Woodrow Lloyd and Tommy Douglas, fathers of Medicare in Saskatchewan.
By: C. Stuart Houston et John A. Boan
Although most Canadians are aware that Saskatchewan was a leader in establishing national medicare, few people, even in Saskatchewan, know how the province came to take on its leadership role. The story of how a thinly settled, often impoverished province became a global leader in universal health care is a remarkable one. The following account describes the evolution of community health care and highlights some of the impressive contributions made by Saskatchewan health care professionals and civic leaders.
In Saskatchewan, an early step toward medicare was the creation of the first municipal doctor and municipal hospital schemes in North America. In 1915, the people of the Rural Municipality (RM) of Sarnia at Holdfast learned that the doctor in the nearby community of Craik was about to join the army when a delegation of Craik people tried to entice Dr. H.J. Schmitt to move from Holdfast to Craik. To retain Schmitt, RM Sarnia voted $1,500 to pay him a retainer, and thus invented a new use for tax dollars. Dr. Maurice Seymour, the equivalent of a Deputy Minister of Health, responded quickly: he drafted an amendment to the Municipalities Act to make it legal to pay municipal doctors from taxation funds. A municipal hospital act was passed in 1916; eventually there were 173 municipal doctors in Saskatchewan.
Tuberculosis was at the time the leading cause of morbidity and mortality. Dr. R.G. Ferguson, the head of the Saskatchewan sanatorium near Fort Qu’Appelle, persuaded the government to appoint the Saskatchewan Anti-tuberculosis Commission in 1921–22, the first in any state or province in North America to assess the prevalence of tuberculosis in non-Native and Native children and adults. Ferguson was named the commission’s secretary; by directing the research and writing the report, he produced a blueprint for combating tuberculosis across the province. Research for this report included the first representative cross-sectional studies of school children. Twelve of the twenty-one commission recommendations were implemented, resulting in new sanatoria at Saskatoon and Prince Albert, and in the creation of the first traveling TB clinics. Dr. Ferguson next campaigned for the commission’s ultimate proposal: universal diagnosis and treatment of tuberculosis at public expense. After three failed attempts, he finally gained unanimous support for this revolutionary idea from the most influential organization in the province, the Saskatchewan Association of Rural Municipalities (SARM), at their annual meeting in May 1928. The government lost no time: at the next legislative session in December 1928, the necessary legislation was passed. It came into effect on January 1, 1929—eight years ahead of the next province (Alberta). The provincial government and the rural municipalities each paid half the cost of universal “free” treatment; some municipalities thus spent more tax dollars on one disease, tuberculosis, than they did on roads.
Under Ferguson, Saskatchewan’s tuberculosis research and treatment garnered impressive grassroots support, particularly from farm women and rural municipalities, and led all of North America. Ferguson used controversial BCG vaccination to cut the TB infection rate among Indian infants and student nurses to between a quarter and a fifth of the previous rate, and his published scientific reports remain landmarks. With a made-in-Saskatchewan miniature photofluorography system, the province was the first jurisdiction in North America to embark on general surveys of asