray. McDonald informed Murray that the province of Quebec had just purchased a gram of radium for $75,000 and suggested that Saskatchewan should take similar action. In response, Murray wrote to Saskatchewan Premier Charles A. Dunning on 6 October 1922 to offer the services of university physicists if the province should decide to follow Quebec’s example and offer cancer treatment to its citizens.3 Dunning replied that the province’s higher health priority was tuberculosis.4

High-voltage Cancer Treatment

31. The first cancer control agency in Canada, 1930, with government-sponsored cancer clinics, 1931 In 1929, the Saskatchewan Medical Association formed a Cancer Committee. This committee proposed the establishment of a voluntary lay-medical Canadian Society for the Control of Cancer, which gradually developed into today’s Canadian Cancer Society.5 The Saskatchewan Cancer Committee enlisted Dr E.L. Harrington (figure 10.1), professor of physics at the University of Saskatchewan, as their only non-medical member.6 Harrington’s advice led to the drafting of the Saskatchewan Cancer Commission Act, passed by the Conservative government of J.T.M. Anderson in 1930.7 This act established the first cancer control agency in Canada and probably the first in North America. North America’s first government-sponsored, part-time (two mornings a week) consultative, diagnostic, and treatment clinics were staffed by radiologists: Dr Earle E. Shepley (figure 10.2) at the Saskatoon City Hospital (beginning in 1931),8 and Dr Clarence M. Henry at the Regina General Hospital (1932).9 Patients were treated with what were then called “high-voltage” machines, operating at 400 kilovolts peak.10 Treatment and hospitalization were the financial responsibility of the patient,11 but the government funded the equipment.

32. The first cancer registry system in Canada, 1932 In 1931, Dr Shepley visited the leading cancer centres, particularly the Cancer Institute in Philadelphia, operated by Ellice McDonald, and the New York Memorial Hospital, under Dr James Ewing. On his return, Shepley submitted to the Sask atchewan Cancer Commission a thoughtful document, “The

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Figure 10.1 Dr Ertle L. Harrington (University of Saskatchewan Archives)

Figure 10.2 Dr Earle E. Shepley (A. Becker)

Essentials of an Ideal Cancer Policy.” In the following year, the Saskatchewan Tumour Registry began, requiring compulsory reporting of all new cancer cases. It was the first cancer registry system in Canada.12 The Saskatchewan government allocated $115,000 for the purchase of radium in 1931, an extraordinary measure given

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High-voltage Cancer Treatment

Figure 10.3 Dr Allan W. Blair (sab r-b11015)

the fiscal constraints of the Great Depression.13 From the university, Dr Harrington distributed radon to each of the cancer clinics in small gold tubes or “seeds” which had a 3.8-day halflife. Harrington was a proficient and enthusiastic glass-blower who built and operated the radon plant from 1931 until 1962, extracting the radioactive gas emitted by radium in solution.14 The average number of patients referred per year to the two clinics increased, from 575 to 735 to 1,065, in the first four three-year periods until the end of 1943. In 1939, Dr Allan W. Blair (figure 10.3), a Regina boy, a graduate of McGill University, and a radiotherapist at the Toronto General Hospital, took over as director of the Regina cancer clinic.15 On 1 April 1944, the outgoing Liberal government of W.J. Pat terson, under pressure from Dr George Dragan, who had been a backbench Liberal member from Kelvington in the eighth legislature, proposed a bare-bones cancer bill, An Act Respecting the Control and Treatment of Cancer. The bill died on the floor as the ninth legislature prorogued, leading to an election.

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33. The first Cancer Control Act in North America, 1944 Following the landslide victory of the ccf on 15 June 1944, T.C. Douglas lost no time. Dr Blair was promoted to director of cancer services for the province. The first session of the legislature began on 19 October and ended on 10 November 1944. High on the Douglas agenda was the Cancer Control Act, which passed in October. Any person who had resided in the province for three months was now eligible for all services necessary for the diagnosis and treatment of cancer, without charge.16 The program was paid entirely from government revenues and took effect 1 January 1945, at the same time as the new Social Assistance Care plan (see chapter 5). With free treatment, between 1944 and 1946 the number of patients jumped twofold to reach 2,626 in 1946.17

34. Canada’s first full-time cancer physicist, Harold Johns, 1945 Blair was extremely foresighted in his recognition that the radiation treatment program would benefit from a full-time radiation physicist. Blair’s first letter, dated 12 December 1944, to Dr Harrington at the university, suggested that a full-time physicist be hired jointly by the Saskatchewan Cancer Commission and the university. Six days later, Harrington replied, offering full co-operation. On 25 March 1945, Harrington hired Dr Harold E. Johns (figure 10.4) for this joint position, with the rank of assistant professor, at $3,600 per annum. Johns was a thirty-year-old instructor at the Radar School at the University of Alberta, working for Canada’s war effort. He had received his bachelor’s degree in physics from McMaster University in 1936, his master’s from the University of Toronto in 1937, and

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Figure 10.4 Dr Harold E. Johns (sca)

his PhD from Toronto in 1939.18 In his previous work at Edmonton, Johns had used a radium source to obtain industrial photographs of steel propeller shafts to search for metal fatigue, a very early example of industrial radiography. In Saskatchewan, he was to give “half his time to supervision of the radium and x-ray therapy equipment of the two cancer clinics.” Johns later told Lauriston Taylor19 that he thus became Canada’s first full-time cancer physicist.20 In May 1946, Johns was given a travelling scholarship of $800,21 which allowed him to visit, by train, the leading radiation physics centres in Canada and the United States. While in Toronto, he attended a series of lectures given by Professor M.V. Mayneord, a senior medical physicist from the Royal Cancer Hospital in London, England. Mayneord, probably the first to do so, mentioned the possibility of using cobalt-60 as a radiation source. Harrington picked up on the idea; the next year

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in his presidential address to the Chemical, Mathematical and Physical Sciences Division of the Royal Society of Canada, he predicted that cobalt-60 “may become a more suitable source than radium itself in the treatment of cancer.”22 Meanwhile, Johns returned home in 1946 with the conviction that another type of high-energy radiation source under development, the betatron, offered immediate promise. After a quick visit to Premier and Health Minister Douglas in Regina (see introduction), Johns and Blair asked for a betatron of perhaps 35 MeV. The first 2.3-MeV betatron had been built in 1940 by Dr D.W. Kerst at the University of Illinois in Urbana and a 20-MeV prototype had then been built in 1942, based on the preliminary work of Dr Lester Skaggs. University of Saskatchewan President James S. Thomson wrote to Blair on 18 November 1946: “I called last week upon Dr C.J. Mackenzie, President of the National Research Council, to discuss with him the use of a betatron in connection with the cancer treatment in this province. Dr MacKenzie … expressed some doubts as to whether research was fully advanced to make such a project practicable … Matters affecting the use of atomic energy are really under the control of the Atomic Energy Commission of which General A.G.L. McNaughton is the chairman.” It did not hurt the cause that McNaughton was a native of Moosomin, Saskatchewan.23 Blair’s reassuring letter to Mackenzie on 11 December 1946 was the cornerstone of all future developmental research in radiation therapy: “It is not planned to use it for any actual treatment until the physical measurements have been completed to everyone’s satisfaction.” This time-consuming attention to fine detail by Saskatoon physicists allowed those in another province, without such scruples, to, five years later, be the first to treat a patient with cobalt-60.

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Meanwhile, other centres viewed the progress in Saskatchewan with suspicion. Harrington indicated their concerns in a letter to University of Saskatchewan President James S. Thomson on 20 February 1947: In the earliest part of the discussion regarding the betatron, it appeared that a certain member of the Atomic Energy Commission, to which this matter must be referred for decision, had expressed the belief that if the reason for the betatron was mainly medical it would be in the interest of the country as a whole to locate it in a large medical centre, say, in Toronto. In the mind of Dean Mackenzie, the chance of obtaining a favourable action on our request for this equipment would be better if any possible uses in medicine of the betatron were given but little emphasis.24 The price tag for the betatron was high – $80,000. The Atomic Energy Control Board provided $30,000. Johns was disturbed because this amount was insufficient, but Blair was jubilant. “Spend that money, Johns,” he said, “When it is gone more will be found.”25

35. The first concerted clinical use of the betatron in the world, 1949 On 3 May 1948, Johns, accompanied by Drs R.N.H. Haslam and L. Katz of the physics department, arrived in Milwaukee to examine “their” betatron. Where else could an agricultural province have found a manufacturer of heavy-duty machines more suitable than an agricultural equipment company, in this case, Allis-Chalmers in Milwaukee, Wisconsin? Johns wrote back to Blair on 12 May 1948:

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The betatron is finished but has not been tested. The machine which we are getting is the one ordered by the University of Pennsylvania, but they have no building finished to house it and have allowed us to have it … Professor Kerst has been more than cooperative. First he introduced us to all his men and gave us full access to all blueprints, all reprints, keys to the building … Kerst then presented us with two donuts [sic] for nothing and one electron donut for a nominal sum … Kerst is amazed at the rapidity with which we have pursued our program and in the fact we are getting the first betatron to be installed in any university or hospital … The University of Illinois medical school gets the third betatron (second to the University of Pennsylvania) and I heard yesterday that the University of California is getting one, at Berkeley.26 The 24-MeV betatron was installed in the physics department at the University of Saskatchewan that summer (figure 10.5). In keeping with the earlier promise, about seven months were spent in meticulous calibration of this machine for its first use, and dose distribution measurements were ongoing.27 The first patient was treated on 29 March 1949.28 Sadly, Dr Blair (Saskatchewan’s director of cancer services) did not live to see this historic day: he suffered a sudden and untimely death from a heart attack on 9 November 1948. As Milford D. Schultz said of this Saskatoon machine in his historical review in 1975, “Thus started the really first concerted clinical investigation of the usefulness of multimegavoltage as a radiotherapeutic tool.”29 The location of the betatron, in the physics department on the university campus, meant that patients were brought across the river from Saskatoon City Hospital and then across the campus. Even after University Hospital was completed on campus

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in 1955, there were still difficulties in transporting patients outdoors for a distance equivalent to several city blocks. The operating costs of the betatron were also exorbitant. Dr T.A. Watson (figure 10.6), head of radiation oncology at the University of Saskatchewan, reported on 10 November 1949 to Dr O.H. Warwick of the National Cancer Institute that each betatron tube or “doughnut” cost $3,800 (figure 10.7). Although “guaranteed” to last for 150 hours, “No doughnut which has so far been used has lasted nearly as long as this … [T]he cost of the doughnut alone is $25.70 an hour … eleven patients were treated at an average cost of $224 per patient.” In seventeen years, only 301 patients were treated with the betatron.30

Figure 10.5 Betatron (sca)

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Figure 10.6 Dr T.A. Watson (sca)

Figure 10.7 High-energy tube or “doughnut” (sca)

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Nevertheless, as with any high energy source, the betatron offered “a method of delivering easily a high dose to tumours at a depth, without appreciably affecting the overlying skin … Radiation sickness and blood changes are much less likely.”31

36. The first use of calibrated cobalt-60 in the world, 1951 In June 1949, Johns, keen to develop cobalt-60 as a more economical source of high-energy radiation, visited the Chalk River reactor in Ontario, the only installation in the world then capable of producing large quantities of radioactive cobalt. There he visited with Drs A.J. Cipriani and W.B. Lewis of the Atomic Energy Project. On 15 July 1949 Johns wrote to University of Saskatchewan President W.P. Thompson, asking for an effective source of 1,000 curies of cobalt-60, about 100 times the activity of any radium unit. Johns asked for “between $2500 and $7000 to cover the total cost of construction.” Johns, Cipriani, and Lewis agreed that this project would receive greater priority if it were considered as a research project, not a cancer treatment project. Saskatchewan’s simple two-page, three-copy application for the isotope was sent to the National Research Council at Chalk River on 13 August 1949.32 It was a timely application. Three radioactive cobalt sources were placed in the Chalk River pile to “cook” in the fall of 1949.33 Saskatchewan received Chalk River’s first cobalt source on 30 July 1951 and the University of Western Ontario received its source on 16 October of that year. These dates are of crucial importance, as will become evident. The third source was released for use in the United States in 1952. Each cobalt source was 2.5 cm in diameter and 1.25 cm thick. Sybil Johns, Harold’s wife, later described these as “a little half-

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inch stack of these cobalt discs about the size of a quarter.”34 As Johns had forecast, the approximate strength was 1,000 curies, or 37 GBq. The Saskatoon unit was designed by Johns and Lloyd Bates, a graduate student, and was built by Johnny MacKay, the proprietor of Acme Machine and Electric in Saskatoon. It was installed in Room 167 in the newly constructed cancer wing of University Hospital, adjacent to the medical college, on 17 August 1951. The room was hardly ready for use: the walls were still being plastered and the concrete floor had not yet been poured. Rigorous depth-dose measurements, using phantoms, soon began.35 The unit, weighing approximately 0.9 tonnes, consisted of a steel-encased cylinder suspended from an overhead carriage. A rotating, circular platform, flush with the floor, permitted rotation therapy (figure 10.8). A variety of treatment fields could be obtained by using interchangeable lead plugs, developed and manufactured by MacKay. In order to turn the machine on and off, Johns and MacKay in essence reinvented the wheel (figure 10.9). The radioactive cobalt source was mounted on the circumference of a wheel near the centre of the head. By rotating the wheel, the source could be moved 180 degrees from its shielded resting position until it was opposite an opening through which the radiation emerged.36 The Saskatoon Star-Phoenix on 18 August 1951 printed a photograph of the installation (figure 10.10). The Saskatoon unit was officially commissioned on 23 October, but even more rigorous measurements were continued until 8 November, when the first patient was treated by Watson. Watson modestly but sincerely downplayed attempts to publicize the importance or the priority of Saskatoon’s achievement, saying this was “merely a device that might provide more efficient and economical cancer treatment.”37 Steadfast to scientific integrity, being first

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Figure 10.8 Cobalt-60 unit with Sylvia O. Fedoruk (sca)

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Figure 10.9 Diagram of Cobalt-60 (sca) Figure 10.10 Installation of Cobalt-60 (sca and Saskatoon Star-Phoenix)

was not important to any of the Saskatoon players, whereas London seems to have viewed it as a race to be won at almost any cost. Eldorado Mining and Refining had completed the second unit for installation at Victoria Hospital in London, Ontario, on 23 October. Their unit, using a somewhat different design, consisted of a head pivoted between the arms of the horizontal “Y”

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that could be raised and lowered. The beam was turned on and off when a pool of mercury was introduced between the source and a conical opening in the head. The field size was varied by means of four lead blocks at right angles to each other. This was the prototype of the Atomic Energy of Canada Limited (aecl) cobalt unit.38 Dr Ivan H. Smith quickly treated the first patient in London, Ontario, on 27 October, four days after installation. The first cobalt treatment at London was widely publicized in the Canadian press. The Saskatoon Star-Phoenix commented on the “cobalt race” in an editorial on 7 November 1951: We hope Messrs Truman, Stalin, Peron, et al won’t think someone is trying to steal their thunder, but we think they ought to know theirs is not the only atomic race going on in the world. Another has been declared by The London Free Press which claims, editorially, “the world’s first cobalt bomb” for … the Ontario city. With all due respect to the preservation of national peace and goodwill, that is a boast which this newspaper cannot allow to go unchallenged – especially since the Free Press reports that “one is also being installed at Saskatoon, Sask.” One is indeed. Or, to be more accurate, one has been installed. Historians can assess the relative merits of the two claims. Suffice it to say that the first patient at London was treated with a machine that had not been calibrated. The patient had no hope of cure and died soon afterwards. The first patient at Saskatoon had advanced carcinoma of the cervix at age forty, unlikely to be cured by any treatment regimen then known. She received a precise dose to an exact area, with the radiation depth dose carefully plotted at each level. Not only was she cured of her

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cancer, but she lived to the advanced age of ninety years in Victoria, British Columbia. She died on 26 October 1998.39 London was first in the public relations competition, but would its methodology have passed an ethics committee? In retrospect, one might question the ethics of “treating” a patient with an approximate dose of radiation to an approximate area of her body, with an uncalibrated machine, and with little hope for palliation, much less cure. The Saskatoon group may have come out second in boasting to the public, but they were first in achievement and in promulgation of their results to the scientific world. The first formal publication giving details of cobalt therapy was from Saskatoon, not London. It was brief and to the point, much as Wilhelm Carl von Röntgen’s first published description of x-rays had been fifty-four years earlier.40 The authors of the report from Saskatoon, sometimes referred to privately and affectionately as the “Saskatchewan mafia,” were H.E. Johns, L.M. Bates, E.R. Epp, D.V. Cormack, and S.O. Fedoruk, all from Saskatchewan, and three University of Saskatchewan physics graduates (A. Morrison, W.R. Dixon, and C. Garrett), working at the radiology laboratory in the physics division of the National Research Council in Ottawa. Their paper was fasttracked and appeared in print in London, England the very next month, December 1951. The paper describes both Canadian cobalt units and concludes, “The cobalt units are flexible, simple to operate, and should require little servicing. They may prove to be very convenient sources of high-energy radiation.”41 A second paper by the same authors appeared in Science in March 1952.42 More detailed papers on depth doses and use of the two units and the Saskatchewan betatron filled an entire issue of the Journal of the Canadian Association of Radiologists

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in March 1952. The Saskatchewan cobalt-60 depth-dose data43 were included in a regular issue and a special supplement to the British Journal of Radiology in 1951 and 1952. Additional Saskatoon contributions to dosimetry appeared in other American, British, and Swedish radiology journals. Sylvia’s July 1951 Master’s thesis (ma rather than MSc in those years) was titled simply “Depth Dose.” The Saskatchewan-based depthdose charts were on the walls of active radiotherapy departments throughout the world.44 Johnny MacKay of Acme Machine and Electric turned his attention to designing a new collimator system, whereby a large number of interleaved diaphragms replaced the lead plugs, to direct the rays precisely (figure 10.11). MacKay’s small engineering firm in Saskatoon produced these collimators for over

Figure 10.11 Collimation apparatus for Cobalt-60 (sca)

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100 Picker Cobalt units that were distributed around the world. The original Saskatoon cobalt-60 unit treated 6,728 patients over twenty-one years until finally it was replaced by a commercial aecl cobalt-60 machine in 1972. Since the cobalt-60 unit was compact and economical to purchase and maintain, it became the “workhorse” for high-voltage radiotherapy for thirty years. By 1984, there were about 2,500 cobalt-60 units in routine use in the free world, 1,500 of which had been built in Canada by aecl.45 These machines remain the only affordable radiotherapy option in some third-world countries. liver and whole body photoscanning

Sylvia Fedoruk was a pioneer in nuclear imaging. She modified a Reed Curtis scanner to image the size and shape of the liver in 250 patients, the first images of isotope liver scanning published in the world’s most prestigious medical journal, the New England Journal of Medicine46 in 1960. Sylvia Fedoruk47 and Doug Cormack supervised Trevor Cradduck for his MSc thesis in 1962, for which he constructed a whole-body rectilinear scanner.48 That scanner was soon joined by the first gamma camera in Canada, designed by Sylvia Fedoruk and Trevor Cradduck in collaboration with Nuclear Enterprises of Winnipeg, and installed in the Saskatoon Cancer Clinic in 1964.49 Fedoruk also served on an International Commission on Radiation Units that recommended, in the late 1960s, use of modulation transfer function (mtf) as the most appropriate means of measuring collimator resolution for both rectilinear scanners and gamma cameras. mtf was regarded as the standard into the 1970s.50 Although Fedoruk’s nuclear medicine research tended to be forgotten, in October 2012, the year-old, 47-million-dollar

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Figure 10.12 Photoscan of normal liver (Sylvia Fedoruk collection)

Canadian Centre for Nuclear Innovation at the University of Saskatchewan was posthumously named in her honour. As Sylvia Fedoruk and I wrote in our chapter in the book produced to celebrate the 100th anniversary of Röntgen’s discovery of the x-ray: “Though born of war-time nuclear research, the cobalt bomb was in practice a ploughshare rather than a sword, and a largely Canadian contribution to medical care. With its flair for trend-setting performance in medicine, Saskatchewan had led the way.”51 Yes, indeed, Saskatchewan had led the entire world!

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EPILOGUE

The ccf government, from its election in 1944, had a clear goal: to build on Saskatchewan’s unique fifteen years of free diagnosis and treatment of the most expensive disease, tuberculosis, by adding health care for pensioners and widows, for those with cancer and mental diseases, and then provincewide hospitalization. These represented step-wise progressions from innovative policy formation, a view of community-based health and wellness, direct attacks on insidious diseases, to psychedelic experimentation – always within the annual provincial budget. Success in provincewide hospitalization as well as the example of the Swift Current Health Region became models upon which to build the gift for which both Saskatchewan and ccf Premier Tommy Douglas are now famous: universal medicare. The introduction of medicare became one of Saskatchewan’s defining moments.

Epilogue

the first universal medicare in north america, 1962

Medicare became law in Saskatchewan on 1 July 1962. It was a tumultuous time. Inadequate communication and bad timing between the physicians and the government bred misunderstanding and confrontation, which led to an action not contemplated by the government: withdrawal of services by the great majority of doctors. Each side, government and medical profession, “was convinced of the legitimacy of its role, the rightness of its goals, and of its power to achieve them.”1 My father, Dr C.J. Houston, believed that the impasse resulted first from the misguided attempt by the medical profession to use advertising to influence the 1960 provincial election. The doctors hired a public relations firm from central Canada, possibly more experienced in selling soft drinks or motor cars, who had no understanding of the Saskatchewan psyche, or the inappropriateness of such an intervention from a professional group. Dr Noel Doig’s recent book, Setting the Record Straight: A Doctor’s Memoir of the 1962 Medicare Crisis, refers repeatedly to the harmful effects of political intervention by a profession.2 Tommy Douglas had been minister of health from 1944 to 1949, but gave up the health portfolio on 14 November 1949. T.J. Bentley, who succeeded Douglas as minister, changed tack. He wished the health scheme to be under the direct control of the Department of Health, not an independent commission. Relations had been changing, hardening between the doctors and the department. Douglas and his ministers, when they put forward the medicare plan, “believed – indeed, were confident – that a consensus could be achieved”3 between the College of Physicians and Surgeons and the government over the details of the plan. But Douglas, by 1961 had resigned to lead the federal ndp and was succeeded as premier by Woodrow Lloyd. My father felt that Douglas, had he remained premier, would have

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permitted a commission rather than allow the doctors to carry out their threat to strike. Given his previous experience during the give-and-take setting up the Social Assistance Plan, Dad was sure that, if an arm’s length commission with representatives from both sides had been established, the doctors might have agreed to certain payment schedules, including a cap on fee-forservice or a prorated schedule of fees per year. During the dispute, Douglas’s previous unequivocal support for the commission model no longer seemed an option for Woodrow Lloyd. The withdrawal of medical services, the so-called doctors’ strike in July 1962, brought tension even to those outside the doctor-government divide. Mary Kirychuk and Sargent Mc Gowan of Paddockwood had a wedding date of 28 July 1962. Sargent later recalled: “This was the year of the doctors’ strike regarding the imposition of Medicare and there was concern about whether prospective couples could get blood tests which are essential prior to marriage. In this, as in so many others, the public ‘hue and cry’ was much greater than the actual threat and to my knowledge little real difficulty was experienced by people who were either physically ill or merely in love.”4 Under the distinguished arbitration of Lord Stephen Taylor, a socialist and a medical doctor, who shuttled back and forth between the government and representatives of the Saskatchewan College of Physicians and Surgeons, and earned the trust of both sides, the Saskatoon Agreement was signed on 23 July.5 One objective account of this trying time is provided in chapter 5 of Malcolm Taylor’s 1978 book.6 Although a public poll in 1965 still preferred a voluntary health plan, rather than a compulsory one,7 the doctors saw an immediate benefit: in 1963, Saskatchewan physicians’ incomes had quickly become the highest in Canada.8 Greg Marchildon and Klaartje Schrijvers

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noted that “the government was generally perceived to have won the strike.” But the truth supports a deeper victory for the doctors: “organized medicine was able to improve the economic position of its members even while it preserved the contractual system of remuneration and private practice, protected the role of physicians at the centre of the healthcare system, and prevented major changes to primary healthcare.”9 medicare in other provinces

The national initiative of Prime Minister John G. Diefenbaker, the Member of Parliament from Prince Albert, Saskatchewan, prepared the way for medicare in the rest of Canada. Diefenbaker appointed Mr Justice Emmett M. Hall, chief justice of Saskatchewan, to chair a commission. The other six members were not appointed until July 1961.10 The commission’s report was released on 19 June 1964. It recommended that “as a nation, we now take the necessary … decisions to make all the fruits of the health sciences available to all our residents without hindrance of any kind.”11 The medicare bill was not passed by the federal government until 16 December 1966. Federal medical care insurance program funding did not become available until 1 July 1968, the date on which the second province, British Columbia, joined. Manitoba, Newfoundland, and Nova Scotia joined in on 1 April 1969; Alberta on 1 July 1969; Ontario on 1 October 1969; Quebec, 1 November 1970; Prince Edward Island, 1 December 1970; New Brunswick, 1 January 1971; and the North West Territories and Yukon on 1 April 1972.12 Thus, it took almost nine years for medicare to reach all of Canada. Saskatchewan had led, not only in many steps on the road to medicare, but in the implementation of medicare itself.

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why did saskatchewan take the lead?

Medicare got its start in Saskatchewan because, as in the biblical parable, the seeds fell on fertile ground. In 1941, despite the scourge of the Depression, Saskatchewan still had the third highest population in Canada. Although stable, its status relative to the rest of Canada quickly declined: other provinces surged, and by 1961 Saskatchewan had fallen to fifth place.13 Despite (or perhaps because of) the “Great Divide” of the Depression, where people faced terrible choices due to extreme poverty,14 Saskatchewan consistently led all of Canada in public health innovations and legislation, including the many Canadian, North American, and world “firsts” recounted in this book. Even more remarkable were the two instances in which Saskatchewan led the entire world: the first provincewide hospital plan (1947) and the first provincewide medicare plan (1962). But why Saskatchewan? In a province without a large city, there were few rich people or powerful corporations. Rarely did people have surplus cash, but there was an abundance of good will, of trust in one another, of a willingness to help each other, and of a sense that lives could be improved through communal effort. Mutual co-operation among pioneer settlers was more the rule than the exception; it was better to do things together than separately. If a family had to build a barn, neighbours came to help raise the rafters. The entire community would turn out to build a curling rink. Throughout the twentieth century, community co-operation manifested itself in public ways; not only in health concerns, but also in the development of the farmer-owned and -operated Saskatchewan Wheat Pool, and politically through the creation and election of the social-democratic ccf party. Saskatchewan residents had a strong sense of justice and fairness. Honesty was the rule. Municipal politicians were forward-

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thinking and innovative, using and changing the municipal structure to full advantage to meet the needs of local residents. A high priority was given to health matters by the public, especially women. Church women set up hospitals, while farm women, through the Homemakers, the women’s section of the Grain Growers Association, the Red Cross societies, the iode, and the many union hospital auxiliaries (among others) underscored the connection between gender and health. Saskatoon provided an outstanding example when, in 1914, to combat the spread of bovine tuberculosis through milk, it became the first city in the British Empire to forbid the sale of raw milk. We suggest that the co-operative spirit of the predominantly rural Saskatchewan people, most of them immigrants from Europe, had been developed to a higher and more practical degree than in any other jurisdiction in North America. That community spirit was reforged in the fires of the Great Depression. In the face of immense economic, environmental, and social adversity, the world shifted. As the drought receded, war and postwar affluence brought a reordering of priorities. There was a willingness to try new social experiments, to pool the collective economic might for the social stability of all. The advances made in Saskatchewan required two ingredients: the co-operative spirit, as described above, and the individuals whose passion and direction became the catalyst. It is our thesis that without the unique community spirit, coupled with “the right person in the right place at the right time,” some or most of the events recounted here would not have come to pass. These leaders possessed unusual wisdom and prudence. Survivors of the Depression, severe drought, and dust storms (“the Dirty Thirties”), these men and women were more frugal than any group since and not in the least litigious. Much effort went unpaid. Every dollar went a long way. The people of

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Saskatchewan were, to use today’s term, proactive. Whether bureaucrat, politician, or scientist, each leader saw a need, gathered the evidence necessary for an informed decision, and then acted expeditiously. Nearly immediate response by government was then more the rule than the exception. Each visionary’s effort added to the foundation built by a predecessor. These were simple times, without red tape. The time was right. From a historical perspective, we can look back over the Saskatchewan events chronicled in this book and at least dream about returning to our roots. At the local level, think of the grass roots empowerment felt by the pioneers whose municipal taxes paid for innovative municipal doctors and hospital plans and contributed directly to tuberculosis control and the Swift Current Health Plan! Centralized control proved to have some down-sides. The loss of local control was brought home to me on 5 July 2002 when I was the guest speaker at the 100th anniversary of the Yorkton hospital. This hospital had a superb nursing training program from 1903 until 1969;15 the near-overflow crowd at the banquet was composed mainly of nurses who had trained in Yorkton and had gathered from across Canada to demonstrate their undiminished loyalty and esprit-de-corps.16 They still resent the closure of this successful program by centralists. Canada’s present nursing shortage (and the doctor shortage in rural areas!) were the predictable result of bad decisions and poor planning that were not evidence-based. Nurses have always been the backbone of the health care system. Provincially, consider the assumption by both Sigerist and Douglas that the medical school should be the linchpin of the health care system; the unstated corollary would be that it requires commensurate funding. As my father warned T.C. Douglas

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in 1946, medical schools are extremely expensive and a secondrate medical school would be worse than no medical school.17 Federally, funding of medicare would be less of a problem if the federal contribution were restored to the 50 per cent provided to each province in the early years, rather than the current figure, said to be about 14 per cent. Moving medicare forward may ask of us all, at each level, to learn from our history. Can we emulate the co-operative spirit, altruism, and ingenuity shown by Saskatchewan pioneers?

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NOTES

in t roduc tion 1 Louis Horlick, “Medicare and Canadian Federalism.” In A.M. Herzberg and I. Krupka, eds., Statistics, Science and Public Policy. The Two Cultures? Proceedings of the Fourth Conference on Statistics, Science and Public Policy, Hailsham, UK, 1999 (Kingston: Queen’s University 1999), 153–8. 2 Lewis H. Thomas, The Making of a Socialist: Recollections of T.C. Douglas (Edmonton: University of Alberta Press, 1982), 372–3. 3 Eleanor McKinnon. “Open Door Policy,” in Ed and Pemrose Whelan, Touched by Tommy (Regina: Whelan Publications, 1990), 25. 4 A slightly different version of the story can be found in C.S. Houston and S. Fedoruk, “Radiation Therapy in Saskatchewan,” in J. Aldrich and B. Lentle, eds., A New Kind of Ray: The Radiological Sciences in Canada (Canadian Association of Radiologists, 1995), 153–4; and C.L. Greenstock, “From Szechuan to Saskatchewan,” 247–51.

Notes to pages 4–6

1

2

3

4

5

6 7 8

9 10

c ha pter one E.E. Rich, ed., The Publications of the Hudson’s Bay Record Society: Cumberland and Hudson House Journals 1775–82, Second Series, 1779–82 (London: The Hudson’s Bay Record Society, 1952), 228; 232–3. John W.R. McIntyre and C. Stuart Houston, “Smallpox and Its Control in Canada.” Canadian Medical Association Journal 161, 12 (14 Dec. 1999): 1543–7; C. Stuart Houston and Stan Houston, “The First Smallpox Epidemic on the Canadian Plains: In the Fur-Trader’s Words,” Canadian Journal of Infectious Diseases 11, 2 (March/April 2000): 112–15. Sally Clubb, Our Story: 75 Years of Caring (Saskatoon: St Paul’s Hospital, 1982), 2; Marguerite E. Robinson, The First Fifty Years (Regina: Saskatchewan Registered Nurses Association, 1967), 8. John Murray Gibbon and Mary S. Mathewson, Three Centuries of Canadian Nursing (Toronto: Macmillan, 1947), 214. Not until 1927 was a two-storey brick building, St Joseph’s Hospital, built at Ile-à-la-Crosse with government support. H.C. Jamieson, Early Medicine in Alberta (Edmonton: Douglas, 1947), 21; see also Marcel M.C. Dirk, A Healthy Outlook: The Centennial History of the Medicine Hat Regional Hospital (Medicine Hat: Holmes Printing, 1989). R.B. Deane, “Augustus L. Jukes, a Pioneer Surgeon,” Calgary Associate Clinic Historical Bulletin 2, 4 (1938): 1–4. Robinson, First Fifty Years, 8. Joyce Morgan and Barb Straker, “Medical History of Saltcoats,” in Saltcoats Roots and Branches (Saltcoats: Saltcoats and District Historical Society, 1982), 217–23. Robert Lampard, “Medicare: An Alberta Legacy,” Legacy May–July 1998: 34. Lewis Thomas, “Early Territorial Hospitals,” Saskatchewan

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Notes to pages 6–18

11 12 13

14 15 16 17 18 19 20 21

History 2, 2 (1949): 16–20. In the 1891 census the entire Medicine Hat district had a population of only 1,316. The Calgary hospital opened later in 1890 and the Lethbridge hospital in 1894. Gibbon and Mathewson, Three Centuries, 208. In 1901 there were 91,279 people in the area that was to become Saskatchewan in 1905. Personal copies of this large book, owned by each midwifery student in most English-speaking countries, were affectionately named “Maggie.” Robinson, First Fifty Years, 32, 39. Saskatchewan Department of Agriculture, Annual Report 1906 (Regina), 156–8. A. Becker, “The Lake Geneva Mission, Wakaw, Saskatchewan,” Saskatchewan History 29 (1976): 51–64. Clubb, Our Story, 6. Saskatoon City Hospital Golden Anniversary, 1909–1959 (Saskatoon: City Hospital, 1959), 18. Joan Feather and Vincent L. Matthews, “Early Medical Care in Saskatchewan,” Saskatchewan History 37 (1984): 41–54. Sister Yvonne Bezaire, Our Roots: A Promise (Saskatoon: Catholic Health Association of Saskatchewan, 1993), 4. C.S. Houston, “Early Saskatchewan Hospitals,” Annals of the Royal College of Physicians and Surgeons of Canada 23 (1990): 265–70.

c ha pter two 1 C.S. Houston, “Maurice MacDonald Seymour: A Leader in Public Health,” Annals of the Royal College of Physicians and Surgeons of Canada 31 (1998): 41–3, by permission. 2 Evelyn Eager, Saskatchewan Government: Politics and Pragmatism (Saskatoon: Western Producer Prairie Books, 1980), 147.

149

Notes to pages 18–22

3 Seymour eventually became the Commissioner of Public Health, among other distinctions. See Statutes of Saskatchewan 1909 C. 8, Sec. 33; see also Robert I. McLaren, The Saskatchewan Practice of Public Administration in Historical Perspective, Studies of Health and Human Services, Canadian Studies Volume 19 (Lewiston, ny: The Edwin Mellen Press, 1998): 12–13. 4 M.M. Seymour, “Public Health Work in Saskatchewan,” Canadian Medical Association Journal 15 (1925): 276. 5 Brief from Society of Obstetricians and Gynecologists via College of Physicians and Surgeons to the Thompson Committee, in the files of C.J. Houston, Saskatchewan Archives Board (sab). 6 Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan, 1944–1964” (Master’s thesis, University of Regina, 1990), 6. 7 Seymour, “Public Health,” 274. 8 Ibid., 275. 9 Ibid., 277. 10 M.M. Seymour, “A Study of Milk Problems in Canada,” [Canadian] Public Health Journal 17 (1926a): 241–4, 295–301, 353–8, 394–404. 11 Ibid., 300. 12 M.M. Seymour, “The Seymour Plan,” [Canadian] Public Health Journal 17 (1926b): 593–6. 13 Seymour, “Public Health,” 275, 277. The Saskatchewan Department of Health Annual Report (1929: 95) again made the claim that Saskatchewan was acknowledged as still having the “lowest death rate in the Dominion and in the Empire.” Presumably the relative youth of newcomers was the main explanation.

150

Notes to pages 23–8

14 Lillian Chase, “Maurice MacDonald Seymour,” Canadian Medical Association Journal 30 (1929): 212–13. 15 McLaren, Saskatchewan Practice of Public Administration, 12–13. c h a pter three 1 Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan, 1944–1964” (Master’s thesis, University of Regina, 1990), 16. 2 Holdfast History and Heritage Committee, Holdfast, History and Heritage (Author: 1980), 39. 3 Doris Hungle, “Medical Services.” In Holdfast, History and Heritage, 83–5. Dilke was the nearest village on the Regina side of Holdfast. 4 A vacancy was pending at Craik, population 427, about twenty miles west; the doctor there was about to enlist, and hoped that Schmitt could replace him (Mrs J.A. Dunn, “Our First Municipal Doctor,” Western Producer, 1 March 1962). 5 In the 1916 census, the population of Holdfast was 167, Chamberlain 138, Dilke 93, and Penzance 60. Initially, none of the inhabitants of the four villages was covered by the doctor plan. The rural population in rm Sarnia numbered 2,090; payment of taxes earned medical care from Dr Schmitt. 6 C.S. Houston, “Saskatchewan’s Municipal Doctors: A Forerunner of the Medicare System that Developed 50 Years Later,” Canadian Medical Association Journal 151 (1994): 1642–4, by permission. 7 Holdfast, History and Heritage, 83. 8 Arthur E. Childe was the municipal doctor for rm Victory #226 at Beechy. Present for only two years, he was nevertheless

151

Notes to pages 28–33

9

10 11

12 13 14 15 16 17 18 19 20 21 22 23

24

remembered fondly thirty years later. He became Winnipeg’s foremost scientific radiologist, with special skills in pediatric radiology (my field) and neuro-radiology. D.S. Johnstone, “Report of the Committee re Municipal Physicians,” Canadian Medical Association Journal 17 (1927): xii–xiv. C. Rufus Rorem, The “Municipal Doctor” System in Rural Saskatchewan (Chicago: University of Chicago Press, 1931). Ibid., 13. Rorem came to Saskatchewan because of information that Alberta had only two municipal doctors and Manitoba, three. They operated under the provincial Rural Municipality Act of 1929, Secs. 168 and 169. Rorem, “Municipal Doctor,” 12, 16. Gordon Ferguson, “Income Tax and the Municipal Physician,” Saskatchewan Medical Quarterly 14, 2 (1950): 407–10. Rorem, “Municipal Doctor,” 61. Ibid., 62–3. Ibid., 61. Ibid., 74. W.W. Wheeler, “Where Doctors Send No Bills,” Reader’s Digest, July 1935: 75–7. Rorem, “Municipal Doctor,” 83–4. G.E. Britnell, “Saskatchewan,” Encyclopedia Canadiana 9 (1958): 205–28. Mombourquette, “A Government and Health Care,” 28–30. Gordon Lawson, “The Co-operative Commonwealth Federation, Health Care Reform, and Physician Remuneration in the Province of Saskatchewan, 1915–1949” (Master’s thesis, University of Regina, 1998), 38. R.G. Ferguson, “Report of [the] Committee on Economics,” Saskatchewan Medical Quarterly 2, 4 (1938): 12–18.

152

Notes to pages 33–6

25 Ibid., 15. 26 J.J. Collins, “Report of the Municipal Doctors’ Questionnaire,” Saskatchewan Medical Quarterly 5, 4 (1941): 11–24. 27 Health Services Board, Saskatchewan Medical Association, “Model Municipal Contract,” Saskatchewan Medical Quarterly 6, 2 (1942): 17–25. 28 Lawson, “Co-operative Commonwealth,” 131, 145; Advisory Planning Committee Special Document 2A, footnote 138 in Gordon Lawson, “The Road Not Taken: The Health Services Planning Commission Proposals and Physician Remuneration in Saskatchewan,” Canadian Bulletin of Medical History 26, 2 (2009): 426. 29 Joan Feather and Vincent L. Matthews, “Early Medical Care in Saskatchewan,” Saskatchewan History 37 (1984): 41–54. 30 Ibid., 47. The ten uhds were at Davidson, Edam, Eston, Kerrobert, Kindersley, Lloydminster, Lampman, Rosetown, Shaunavon, and Wadena. 31 Statutes of Saskatchewan, 1916, C.12; 1917, C.9; Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 71. 32 A.G. MacKay, Municipal Hospitals 1919 (Edmonton: Municipal Hospital Branch, 1919). 33 Arthur K. Whiston, Municipal Hospitals (Edmonton: Hospitals Branch, Department of Public Health, 1922). 34 Later, in 1948, hospital construction was further supported by federal funds from the National Health Grants Programme, the first federal initiative in health care. See chapter 8. 35 F.D. Mott, “Hospital Services in Saskatchewan,” American Journal of Public Health 37 (1947): 1539–44. 36 Feather and Matthews, “Early Medical Care,” 47. 37 Statutes of Saskatchewan: 1918–19, C.100, Sec. 2. The two rural municipalities named in the Saskatchewan legislation, of

153

Notes to pages 36–41

38

39

40 41

42 43

44

45 46

47

course, are both within Saskatchewan; Malcolm G. Taylor, “The Saskatchewan Hospital Services Plan” (PhD dissertation, University of California, Berkeley, 1949, mimeographed), 72. David Tuckwell wrote “Helping to Solve a Prairie Problem” about the Lloydminster experience in 1917, published in the Canadian Medical Association Journal 7: 800–3. Statutes of Saskatchewan: 1927, C.67, The Union Hospital Act, Sec. 2; 1936, C.37, The Village Act, Sec. 236; 1936, C.36, The Town Act, Sec. 8. Statutes of Saskatchewan: 1934–35, C.30, Sec. 245. C. Stuart Houston and Merle Massie, “Four Precursors of Medicare in Saskatchewan,” Canadian Bulletin of Medical History 26 (2009): 379–93. Taylor, Health Insurance, 72. sab files, sarm brief to Sigerist 25 September 1944; Stuart Houston, “Matt Anderson’s 1939 Health Plan: How Effective and How Economical?” Saskatchewan History 57, 2 (2005): 4–14; see also Houston and Massie, “Four Precursors of Medicare.” Merle Massie, “Red Cross Outpost Hospitals,” Encyclopedia of Saskatchewan (Regina: Canadian Plains Research Centre, 2005): 742; Merle Massie, “Ruth Dulmage Shewchuk: A Saskatchewan Red Cross Outpost Nurse,” Saskatchewan History 56, 2 (2004): 35–44. Taylor, Health Insurance, 72. Robin F. Badgley and Samuel Wolfe, Doctors’ Strike: Medical Care and Conflict in Saskatchewan (Toronto: Macmillan, 1967), 24. Taylor, Health Insurance, 72.

c ha pter four 1 C.S. Houston, R.G. Ferguson, Crusader against Tuberculosis

154

Notes to pages 43–53

2

3 4 5 6 7 8 9

10

11

12

13

(Toronto: Hannah Institute and Dundurn Press, 1991), by permission Associated Medical Services Inc. through its Hannah Institute for the History of Medicine Program. A.B. Cook, R.G. Ferguson, J.F. Cairns, and R.H. Brighton, Report of the Saskatchewan Anti-tuberculosis Commission (Regina: J.W. Reid, King’s Printer, 1922). Helen Ferguson, “That a child might live,” Valley Echo 40, 12 (1959): 4–6. H. Boughton, “A.C.T. million dollar story,” Valley Echo 45, 3 (1964): 19–20. Saskatchewan Anti-tuberculosis League. Annual Report, 1942. Conveying formal membership in the prestigious Royal College of Physicians, thus allowing use of the initials mrcp. Houston, R.G. Ferguson, 58. Cook et al., Report … Anti-tuberculosis Commission. R.G. Ferguson, “A Tuberculosis Survey of 1,346 School Children in Saskatchewan,” Canadian Medical Association Journal 12 (1922): 381–3. G.J. Wherrett, The Miracle of the Empty Beds: A History of Tuberculosis in Canada (Toronto: University of Toronto Press, 1977), 35, 187. In 1922, the Canadian Red Cross provided funds for the Canadian Tuberculosis Association to undertake similar representative school surveys in the other provinces. G.J. Wherrett and S. Grzybowski, Report and Recommendations on Tuberculosis Control in Saskatchewan (Ottawa: Department of National Health and Welfare, 1966), 8. Jean B.D. Larmour, A Matter of Life and Breath: The 75-year History of the Saskatchewan Anti-tuberculosis League and the Saskatchewan Lung Association (Saskatoon: Saskatchewan Lung Association, 1987), 18, augmented by Dr Dudley G. Barnett, personal communication, May 2002. Houston, R.G. Ferguson, 81–2.

155

Notes to pages 54–63

14 15 16 17 18

19

20 21 22

23

24

25

26

27

Ibid., 83. Wherrett & Grzybowski, “Report and Recommendations,” 5, 6. Houston, R.G. Ferguson, 83. Ibid., 84. For an important recent look at tuberculosis, First Nations, and Saskatchewan, see Maureen Lux, “Perfect Subjects: Race, Tuberculosis, and the Qu’Appelle bcg Vaccine Trial,” Canadian Bulletin of Medical History 15 (1998): 277–95. R.G. Ferguson, “Tuberculosis Among the Indians of the Great Canadian Plains,” Transactions of the National Association for the Prevention of Tuberculosis 14 (1928): 625–45. C.S. Houston, “Ferguson’s bcg Research: Canada’s First Randomized Clinical Trial?” Investigative Medicine 16 (1983): 89–91. R.G. Ferguson and A.B. Simes, “bcg Vaccination of Indian Infants in Saskatchewan,” Tubercle 30 (1949): 5–11. R.G. Ferguson, “bcg Vaccination in Hospitals and Sanatoria of Saskatchewan,” Canadian Journal of Public Health 37 (1946): 435–51. G.D. Barnett, “Results of Mass Surveys in the Province of Saskatchewan, 1942–1947,” Canadian Tuberculosis Association Annual Papers 50 (1950): 33–6. Wherrett, Miracle, 255. Later, from 1941 through 1955, Ontario had the lowest tb death rate, except for 1944 and 1954, when Saskatchewan briefly regained the lead. Anonymous, Canadian Tuberculosis Association Bulletin 22, 2 (1943): 4; Wherrett and Grzybowski, Report and Recommendations, 7–8. Wherrett and Grzybowski, Report and Recommendations, 4. In Canada, only the Manitoba Sanatorium Board was similarly constituted. Ibid., 10.

156

Notes to pages 63–9

28 Larmour, A Matter of Life, 101–15. 29 Wherret, Miracle, 255. 30 R.G. Ferguson, Studies in Tuberculosis (Toronto: University of Toronto Press, 1955). 31 C. Smith, “Saskatchewan’s ‘Health Hero’ Enshrined in Hearts of People,” Saskatchewan Health Newsletter 15, 3 (1964): 2, 15. 32 V.H. Hoeppner, Life and Breath 1, 3 (August 1989): 4. 33 Houston, R.G. Ferguson, 134–6. 34 V.H. Hoeppner “Tuberculosis in Saskatchewan Treaty Indians,” Prairie Medical Journal 65 (1995): 18–20. 35 Dr Assaad Al-Azem, TB Control Saskatchewan, Public Health Services. 36 Hoeppner “Tuberculosis,” 19–20.

1

2

3

4

c h a pter five E.W. Barootes, “The Role of Saskatchewan in GovernmentSponsored Health Care: A Retrospective Review,” Annals of the Royal College of Physicians and Surgeons of Canada 24, 2 (1991): 117–19. Thomas H. McLeod and Ian McLeod, Tommy Douglas: The Road to Jerusalem (Edmonton: Hurtig, 1987), 112. This is a superb biography of Douglas. Jacalyn Duffin, “The Guru and the Godfather: Henry Sigerist, Hugh Maclean, and the Politics of Health Care Reform in 1940s Canada,” Canadian Bulletin of Medical History 9, 2 (1992): 191–218. During its final fifteen months in office, W.J. Patterson’s Liberal government had appointed two committees to study the possibility of health insurance. The bipartisan Select Special Committee of twenty-five Liberal and ccf mlas, chaired by Bamm Hogarth, a Liberal mla from Regina, had been appointed on

157

Notes to pages 71–3

5

6

7 8 9

10

11

2 March 1943; they gave an interim report on 12 April 1943 and a final report on 31 March 1944. The Saskatchewan Reconstruction Council, established on 20 October 1943, did not give its final report until August 1944, after the election. Sigerist made “extensive use” of the briefs presented to both groups (Gordon S. Lawson, “The Co-operative Commonwealth Federation, Health Reform and Physician Remuneration in the Province of Saskatchewan, 1915–1949” [Master’s thesis, University of Regina, 1998], 50–4). Dr Hugh MacLean, a Regina surgeon from 1913 to 1938, and ccf candidate in the 1935 federal election, advised Douglas to take the health portfolio (Duffin, “The Guru and the Godfather,” 191–218). Douglas phoned Sigerist first on 16 June. (Nora Sigerist Beeson, ed. & trans., Henry E. Sigerist: Autobiographical Writings [Montreal: McGill University Press, 1966], 187). Henry E. Sigerist, Socialized Medicine in the Soviet Union (New York: W.W. Norton, 1937). Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 88, 434. Also assisting Sigerist were Dr Mindel Cherniak Sheps, a family practitioner and Manitoba ccf executive member from Winnipeg, as secretary; Ann Heffel, a nurse; C.C. Gibson, a hospital administrator; and Dr J.L. Connell, a dentist. (Duane John Mombourquette, “A Government and Health Care: the Cooperative Commonwealth Federation in Saskatchewan, 1944–64” [Master’s thesis, University of Regina, 1990], 54.) Stuart Houston, “Matt Anderson’s 1939 Health Plan: How Effective and How Economical?” Saskatchewan History, Fall 2005: 4–14. C. Stuart Houston and Merle Massie, “Four Precursors of Medicare in Saskatchewan,” Canadian Bulletin of Medical History 26, 2 (2009): 379–93.

158

Notes to pages 72–7

12 13 14 15 16 17 18

19 20 21 22

23 24 25

26

27 28

Houston, “Matt Anderson’s 1939 Health Plan,” 10. Chapin, Report to shssc, 6 (sab R251 file 2 no. 21). Beeson, Henry E. Sigerist, 190. H.E. Sigerist, Report of the Commissioner (Regina: Health Services Survey Commission, 1944). Ibid., 5; also cited by Lawson, “Co-operative Commonwealth Federation,” 62. Houston, “Matt Anderson’s 1939 Health Plan,” n62. This figure was unrealistic, given that the average cost of hospitalization per capita in Saskatchewan had that year already reached $5.20, having risen from $1.93 in 1934 (Malcolm G. Taylor, “The Saskatchewan Hospital Services Plan” [PhD dissertation, University of California, Berkeley, 1949, mimeographed], 140.) Sigerist, Report of the Commissioner, 5. Cited by Taylor, Health Insurance, 434. Beeson, Henry E. Sigerist, 231. Lawson’s 1998 thesis explains how fee-for-service payment became entrenched, and why the ccf government chose not to follow the Health Services Planning Commission’s recommendation that doctors be placed on salary. T.C. Douglas to Dr J.L. Brown, letter reprinted in Saskatchewan Medical Quarterly 9, 3 (1945): 31–4. Taylor, Health Insurance, 87. Advisory Committee on Health Insurance, Report (Ottawa: 1942–43). This 558-page report was presented by Chairman J.J. Heagerty to the House of Commons in December 1942. F.B. Roth and R.B. DeFries, “The Saskatchewan Department of Public Health,” Canadian Journal of Public Health 49, 7 (1958): 276–85. Taylor, Health Insurance, 252. See chapter 8, n8. Ibid, 244.

159

Notes to pages 77–81

29 The Social Assistance Plan was administered by the Medical Services Division of the Saskatchewan Department of Public Health (ibid., 252). 30 Ibid., 252. 31 Mombourquette, “A Government and Health Care,” 119. 32 McLeod and McLeod, Tommy Douglas, 312. Thomas H. McLeod was a trusted economic advisor to T.C. Douglas. See A.W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961 (Toronto: University of Toronto Press, 2004), 61. c h apter six 1 Joan Feather, “From Concept to Reality: Formation of the Swift Current Health Region,” Prairie Forum 16 (1991a): 59. 2 Curtis McManus, Happyland: A History of the “Dirty Thirties” in Saskatchewan, 1914–1937 (Calgary: University of Calgary Press, 2011). 3 Hazlet Historical Society, Hazlet and Its Heritage (Hazlet, 1987), 1, 3. 4 Somewhat similar plans that, unlike the municipal doctor plans, allowed free choice of doctor, had begun in Alberta at Cardston in 1932 (Beryl Shaw, “Medicare in Cardston,” in Chief Mountain Country: A History of Cardston and District. [Cardston: Cardston and District Historical Society, 1987], 72–4), and at Lamont in 1933 where, for the first two years, “services exceeded payment five-fold” (Robert Lampard, “Medicare: An Alberta Legacy,” Legacy, May–July 1998: 34–5). The Cardston plan ran until 1968; Shaw failed to claim this as “the longest continuous, voluntary, prepaid medical insurance program in Canada for thirty-seven years” (Robert Lampard, Alberta’s Medical History: “Young and Lusty, and Full of Life” [Red Deer, ab, Published by Robert Lampard; printed by Friesens, 2008], 631–6).

160

Notes to pages 81–4

5 6 7 8 9 10 11 12

13 14

15

16

17

18 19 20 21 22

Houston and Massie, “Four Precursors,” 383. Feather, “From Concept to Reality,” 70. Houston and Massie, “Four Precursors,” 383–5. Webb History Book Committee, Prairie Memories (Webb, 1982), 62. Houston and Massie, “Four Precursors,” 385. Ibid., 386. Swift Current Sun, 25 August 1945. Syd Munt, “How Swift Current Region Was Organized.” (Mimeographed, 3 pages, 1946). As postmaster at Hazlet (Oct. 1943–Sept. 1950: Hazlet and Its Heritage, 61), Munt’s father, John, had handled the voluminous mail sent out by Burak the previous year. Munt, “How Swift Current Region,” 1. Lester Jorgenson, “Rural Municipality of Miry Creek No. 229 and Health Region No. 1,” in Bridging the Centuries (Abbey, sk: Miry Creek Area History Book Committee, 2000), 52–8. F.D. Mott, “Prepaid Medical Care under Governmental Auspices in Saskatchewan,” Canadian Journal of Public Health 41 (1950): 403–10. Munt, “How Swift Current Region,” 1. Burak met in person with Dave Belbeck of the Swift Current Sun, S.H. Gamble of the Gull Lake Advance, and W. Sharpe of the Shaunavon Standard. Burak attended council meetings at rm Grassy Creek #78 at Shaunavon, rm Arlington #79 at Dollard, rm Bone Creek #108 at Instow, rm Carmichael #109, and rm Gull Lake #139. Feather, “From Concept to Reality,” 72–3. Ibid., 74. T.C. Douglas, “The Doctor in Saskatchewan’s Health Plans,” Saskatchewan Medical Quarterly 9, 1 (1945): 24–31. Feather, “From Concept to Reality,” 74. Munt, “How Swift Current Region,” 2.

161

Notes to pages 84–6

23 Burak suffered a crushing personal disappointment when Stewart Robertson was appointed to the job that he had coveted. Burak moved out of the area permanently to become secretarytreasurer in other municipalities at Hafford, Ogema, and lastly rm Aberdeen #373. He died in Saskatoon on 8 June 1976. 24 Feather, “From Concept to Reality,” 74. 25 Pat Cammer, “Some Memories of the Beginnings of Health Region #1” (Typescript of speech given at the final Swift Current Health Region information meeting, Swift Current, 3 June 1993). 26 Feather, “From Concept to Reality,” 75. 27 Sadly, on 5 December 2001, a Ministry of Health bureaucrat in Regina, lacking any sense of history or justice, renumbered Saskatchewan’s health regions, from east to west. Swift Current was stripped of its historical right to continue a hallowed tradition as “Number One” – not only in Saskatchewan, but in all of North America. 28 Gull Lake was at first hesitant to join a health region and opposed the plan. It sought discussion and confirmation regarding financing. Letter, 25 September 1945, Town of Gull Lake to Ministry of Health. Files in Gull Lake town office. 29 Stewart Robertson, “New Horizons for Better Health.” In Winds of Change (Swift Current: Swift Current Health Region, 1966), 23–6. From the beginning the plan provided a dental program for children, although it was not fully implemented during the first two years. 30 The vice-president was Ken Rutherford, a school principal who was also mayor of Swift Current. In 1960, Ken was an unsuccessful ccf candidate in the 1960 provincial election in British Columbia. 31 Drs O.M. Irwin and R.R. Stirrett of Swift Current, Dr J.A. Matheson of Gull Lake, and Dr F.B. Dawson of Maple Creek. 32 Swift Current Sun 30 April 1946.

162

Notes to pages 86–8

33 Dr Lloyd Davey lasted seventeen months, resigning 30 June 1948. Pay was inadequate. Later, Peart was general secretary of the Canadian Medical Association, based in Toronto in 1966. 34 Dr Alan Gregg of the Rockefeller Foundation, when touring western Canada to examine medical services, visited the Health Services Planning Commission in Regina. In answer to the question, “In which countries are health services supplied to residents … under a plan sponsored by the State,” he answered: 1. Russia. 2. Peking [Beijing] China, for 200,000 people. 3. Swift Current Health Region No. 1. This story was related to the first annual meeting of Health Region No. 1 on 25 September 1947 by Carl Kjorven. 35 Apart from one leave, during which he still served part-time. 36 Fred D. Mott, “Prepaid Medical Care,” 403–10. Mott called this unique arrangement a “dual and yet co-ordinated program of community and personal health services.” 37 Vince Matthews was director, Medical and Hospital Services Branch, 1957–62; acting deputy minister, 1962–63; and associate deputy minister, 1963–64, Saskatchewan Department of Health. Thereafter he was professor and head, Department of Social and Preventive Medicine at the University of Saskatchewan. He retired and became professor emeritus in 1987 and died suddenly on 7 October 1988. 38 Swift Current Health Region, Winds of Change, 8. 39 McManus, Happyland. 40 Two surgeons, an obstetrician, and an anaesthetist. 41 J. Lloyd Brown, “Swift Current Health Insurance Scheme,” Saskatchewan Medical Quarterly 14, 2 (1949): 353–67. 42 Cammer, “Some Memories.” In April 1947, when she married Ross Cammer, a farmer west of Webb, Patricia Ditner left her position as Stewart Robertson’s secretary. 43 Dr Orville Hjertaas, interview by Maureen Matthews, “The

163

Notes to pages 88–92

44 45 46

47

48 49 50 51 52 53 54 55 56 57 58 59 60 61

Origins of Medicare,” Ideas, Canadian Broadcasting Corporation, 5 December 1990, transcript, 2. Cammer, “Some Memories.” Brown, “Swift Current Health Insurance,” 357. J.A. Matheson, O.M. Irwin, F.B. Dawson, and G.G. Ferguson, “Report of the Swift Current Health Region No. 1,” Saskatchewan Medical Quarterly 11 (1947): 21–5. E.A. Tollefson, Bitter Medicine: The Saskatchewan Medicare Feud (Saskatoon: Modern Press, 1964); Gordon Lawson, “The Road Not Taken: The 1945 Health Services Planning Commission Proposals and Physician Remuneration in Saskatchewan,” Canadian Bulletin of Medical History 26, 2 (2009): 395–427. Matheson et al., “Report of Health Region No. 1,” 24. Brown, “Swift Current Health Insurance,” 358. J.A. Matheson, “Swift Current Health Service,” Saskatchewan Medical Quarterly 14 (1950): 368–70. Gordon Howden, “General Practice in Health Region No. 1,” Saskatchewan Medical Quarterly 13 (1949): 335–9. Swift Current Health Region, Winds of Change, 55. A.D. Kelly, “The Swift Current Experiment,” Canadian Medical Association Journal 58 (1946): 506–11. V.L. Matthews, “Patterns for Progress Emerge.” In Swift Current Health Region, Winds of Change, 18–21. Maureen Matthews is the daughter of the late Dr Vincent L. Matthews. Maureen Matthews, “The Origins of Medicare,” Ideas, Canadian Broadcasting Corporation, 5 December 1990, transcript, 10. Ibid., 5, 8. V.L. Matthews, Winds of Change, p. 19 Regina Leader Post 19 January 1967. Jorgenson, “Rural Municipality of Miry Creek,” 56. Ibid., 56.

164

Notes to pages 92–4

62 Joan Feather, “Impact of the Swift Current Health Region: Experiment or Model?” Prairie Forum 16 (1991b): 225–48. 63 Swift Current Health Region, “The Swift Current Medical – Dental Program, 1946 to 1962.” (Mimeographed, n.d.). 64 Feather, “Impact,” 243. 65 Jorgenson, “Rural Municipality of Miry Creek,” 57. 66 Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 266. 67 Vince Matthews (Address to annual meeting, Swift Current Health Region Board, 5 June 1985). 68 I was shocked to realize that Saskatchewan lagged behind other provinces in establishing rural health regions. The Swift Current Health Region No. 1 was the only fully functioning health region in Saskatchewan – in one respect a beacon in a land of darkness; by 1943, all other provinces except Saskatchewan had a system of rural public health units for preventive medicine (Feather, “From Concept to Reality,” 66). 69 Jorgenson, “Rural Municipality of Miry Creek,” 55. c ha pter seven 1 Henry E. Sigerist, Report of the Commissioner (Regina: Health Services Survey Commission, 1944), 11. 2 Gibson went on to become professor of neurological research and of the history of medicine at the University of British Columbia. 3 Douglas J. Buchan, Greenhouse to Medical Centre: Saskatchewan’s Medical School 1926–1978 (Saskatoon: University of Saskatchewan, 1983), 39. 4 On a personal note, my medical class at the University of Manitoba elected Wendell Macleod as our honorary president. As a result, he gave the address, “The Gold-headed Cane” at our graduating banquet in Winnipeg in 1951.

165

Notes to pages 94–7

5 Buchan, Greenhouse, 21–2. 6 Ibid. 7 Louis Horlick, Medical College to Community Resource: Saskatchewan’s Medical School, 1978–1998 (Saskatoon: University of Saskatchewan, 1999). 8 Louis Horlick, They Built Better Than They Knew: Saskatchewan’s Royal University Hospital. A History, 1955–1992 (Saskatoon: Royal University Hospital Foundation, 2001), 16. 9 Ibid., 19. 10 Buchan, Greenhouse, 36. 11 Horlick, They Built Better.

1 2

3 4

5 6

7

c h apter eight W. Douglas Piercey, “Hospitals,” Encyclopedia Canadiana 5 (1958): 161–4. Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan” (Master’s thesis, University of Regina, 1990), 68. Ibid., 103–4. A.W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan 1944–1961 (University of Toronto Press, 2004), 145. H.E. Sigerist, Report of the Commissioner (Regina: Health Services Survey Commission, 1944), 7. Aided by “provincial hospital construction grants … the ratio of hospital beds to population increased from 4.8 per 1,000 in 1946 to 6.5 per 1,000 in 1951.” Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGillQueen’s University Press, 1978), 103–4. Louis Horlick, They Built Better Than They Knew: Saskatchewan’s Royal University Hospital. A History, 1995–1992 (Saskatoon: Royal University Hospital Foundation, 2001), 10.

166

Notes to pages 98–101

8 Johnson, Dream No Little Dreams, 80. See chapter 5, nn26–8. 9 Harley D. Dickinson and Renée Torgerson, “Medicare: Saskatchewan’s Gift to the Nation?” in Jene M. Porter, ed., Perspectives of Saskatchewan (University of Manitoba Press, 2009): 175–96. 10 By 1949, the Paddockwood hospital closed its doors. Merle Massie, “Ruth Dulmage Shewchuk: A Saskatchewan Red Cross Outpost Nurse,” Saskatchewan History 56, 2 (Fall 2004): 35–43. 11 Most doctors were also accepting of Thomas H. McLeod, the brilliant economist seconded to the Health Services Planning Commission, but they were suspicious of Dr Cecil Sheps, Mott’s predecessor, and especially of Cecil’s wife, Mindel, who had served for a longer time as secretary of the hspc. Most physicians thought this couple had too much power, and sensed that they wished to impose their version of socialist ideology on the province. 12 Taylor, Health Insurance, 102–3. 13 Hospitals were graded and paid a per diem rate that varied with the facilities and services provided (ibid., 102). 14 Ibid., 103. 15 Johnson, Dream No Little Dreams, 145. 16 F.D. Mott, “Prepaid Medical Care under Government Auspices in Saskatchewan,” Canadian Journal of Public Health 41 (1950): 407. 17 F.D. Mott, “Hospital Services in Saskatchewan,” American Journal of Public Health 37 (1947): 1542. 18 Taylor, Health Insurance, 104; 167, 435n84. 19 James A. McAllister, The Government of Edward Schreyer (Montreal: McGill-Queen’s University Press, 1984), 43. 20 Christopher J. Rutty, “The Middle–Class Plague: Epidemic Polio and the Canadian State, 1936–1937,” in Canadian Bulletin of Medical History 13, 2 (1996): 277–314; 277.

167

Notes to pages 101–5

21 Janet MacKenzie, “The Saskatchewan Response to Poliomyelitis,” Report for the Saskatchewan Western Development Museum, 2002. 22 Johnson, Dream No Little Dreams, 145. 23 Milton I. Roemer, “‘Socialized’ Health Services in Saskatchewan,” Social Research 25 (1958): 87–101. 24 Privy Council (Canada) 3408. This was followed by Saskatchewan Order-in-Council 74/49 on 11 January 1949. 25 By chance, two other members in addition to my father, Dr C.J. Houston, were from Yorkton, population 5,000. City clerk Howard Jackson represented the Saskatchewan Urban Municipalities Association and newspaper publisher S.N. Wynn represented the Saskatchewan Hospital Association. 26 C.S. Houston, “The Early Years of the Saskatchewan Medical Quarterly,” Canadian Medical Association Journal 118 (1978): 118–19, by permission. 27 Ken McTaggart, The First Decade (Ottawa: Canadian Medical Association, 1973), 43. 28 C.J. Houston, “Report,” Saskatchewan Medical Quarterly 15, 4 (1951), 626. 29 Health Survey Committee, Saskatchewan Health Survey Report (Regina: Government of Saskatchewan, 1951), 225. During these meetings, Malcolm Taylor and C.J. Houston became lifelong friends. Taylor later was in charge of research for the federal Royal Commission on Health Services chaired by Saskatchewan Chief Justice Emmett Hall, 1961–64. 30 Taylor, Health Insurance, 167, 233. c h apter nine 1 Fannie H. Kahan, Brains and Bricks: The History of the Yorkton Psychiatric Centre (Regina: White Cross Publications, 1965), 13–15.

168

Notes to pages 106–9

2 Ibid., 16. 3 Joe Cherwinski, “The Rise and Incomplete Fall of a Contemporary Legend: Frozen Englishmen in the Canadian Prairies during the Winter of 1906-1907,” Canadian Ethnic Studies/Etudes ethniques au Canada 30, 3 (1999): 20–43. 4 Harley Dickinson, The Two Psychiatries: The Transformation of Psychiatric Work in Saskatchewan, 1905–1984 (Regina: Canadian Plains Research Centre, 1989), 21. 5 Colin M. Smith, “Mental Health Services in Saskatchewan, 1914–1978” (Typescript of talk given to psychiatry rounds, University Hospital, 17 February 1984). 6 D.G. McKerracher, “A New Program in the Training and Employment of Ward Personnel.” American Journal of Psychiatry 106 (1949): 259–64. 7 Colin M. Smith, “A Decade of Psychiatry in Saskatchewan,” Saskatchewan Medical Quarterly 38, 3 (1974): 31–3. 8 Humphry Osmond, “Function as the Basis of Psychiatric Ward Design,” Mental Hospitals 8, 4 (April 1957): 23–9; also paraphrased in Kahan, Brains and Bricks, 25, 83. 9 Colin Smith, “Mental Health Services,” Encyclopedia of Saskatchewan (Canadian Plains Research Centre, 2005): 599–600. 10 Erika Dyck, Psychedelic Psychiatry: LSD from Clinic to Campus (John Hopkins University Press, 2008), 22. 11 Saskatchewan Legislative Records, Legislative Journal, sess. 1945, vol. 44, p. 14; cited in Dyck, Psychedelic Psychiatry, 23, 149. 12 Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961 (University of Toronto Press, 2004), 80 13 Smith, “Mental Health Services,” 600. 14 Dyck, Psychedelic Psychiatry, 23. 15 Smith, “Mental Health Services,” 600.

169

Notes to pages 109–12

16 John Mills, “Lessons from the Periphery: Psychiatry in Saskatchewan, Canada 1944–1968.” History of Psychiatry 18, 2 (2007): 179–201. Mills, a retired psychology professor from the University of Saskatchewan, died 14 March 2012 in Comox, bc. 17 Dyck, Psychedelic Psychiatry, 25. 18 Mills, “Lessons from the Periphery,” 182. 19 Ibid., 181. 20 Angela Martin, “Psychiatric Nursing,” Encyclopedia of Saskatchewan, 729. 21 M.C. Schreder and Colin M. Smith, “La formation des infirmiers psychiatriques,” Information Psychiatrique 50 (1974): 489–94. 22 Instruction for untrained ward attendants had begun in 1930, but they received only sixty hours of lectures over two years. 23 Mills, “Lessons from the Periphery,”195, citing a 1985 presentation by M. Schreder. 24 Dyck, Psychedelic Psychiatry, 24, 149n35. 25 Martin, “Psychiatric Nursing,” 729. See also Chris Dooley, “‘The older staff, myself included, we were pretty institutionalized ourselves’: Authority and Insight in Practitioner Narratives of Psychiatric Deinstitutionalization in Prairie Canada,” Canadian Bulletin of Medical History 29 (2012): 101–23. 26 Smith, “Mental Health Services,” 600. 27 Mills, “Lessons from the Periphery,”182. 28 Dyck, Psychedelic Psychiatry, 26. 29 Ibid., 26; Smith, “Mental Health Services,” 600. 30 Smith, “Mental Health Services,”600. 31 Dyck, Psychedelic Psychiatry, 13, 17–19; Smith, “Mental Health Services,”600. 32 Dyck, Psychedelic Psychiatry, 27.

170

Notes to pages 112–15

33 34 35 36

37

38 39

40 41

42 43

44 45

Ibid., 31. See, e.g., Dyck, Psychedelic Psychiatry, 74. Mills, “Lessons from the Periphery,”184. C.M. Smith and L.L. McKay, “The Open Psychiatric Ward and Its Vicissitudes,” American Journal of Psychiatry 121 (1965): 763–7. C.M. Smith and D.G. McKerracher, “The Comprehensive Psychiatric Unit in the General Hospital,” American Journal of Psychiatry 121 (1964): 52–7. D.G. McKerracher, “Psychiatry in General Practice,” Canadian Medical Association Journal 88 (1963): 1014–16. W.A. Cassell, C.M. Smith, F. Grunberg, J.A. Boan, and R.F. Thomas, “Comparing Costs of Hospital and Community Care,” Hospital and Community Psychiatry 23 (1972): 197–200. F.S. Lawson, “Mental Hospitals: Their Size and Function,” Canadian Journal of Public Health 49 (1958): 186–95. F.S. Lawson and K. Izumi, “The Saskatchewan Plan,” Mental Hospitals 8 (1957): 27–31. Dr Ian McDonald informs me that McKerracher was also at the Denver meeting in 1956, but was watching television – a World Series baseball game famous that day for a no-hitter – while Lawson delivered the paper on the Saskatchewan Plan. Kahan, Brains and Bricks, 27. Saskatchewan’s first and only cottage mental hospital, adjacent to the new 200-bed regional hospital, opened in Yorkton in October 1963, with five cottages of thirty beds each. F.S. Lawson, “Saskatchewan’s First Regional Mental Health Facility,” Mental Hospitals 16 (2) February 1965: 85–6. F.S. Lawson, “The Saskatchewan Plan,” Canadian Nurse 63, 6 (June 1967): 27–9.

171

Notes to pages 116–19

46 Smith, “A Decade of Psychiatry,” 31. 47 D.G. McKerracher, “Psychiatric Care in Transition,” Mental Hygiene 45 (1961): 3–9. 48 D.G. McKerracher, Department of Psychiatry, Annual Report, 1963. University of Saskatchewan Archives. 49 Ibid. 50 W.J. McCorkell and D.G. McKerracher, “The Family Doctor and the Psychiatric Ward,” Mental Hospitals 13 (1962): 300–2. 51 The rural equivalent was at Central Butte, where the three family practitioners received regular twice-monthly support from a visiting psychiatrist for two years. (L.W. Christ, E. Christ, and G.W. Mainprize, “Observations on the Psychiatric Project at Central Butte, Saskatchewan,” Canadian Family Physician 13 [1967]: 35–41). 52 D.G. McKerracher, C.M. Smith, F.E. Coburn, and I.M. McDonald, “General-Practice Psychiatry: Two Canadian Experiments, Lancet 2 (1965): 1005–7. 53 Mills, “Lessons from the Periphery,” 185. c ha pter ten 1 Ellice had been named for his birthplace, Fort Ellice, the Hudson’s Bay Company (hbc) post on the Manitoba-Saskatchewan boundary. 2 The son of Archibald McDonald, an hbc fur trader, Ellice had graduated in medicine from McGill University with his MB and BCh in 1901. 3 Murray to Dunning, 6 October 1922. Premier Dunning papers Y–16–0, pages 25, 918–19 (unpublished letters), Saskatchewan Archives Board (SAB), M6. 4 Dunning to Murray, 11 October 1922, SAB, M6. 5 R.A. Macbeth, “The Origin of the Canadian Cancer Society,” Canadian Bulletin of Medical History 22: 155–73.

172

Notes to pages 119–22

6 B.W. Currie, “Ertle Leslie Harrington, 1887–1956,” Proceedings and Transactions of the Royal Society of Canada 50 (1956): 91. 7 R.O. Davison, “Saskatchewan’s Programme for Cancer Control,” Canadian Public Health Journal 24 (1933): 566–71. 8 A. Becker, “A Sketch of Radiology at St Paul’s Hospital,” Saskatchewan Medical Quarterly 34 (1970): 34–6. 9 J. Hawkes, The Story of Saskatchewan and Its People (Regina: S.J. Clarke, 1924), 1720–1; “Obituary: Dr Clarence Henry,” Canadian Medical Association Journal 70 (1954): 701. 10 Anonymous, “400 K.V. X-ray Therapy Unit Now Available in This Province,” Saskatchewan Medical Quarterly 2 (1938): 22. 11 For a “nominal” fee of $10, an appreciable amount in those times. Duane John Mombourquette, “A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan, 1944–1964” (Master’s thesis, University of Regina, 1990), 25. 12 Charles R. Hayter, “Compromising on Cancer: The Saskatchewan Cancer Commission and the Medical Profession, 1930–1940,” Saskatchewan History 54 (2002): 5–17. 13 Mombourquette, “A Government and Health Care,” 25. 14 D.V. Cormack, “The Saskatchewan Radon Plant, 1931–1962,” Physics in Canada 41 (1985): 3–5. 15 Blair had trained as a surgeon in Winnipeg. Following concentrated cancer training at centres in Great Britain, France, Germany, Belgium and Sweden, he was employed as a cancer specialist at New York Memorial Hospital, the University of Alabama, and then the University of Toronto. 16 Contrary to popular belief in Saskatchewan, Alberta offered free cancer treatment in Calgary and Edmonton, beginning in 1941. Saskatchewan was not first in this regard. 17 M.S. Acker and T.A. Watson, “Saskatchewan’s Experience with

173

Notes to pages 123–6

18 19

20

21

22 23

24

25 26

a Comprehensive Public Cancer Program,” American Journal of Public Health 50 (1960): 65–73. Anonymous, “Portraits in Radiology: Harold Elford Johns, PhD,” Applied Radiology 1978: 25. Lauriston S. Taylor was the founder and chair of the U.S. National Council on Radiation Protection and Measurements (ncrp), 1929–77. He was the guru of radiation protection throughout my radiology career, until he died at age 102 in 1994. He was the leading biographer of other radiation physicists world-wide. Harold Johns, Transcript of interview by Lauriston S. Taylor, Rockville, Maryland, 17 October 1979, cited in C.S. Houston and S.O. Fedoruk, “Radiation Therapy in Saskatchewan,” in J.E. Aldrich and B.C. Lentle, eds., A New Kind of Ray (Vancouver: University of British Columbia, 1995), 141–54. Six years later, in November 1952, the Saskatchewan Division of the Canadian Cancer Society gave Sylvia Fedoruk a $1,000 travelling fellowship to cover a two-month visit to cancer treatment sites in Chicago, Cincinnati, Detroit, New York, Oak Ridge and San Francisco; her expenses came to $996. Houston and Fedoruk, “Radiation Therapy,” 147. McNaughton had been born to a pioneer family at Moosomin, 25 February 1887. Trained as an engineer at McGill University, he was president of the Atomic Energy Control Board of Canada, 1946–48. C.S. Houston and S.O. Fedoruk, “Saskatchewan’s Role in Radiotherapy Research,” Canadian Medical Association Journal 132 (1985): 854–64, by permission. H.E. Johns, “aapm Coolidge Award,” Medical Physics 3 (1976): 375. Houston and Fedoruk, “Saskatchewan’s Role,” 858. The betatron was financed by a joint grant of over $120,000 from

174

Notes to pages 126–9

27

28

29 30 31

32 33

Atomic Energy Control Board and the ccf government, with additional help from the National Cancer Institute Sask Division of the Canadian Cancer Society. Saskatchewan’s application was chosen over several other Canadian universities. Muriel Snider, “Twenty–five Million Volts of Hope.” Saturday Night 18 October 1949. E.L. Harrington, R.N.H. Haslam, H.E. Johns, and L. Katz, “The Betatron Building and Installation at the University of Saskatchewan,” Science 110 (1949): 283–5; H.E. Johns, E.K. Darby, R.N.H. Haslam, L. Katz, and E.L. Harrington, “Depth Dose Data and Isodose Distributions for Radiation from a 22 Mev Betatron,” American Journal of Roentgenology 62 (1949): 257–68; H.E. Johns, E.K. Darby, and R.O. Kornelson, “The Physical Aspects of Treatment of Cancer by 22 Mev X-rays,” British Journal of Radiology 24 (1951): 355–64; S.O. Fedoruk, H.E. Johns, and T.A. Watson, “Isodose Distributions for a 1100 Curie Cobalt 60 unit,” Radiology 60 (1953): 348–54. (Sixteen additional papers concerning radiation dose measurements are cited in Houston and Fedoruk, “Radiation Therapy,” 426). At this time, Dr H. Quastler, with the help of physicist D.W. Kerst, had treated a single patient with a betatron. H. Quastler and G.D. Adams, “Techniques for Application of the Betatron to Medical therapy with Report of One Case,” American Journal of Roentgenology and Radium Therapy 61 (1949): 591–625. M.D. Schulz, “The Supervoltage Story,” American Journal of Roentgenology 124 (1975): 541–59. Houston and Fedoruk, “Radiation Therapy,” 147. Johns, letter to the president, Saskatchewan Division of the Canadian Cancer Society, cited in Houston and Fedoruk, “Saskatchewan’s Role,” 858. Houston and Fedoruk, “Radiation Therapy,” 149. Houston and Fedoruk, “Saskatchewan’s Role,” 859.

175

Notes to pages 130–6

34 Sybil Johns, “At Home with the Atom,” Mayfair Magazine 30 (July 1955): 30–1 and 53–8. 35 Houston and Fedoruk, “Radiation Therapy,” 149. 36 Ibid., 149–50. 37 Ibid., 150. 38 Ibid., 151. 39 Date of death obtained from Medical Records, Saskatoon Cancer Agency. An article by historian Paul Litt, “Photon Finish: The Race to Build the Bomb,” Beaver 82, 2 (April–May 2002): 28–31, fails to mention the drastic difference in the survival of the first two patients treated, nor does it mention that only one of the cobalt-60 machines had been carefully calibrated. 40 W.C. von Röntgen, “Ueber eine neue Art von Strahlen [On a New Kind of Ray],” Sitzungsberichten der Würzburger Physikmedic. Gesellschaft [Proceedings of the Physical-Medical Society of Würzburg], 28 December 1895; second communication in Nature, 1896. Röntgen could have become a very wealthy man, but he deliberately refrained from taking a patent on his invention; he wished to share it with the world. 41 H.E. Johns, L.M. Bates, E.R. Epp, D.V. Cormack, and S.O. Fedoruk, “1,000-Curie Cobalt-60 Units for Radiation Therapy,” Nature 168 (1951): 1035–8. 42 A. Morrison, W.R. Dixon, C. Garrett, H.E. Johns, L.M. Bates, E.R. Epp, D.V. Cormack, and S.O. Fedoruk, “Multicurie Cobalt 60 Units for Radiation Therapy,” Science 115 (1952): 310–12. 43 As isodose curves. 44 S.O. Fedoruk, H.E. Johns and T.A. Watson, “Isodose Distributions for a 1,100-Curie Cobalt60 unit,” Radiology 60 (1960): 348–54. 45 D. Cassels, “Brave New Worlds for Nuclear Medicine,” Ascent 1 (1979): 8–10.

176

Notes to pages 136–9

46 D.A. Fee and S.O. Fedoruk, “Clinical Value of Liver Photoscanning,” New England Journal of Medicine 262 (1960), 123–5. 47 A more complete biography of Sylvia Fedoruk can be found in Stuart Houston and Bill Waiser, Tommy’s Team: The People behind the Douglas Years (Calgary: Fifth House, 2010), 42–8. 48 T.D. Cradduck, “The Design of a Detection and Display System for a Radio-isotope Scanner” (MSc thesis, University of Saskatchewan Department of Physics, 1962). T.D. Cradduck and S.O. Fedoruk, “A Study of Collimators for Use in Radioisotope Scanning Techniques,” Journal of the Canadian Association of Radiologists 13 (1962): 9–13. 49 T. Cradduck, “Flashback, Saskatoon, 1961,” in A New Kind of Ray, edited by J.E. Aldrich and B.C. Lentle (Vancouver, ubc Press, 1995), 386–7. Cradduck’s PhD dissertation in 1965 resulted in two more joint papers with Fedoruk: T.D. Cradduck, S.O. Fedoruk and J.A. MacKay, “A ‘Large Crystal’ Scintillation Scanner,” Journal of Nuclear Medicine 5 (1964): 27–39; T.D. Cradduck and S.O. Fedoruk, “An Experimental Determination of the Overall Spatial Resolution of a Scintillation Camera,” Physics in Medicine and Biology 10 (1965): 67–76. 50 S.J. MacIntyre. S.O. Fedoruk, C.C. Harris, D.E. Kuhl, and J.R. Mallard, “Sensitivity and Resolution in Radioisotope Scanning: A Report to the International Commission on Radiation Units and Measurements,” in Medical Isotope Scintigraphy, vol. 1 (Vienna: International Atomic Energy Agency, 1969): 391–433. 51 Houston and Fedoruk, “Radiation Therapy,” 154. e pi logue 1 Malcolm G. Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen’s University Press, 1978), 239–330.

177

Notes to pages 139–41

2 Noel Doig, Setting the Record Straight: A Doctor’s Memoir of the 1962 Medicare Crisis (Saskatoon: Indie Ink Publishing, 2012). 3 A.W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961 (Toronto: University of Toronto Press, 2004), 251. 4 Sargent E. and Mary McGowan, Cordwood and Courage (Paddockwood and District History Committee: Friesen Printers, 1982): 357–9. 5 Five days before the McGowans’ wedding date. They got their blood tests finished in time, and the wedding went forward 28 July 1962. 6 Taylor, Health Insurance, 239–330; E.A. Tollefson, Bitter Medicine: The Saskatchewan Medicare Feud (Saskatoon, Modern Press, 1964) provides a legal viewpoint. Robin F. Badgley and Samuel Wolfe, Doctors’ Strike: Medical Care and Conflict in Saskatchewan (Toronto: Macmillan, 1967) is a third recommended source. A recent example is Noel Doig, Setting the Record Straight. See also Gregory P. Marchildon and Klaartje Schrijvers, “Physician Resistance and the Forging of Public Healthcare: A Comparative Analysis of the Doctors’ Strikes in Canada and Belgium in the 1960s,” Medical History 55, 2 (April 2011): 203–22. 7 Taylor, Health Insurance, 367. 8 Taylor, Health Insurance and Canadian Public Policy, revised edition 2009, 502. 9 Marchildon and Schrijvers, “Physician Resistance,” 222. 10 Two medical doctors, David M. Baltzan of Saskatoon and Arthur van Wart of Fredericton, New Brunswick; Dean Alice Gerard of the University of Montreal School of Nursing; Dr Leslie Strachan, a dentist from London, Ontario; Wallace McCutcheon, an industrialist from Ontario, and Dr O.J.

178

Notes to pages 141–5

11 12 13 14 15

16

17

Firestone, an economist. Dr Malcolm G. Taylor was research consultant and Professor Bernard Blishen was research director. Taylor, Health Insurance, 342. Ibid., 375. Greg Marchildon, ed., The Heavy Hand of History (Regina: Canadian Plains Research Center, 2005): 61. Ibid., 51. As a family practitioner in Yorkton, 1951–60, my assigned role was to teach the student nurses about dermatology and sexually transmitted diseases. Fourteen of the twenty-one members of the nursing class of 1962 returned; that evening they sang two songs as part of the entertainment. When the new medical school was about to open in Newfoundland in 1967, and Lord Stephen Taylor was president of Memorial University, I was offered the headship of diagnostic radiology. I have since admired from afar the funding and stability of that department. Free from the intervening level of bureaucracy of a city-wide health board, which in Saskatoon has yet to develop appreciable priorities for either teaching or research, impoverished Newfoundland, it appears to me, regards its medical school as a provincial resource and treasure.

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INDEX

Abbey, 37, 81. See also Miry Creek Aberdeen, Scotland, 7 Acme Machine and Electric, 130, 135 Act Respecting the Control and Treatment of Cancer (proposed, 1944), 121 Agnes, Sister, 4 Agriculture, Minister of, 27 air ambulance, 101–2 Alberta, 3; free cancer treatment, 173n16; joined medicare, 141; tuberculosis treatment, 54; Venereal Disease Act (1918), 19; union hospitals, 35–7. Alexander, A.B., 43 Allis-Chalmers Company, 125 American College of Chest Physicians, 66

American Psychiatric Association Mental Hospital Institute, 114 American Public Health Association, 22 Anderson, J.T.M., 119 Anderson, Matt, 38. See also Matt Anderson Plan; McKillop (rm); Municipal Medical and Hospital Services Act; Strasbourg Andrews, C.H., 58 Anglican Sisterhood of St John the Divine, 5 Anna Turnbull Memorial Hospital, 11 Associated Canadian Travelers (act), 46, 61 Assumption College, 18 Atomic Energy Commission, 124–5

Index

Atomic Energy Control Board of Canada, 125 Atomic Energy of Canada Limited (aecl), 133 Atomic Energy Project, 129 Bacille Calmette-Guérin (bcg) vaccination, 55, 59–60 Barnett, G.D., 43 Bassano, ab: municipal union hospital, 35 Bates, L.M. (Lloyd), 130, 134. See also “Saskatchewan mafia” Battleford: hospital, 11; nwmp hospital, 4; population, 11; tuberculosis treatment, 19. See also North Battleford Beechy (municipal doctor), 28 Bell, James, 5 Bentley, T.J., 102, 139 betatron, 124–9, 134 Bethune (municipal doctor), 28 Biggins, nurse, 5 Big River, 58 Big Stick (rm), 84 Birsay (municipal doctor), 28 Blair, Allan, xviii–xix, 121–6 Blakeney, Allan, 55 Boston, ma, 49 Boucher, Sister, 4 Boughton, Harvey, 43, 49, 65 Brandon, mb, 6, 7 Brandon College, xx Britannia (rm), 36

182

British Columbia, 101, 134; hospitalization plan, 103; joined medicare, 141 British Journal of Radiology, 135 Brock (municipal doctor), 28 Brown, J. Lloyd, 71, 75, 86, 89. See also Saskatchewan Health Services Planning Commission Buchan, Douglas J., 94 Buffalo River First Nation reserve, 67 Bureau of Public Health, 18 Cabri, 80, 91 Caldwell, A.L., 80–1 Canadian Cancer Society, 119 Canadian Centre for Nuclear Innovation, 137 Canadian Medical Association, 28, 89 Canadian Pacific Railway, 18 Canadian Public Health Association, 22 Canadian Society for the Control of Cancer, 119 cancer, 22, 43, 61, 98, 118–37 Cancer Control Act, 122 Canora: hospital, 13, 15; tb clinics, 52 Cardston, ab: municipal union hospital, 35 cbc (Canadian Broadcasting Corporation): xxi, 90 “ceiling principle,” 77, 88 Chalk River, on, 129

Index

Chamberlain (municipal doctor), 28 Chapin, Charles H., 72. See also McKillop (rm) Chapman, Roy, 26. See also Dilke charge nurse, 39–40 Charles Mickle Fellowship, 64 Chase, Lillian, 23 Christmas Seal campaign, 46, 61 Churchill River, 4 Cipriani, A.J., 129 Clarke, C.K., 106 Clearwater Sanatorium, 59 cobalt-60, 123–4, 129–37 Collins, John J., 33. See also Ituna Committee on Municipal Physicians, 28. See also D.S. Johnstone Conference of State and Provincial Health Authorities, 22–3. See also Seymour Plan Connell, Robert, 61–2 continuing education, 48–9 Cook, A.B., 51 Coombs, Mother Hannah Grier, 4–5 co-operation (particularly community), 63, 86, 89, 142 Co-operative Commonwealth Federation (ccf), xviii, 66, 69, 75, 82, 84, 88, 122, 138, 142, 157n4, 158n5, 158n9, 159n22, 162n30, 174n26

183

Cormack, D.V., 134, 136. See also “Saskatchewan mafia” cottage hospital, 5, 6, 10, 39, 81, 96; psychiatric cottage hospitals, 105–7, 114–16, 171n43 Craik, 27; municipal doctor, 28; population 151n4 Cumberland House, 3 Cupar: school tb survey, 51 Darling and Pearson (architectural firm), 106 Davey, Lloyd, 86, 163n33 death rate, 22, 54, 56, 64 de Grandmaison, Nicholas, 64 Delco Light Company, 56 Denver, Colo., 114 depth dose, 130, 133–5 Diefenbaker, John G., 141 Dilke, 26, 151n3. See also Chapman, Roy diphtheria, 22, 31, 41 Directly Observed Therapy (dot), 68 Ditner, Pat, 87, 163n42 Dixon, W.R., 134 d-lysergic acid diethylamide (lsd), 112–13. See also psychedelic therapy “doctors’ strike,” xix, 91, 139–41 Doig, Noel, 139 Dominion Health of Animals Branch, 22 “doughnut” or high-energy

Index

betatron tube, 126–8. See also betatron Douglas, Shirley, xxi Douglas, T.C., 63, 66, 69–71; on approving the betatron, xix–xxi; on cancer treatment, 122, 124; as cbc’s “Greatest Canadian,” xxi; promises nonpolitical commission, 75; health policy as Minister of Health, 75–8; on health regions, 81, 84; and medical college and university hospital, 93–5; on mental health, 108–9; on resigning as Minister of Health, 102; role in medicare, 139–40; and Saskatchewan Health Services Planning Commission, 98; epilogue 138–41 Dragan, George, 121 Dr George Ferguson School, 66. See also Regina drought, 32–3, 48, 79, 86, 143 Drumheller, ab: municipal union hospital, 35 Dunning, Charles A., 118 Dyck, Erika, 108–11 dysentery, 20 Echo Lake, 20 Eldorado Mining and Refining, 132 Elkin, Nurse, 5 empowerment, 92, 144

184

Epp, E.R., 34. See also “Saskatchewan mafia” Ewing, James, 119 Feather, Joan, 79, 84 Fedoruk, Sylvia, 134–7. See also Foreword; “Saskatchewan mafia” fee-for-service, xix, 28, 76, 81, 140, 159n22 Ferguson, G. Gordon, 102 Ferguson, Helen, 65 Ferguson Island, 66 Ferguson, Robert George (R.G.), 20, 33, 41–67 File Hills Indian Agency, 56–7 Fines, Clarence, xx First Nations, 3–4, 43, 51, 55–60, 67–8, 156n18 Fort Ellice, 172n1 Fort Qu’Appelle, 43, 118 Fort Qu’Appelle Sanatorium (Fort San), 43, 45, 47, 49, 52, 64–5; nursing course, 49; post office, 43 Fort Walsh: nwmp hospital (and pharmacist), 4 Frappier, Armand, 60 Fraser (Myles), Margaret, 7 Freemont (municipal doctor), 28 Gardiner, James G., 47, 54 Garrett, C., 134 Gibson, Clarence, 77 Gibson, W.C., 93, 165n2

Index

Goderich, on, 19 Golden Prairie, 84 gonorrhea, 19 Grain Growers’ Assocation (women’s section), 143 Grandin, Bishop, 4 Grand Rapids, mb, 5 grassroots, 23, 44, 52, 63, 92 Grey Nuns (Sisters of Charity), 4, 11, 13 Gull Lake, 84, 89, 102 Hall, Emmett M., 141, 168n29 Hanna, ab: municipal union hospital, 35 Harrington, Ertle L., 119–25 Hart, Bob, 65 Hart, F.W., 65 Harvard University, 49 Haslam, R.N.H., 125 Hazlet, 80 Heagerty, J.J., 159n25 Heagerty Interdepartmental Advisory Committee on Health Insurance, 76 Health Insurance District #1, 72. See also McKillop (rm), Chapin, Charles H. Health Services Board, 32–3 Health Services Planning Commission, 77, 81, 98, 159n22 Health Services Survey Commission (Saskatchewan) (shssc), 71

185

Henry, Clarence M., 119 Heward: school tb survey, 51 High River, ab: municipal union hospital, 35 Hingley, E.G., 65 Hitsman, Elden, 73 Hjertaas, Orville, 87 Hoffer, Abram, 112 Hogarth, Bamm, 157n4 Holdfast, 25, 27 Holdfast (municipal doctor), 25–8, 32 Homemakers’ Clubs, 23, 45, 143 Horlick, Louis, 94–5 Houston, C.J. (father of C. Stuart Houston), 102–3; Introduction and Epilogue Howden, Gordon, 89–90 Hudson’s Bay Company (hbc), 3–4; 172n1 Hugh Waddell Memorial Hospital, 15. See also Canora Humboldt: hospital, 16 Ile-à-la-Crosse, 58; first hospital in Saskatchewan, 4 Imperial Order Daughters of the Empire (iode), 46, 143 Indian Head, 19, 65; hospital, 10; nursing training, 10; population, 11 infant mortality rate, 89 Irwin, O.M., 162n31 Islay, ab: municipal union hospital, 35

Index

Ituna, 33 Izumi, Kiyoshi, 114. See also Saskatchewan Plan Johns Hopkins University, 71 Johns, Alfred Edward, xx Johns, Harold, xvii–xx, 122–5, 129–30, 134. See also “Saskatchewan mafia” Johns, Sybil, 129 Johnson, A.W., 160n32 Johnstone, D.S., 28. See also Committee on Municipal Physicians Joliette, nd, 41 Jorgenson, Lester, 83, 85, 92 Journal of the Canadian Association of Radiologists, 134 Jukes, Augustus L., 4 Katz, L., 125 Kelly, Arthur D., 89. See also Canadian Medical Association Kelvington, 121 Kerst, D.W., 124, 126, 175n28 King Edward tuberculosis hospital, 43. See also Winnipeg King George infectious disease hospital, 43. See also Winnipeg Kirkby, R.W., 43 Kirychuk, Mary, 140 Kitchi-Manitou, 58 Kjorven, Carl, 84, 85, 91, 102, 163n34

186

Lady Minto Hospital, 13. See also Melfort La Loche, 58, 67 Langley, George, 27. See also Minister of Agriculture Lashburn: hospital, 15 Latta, S.J., 54 Lawson, F.S. (Sam), 109–10, 113–15. See also Saskatchewan Plan Leader Post, 91 League of Nations, 22–3 Lebret Indian School, 56 Leroy (municipal doctor), 28 Lewis, W.B., 129. See also Atomic Energy Project Lindsay, W.S., 95 Lintlaw (municipal doctor), 28 Lloyd, Woodrow, 139–40 Lloydminster, 36; hospital, 11, 35, 36, 37 Lloydminster Times, 36 London, England, 48, 123, 134 London, on, 132–4 London Free Press, 133 Lorne, Marquis of (governor general), 6 Low, David, 105–7 lsd. See d-lysergic acid diethylamide MacDonald, Maria, 18 MacKay, John, 130, 135–6. See also Acme Machine and Electric

Index

Mackenzie, C.J., 124–5. See also National Research Council MacLean, Hugh, 158n5 Macleod, J. Wendell, 94, 165n4 MacNeill, J.W., 107 Manitoba, 3, 20, 42, 152n11, 158n9; joined medicare, 141; tuberculosis treatment, 54, 59–60, 156n26 Maple Creek, 89, 162n31; hospital and nurse training school, 10; nwmp hospital, 4; population, 11 Marchildon, Gregory, 140 Mary E. Truesdell Nursing Home, 6 maternity grant, 19, 39 Matheson, J.A., 89, 162n31 Matthews, Maureen, 90, 164n65 Matthews, Vincent L., 86–7, 90–1, 163n37 Mayneord, M.V., 123. See Royal Cancer Hospital Matt Anderson Plan, 38–40; 72–3, 81 McAllister, James, 101 McAra, Peter, 65 McCorkell, Wilf, 116–17 McDonald, Ellice, 118–19 McGill University, 19, 94, 121, 174n23, 192n2; medical school, 98 McGowan, Sargent, 140, 178n5 McKerracher, D.G. (Griffith),

187

109–11, 113–16 McKillop (rm), 38, 72–3 McKinnon, Eleanor, ix–xix McLaren, Robert, 23 McLean, C.S., 32 McLeod, Ian, 78 McLeod, Thomas H. (Tommy), 77 McMaster University, 122 McNaughton, A.G.L., 124, 174n23 McTaggart, Ken, 102 Meadow Lake, 67 medical college, 74, 92–3, 130 Medicine Hat, ab: hospital, 6; population, 149n10 medicine men and women, 3–4 Melfort: hospital 13; tb clinics, 52. See also Lady Minto; Victorian Order of Nurses Melrose, Walter, 84 Memorandum on Organization of Health Regions, 81 Mental Health Act, 111 mescaline, 112 milk, 20–1, 44, 143; pasteurization, 22. See also tuberculosis Millar, (nurse), 5 Mills, John, 111, 114, 117, 170n16 Minister of Agriculture, 27 Minto, Lady, 6–7, 10, 13. See also Victorian Order of Nurses (von) Miry Creek (rm), 37, 81, 92

Index

Michi-Manitou, 58 Montreal, qc, 5, 15, 60 Montreal Lake, 66 Moose Jaw: hospital, 4, 11, 12, 16; mental health clinic, 109; polio clinic, 101; population, 11; school tb survey, 51; tb clinic, 52 Moosomin, 19, 124, 174n23; hospital 7, 9; population 11 Morrison, A., 134 Motherwell, W.R., 18 Mott, F.D. (Fred), 98–9, 102, 163n36, 167n11 municipal doctors, 23, 27–35, 72, 144, 152n11; location, 28 municipal hospitals, 23, 36–40; location in ab, 35 Municipal Medical and Hospital Services Act, 38. See also Anderson, Matt; Matt Anderson plan Munroe Wing (Regina General Hospital), 109 Murray, Walter, 118 Muskeke-O-Kemacan (Great White Physician), 28, 58. See also Ferguson, R.G. Myers, G.W., 99 Myles, Margaret Fraser, 7 National Association for the Prevention of Tuberculosis, 57 National Cancer Institute, 127 National Council of Women, 6

188

National Health Grants Program, 96, 153n34 National Health Insurance Plan (Great Britain), 86 National Research Council (nrc), 55, 124, 129, 134 New Brunswick, 178n10; joined medicare, 141 Newfoundland: joined medicare, 141; medical school 179n17 Newton, il, 25 New York City, 20; Memorial Hospital 119, 173n15 Ninette, mb, 20; Sanatorium, 42 Nipawin, 46 Normal School (Teacher’s College), 46, 47, 51 North Battleford, 114: hospital, 16; psychiatric clinic, 109; psychiatric hospital, 107; school tb clinic, 51; tb clinic, 52, 114. See also Saskatchewan Hospital North Dakota, 41 North-West Mounted Police (nwmp), 4; Royal North West Mounted Police, 19 North West Territories: joined medicare, 141 North-West Territories, 6 North-West Territories Medical Council, 22 Nova Scotia: joined medicare, 141 Nuclear Enterprises, 136

Index

nuclear imaging, 136–7 nurses, student, 49, 55, 60, psychiatric nurse training, 109–10 Ogdensburg, ny, 105 Onoway, ab, municipal union hospital, 35 Ontario, 18, 52, 104, 105, 129, 132, 133; joined medicare, 141 Osmond, Humphry, 112, 114–15 Paddockwood, 38–40, 98, 140, 167n10 Paille, Father (Oblate), 11 Palliser Triangle, 80 para-amino-salicyclic acid, 64 Parsons, Phoebe (nurse), 5 Patrick, T.A., 7 Patterson, W.J., 157n4 pavilion-style psychiatric hospital, 107 Peart, Arthur F.W., 86, 163n33 Pennant, 84 Pépin, Sister, 4 peyote cactus, 112 Philadelphia Cancer Institute, 119 photofluorographic surveys, 61–2 photoscanning, liver and whole body, 136–7 Picker Cobalt units, 136 Pierce, S.J.S., 42 “Pile of Bones,” 6. See also Regina

189

Pittville (rm), 38, 71, 80–2 poliomyelitis, 101 Prebble, Peter, xviii Presbyterian Church, 11, 13 preventorium, 46, 50 Prince Albert, 19, 141; hospital, 6, 8, 15; nwmp hospital, 4; population, 11; psychiatric clinic, 109, 115; sanatorium, 43, 47, 58–9, 64 Prince Edward Island: joined medicare, 141 Protestant Hospital for the Insane, 105 Provost, ab: municipal union hospital, 35 psychedelic therapy, 112–13, 138 Psychiatric Services Branch (Saskatchewan), 113 Public Health Act, 18 Qu’Appelle: nwmp hospital, 4 Qu’Appelle Indian agency, 56; reserve, 56 Qu’Appelle Valley, 18, 20 Quebec: joined medicare, 141 Queen Victoria, 6 radium, 118, 120–1, 123–4, 129 radon, 121 Red Cross, 39, 143, 155n10 Red Cross Outpost Hospitals, 38–40, 98 Regina, 6, 7, 8, 18, 19, 21, 28,

Index

38, 47, 56, 65–6, 71, 81, 88–9, 92–3, 99, 104, 106, 114, 121, 124, 157n4, 158n5, 162n27, 163n34; cancer clinic, 121; hospital, 13; nwmp hospital, 4; polio clinic, 101; population, 11; sheriff, 51; school tb survey, 51; tb clinics, 52; vd clinic, 19 Regina College, 21 Regina General Hospital, 109, 119 Regina Leader Post, 91 Registered Nurses, 72, 102, 107; Registered Psychiatric Nurses, 107, 110–11 Riel Rebellion, 4, 18 Riverside (rm), 81, 84–5 Robertson, Stewart, 81, 85, 87, 90–1, 162n23, 163n42 Roemer, Milton, 75 Roman Catholic, 11, 15 Röntgen, Wilhelm Carl von, 134 Rorem, C. Rufus, 28–30, 152n11 Rosthern, 47 Royal Canadian Air Force Clinical Investigation, 93 Royal Canadian Legion, 66 Royal Cancer Hospital, 123 Royal College of Physicians (mrcp), 48 Royal Institute of Public Health, 23

190

Royal North West Mounted Police, 19 Rural Municipal Act, 53 Rush Lake (municipal doctor), 28 St Boniface, mb, 4, 11 salaried doctors, xix, 27–35, 71, 75, 80–1, 159n22; loss of due to medicare, 34 Saltcoats: hospital, 5 Sanatoria Act, 53 sanatorium. See Clearwater; Fort Qu’Appelle (Fort San); Ninette; Prince Albert; Saskatoon; Trudeau Saranac Lake, ny, 20 Sarnia (rm): (municipal doctor), 19, 25–7, 34 Saskatchewan Anti-tuberculosis Commission, 49–50 Saskatchewan Anti-tuberculosis League, 20, 45, 51, 54, 58, 61–6 Saskatchewan Association of Rural Municipalities (sarm), 33, 53, 65, 71 Saskatchewan Cancer Agency, 176n39 Saskatchewan Cancer Commission, 119, 122 Saskatchewan Cancer Commission Act, 119 Saskatchewan College of

Index

Physicians and Surgeons, xix, 33, 38, 76, 102, 103, 139, 140 Saskatchewan Gazette, 82 Saskatchewan Health Service Board, 32–3 Saskatchewan Health Services Planning Commission (hspc), 77, 81, 98, 159n22, 163n34, 167n11 Saskatchewan Health Survey, 96–7 Saskatchewan Hospital: North Battleford, 107, 114, 117; Weyburn, 109, 112, 114, 117 Saskatchewan Hospital Services Plan (shsp), 98–101 Saskatchewan Lung Association (sla), 63–4, 66 “Saskatchewan mafia,” 134 Saskatchewan Medical Association, 22, 33, 47, 65, 66, 76, 102, 119; Cancer Committee, 119 Saskatchewan Medical Care Insurance Commission, 92 Saskatchewan Medical Quarterly, 75, 84 Saskatchewan Plan, 114–16 Saskatchewan Psychiatric Nurses Act, 111 Saskatchewan Psychiatric Nurses Association, 111 Saskatchewan Sanatoria and Hospitals Act, 54

191

Saskatchewan Social Assistance Plan, 75–7, 97, 100, 122, 140 Saskatchewan Tumour Registry, 120 Saskatchewan Urban Municipal Association (Saskatchewan Urban Municipalities Association) (suma), 54, 168n25 Saskatchewan Wheat Pool, 102, 142 Saskatoon, xviii, 21, 47, 73, 89, 93, 94, 113, 116, 124, 126, 143; betatron, 126–9; closure of sanatorium, 64; cobalt-60, 129–36; gamma camera, 136; hospitals, 11, 13, 119, 126; medical college, 115; polio clinic, 101; population, 11; psychiatric clinic, 109; Riel Rebellion base hospital, 5–6; sanatorium, 43, 47, 49; school tb survey, 51; tb clinics, 52; tb survey, 61; typhoid epidemic, 11 Saskatoon Agreement, 140 Saskatoon Star-Phoenix, 130, 133 Schmitt, Henry J., 19, 25–7, 32, 151n4 Schrijvers, Klaartje, 140–1 Schultz, Milford D., 126 Science, 134 Senlac (municipal doctor), 28

Index

Seymour, Maurice Bain, 18 Seymour, Maurice M., 18–24 Seymour Plan for immunization, 22 Sharp-tailed Grouse, 6 Shaunavon, 84, 153n30, 161n17 Shaunavon Standard, 161n16 Shepley, Earle E., 119, 120 Sheps, Cecil, 167n11 Sheps, Mindel Cherniak 77, 81–2, 158n9, 167n11 Shumiatcher, Morris C., xviii Sigerist, Henry, 71–6, 93, 95–7, 100, 144, 157n4, 158n6, 158n9 Sigerist Commission report, 35, 71, 75, 77, 93, 95, 108, 110 Simes, Austin, 59–60 Sinclair, Lister, 90 Sisley, (nurse, nursing home), 11, 13 Sisters of Charity (Grey Nuns), 4, 11, 15 Sisters of Providence, 15, 16 Sisters of St Elizabeth, 16 Skaggs, Lester, 124 smallpox, 3–4; vaccination, 22 Smith, Colin, ix, 109 Smith, Ivan H., 133 Smythies, John, 112 Social Assistance Medical Care Plan, 75–6, 77, 97, 100, 122, 140 Stapleford, E.W., 21

192

St Elizabeth’s Hospital, 16. See also Humboldt sterilization, 74 Stewart, D.A., 20, 42–3 Stirrett, R.R., 162n31 Stoughton: school tb survey, 51 Strasbourg, 38, 73 streptomycin, 64 Swift Current, 11, 79–92, 115, 162n27, 162n30, 162n31; hospital, 16, 17; psychiatric clinic, 109; tb clinic, 52 Swift Current Health Region, x, 72, 79–92, 96, 102, 138, 144, 162n27, 163n34 Swift Current Regional Hospital Council, 90 Swift Current Sun, 86 syphilis, 19 Taché, Father (later Bishop), 4 Taylor, Lauriston, 123, 174n19, 179n17 Taylor, Lord Stephen, 72, 91, 140 Taylor, Malcolm G., ix, 37, 40, 71, 92, 99–100, 102, 140, 168n29, 178n10 Thompson Advisory Planning Committee, xix Thompson, Walter P., 129 Thomson, James S., 124–5 Tisdale tb clinics, 52 Tizley, Richard, 61 Toronto, on, xx, 106, 123

Index

Toronto Asylum, 106 Trudeau Sanatorium, ny, 20 tuberculin test, 51, 56, 60; of cattle 20, 21 tuberculosis, 20–2, 41–68, 101, 118, 138, 143, 144; bovine tuberculosis, 20; epidemic among First Nations graph, 57; and First Nations, 43, 55–9 Tuckwell, David Grieve, 36 typhoid, 11, 20, 22, 42 Uhrich, J.M. (health minister), 47 union hospitals, 35–9, 82, 96–7, 143 United Farmers of Canada (ufc), 32, 54 United Kingdom, 23 United States, 28, 98, 105, 123, 129 United States Air Force, 59 United States Public Health Service, 98 University Hospital, 74, 93–5, 116, 126, 130 University Hospital Act, 94 University of Alabama, 173n15 University of Alberta, 122 University of California, Berkeley, 99 University of California, Los Angeles, 75 University of Chicago, 29

193

University of Illinois, 124 University of Manitoba, 59 University of Ottawa, 23 University of Pennsylvania, 118 University of Saskatchewan, 64, 66, 93–5; college of medicine, 93–4, 113, 118–19, 124 University of Toronto, 22, 64, 122 University of Western Ontario, 129 Vachon, Father (Oblate), 11 venereal disease, 19, 74 Venereal Disease Act, 19 Venice Café, 91 Verdun, qc, 105 Vermilion, ab: municipal union hospital, 35 Victoria, bc, 134 Victoria Hospital: Prince Albert, 6; Regina Victoria, 6–7; Queen Victoria, Yorkton, 7; London, on, 132. See also 7–10 Victorian Order of Nurses (von), 6–7, 13 Victor X-ray Corporation, 56 Voth, Abe, 116–17 Wadena: tb clinics, 52; union hospital district, 153n30 Wakaw: Anna Turnbull Memorial Hospital, 11 Ward Island, 105

Index

Warwick, O.H., 127 Watson, T.A., 127, 130 Webb (rm), 81, 85, 163n42 Wesley College, 41 Weyburn, 112, 114; rm, 53; asylum, 107, 117; hospital, 16; psychiatric clinic, 109; psychiatric nursing, 111 Wherrett, G.J., 52 Wherrett-Grzybowski report, 52 White, Paul, 49 Willoughby, J.H.C. (private hospital), 11, 14 Wilton (rm), 36 Windsor, on, 18

194

Winnipeg, mb, 5, 6, 41–3, 49, 56, 136, 151n8, 158n9, 165n4, 173n15; general hospital, 5 Women’s Missionary Society, 13 Wolan, Casimir, 90–1 Yorkton, 7, 19, 42, 144, 168n25; Yorkton Queen Victoria Hospital, 7, 9, 144, 179n15; population, 11; psychiatric clinics, 109; psychiatric cottage hospital, 115, 171n43; tb clinics, 52 Yukon: joined medicare, 141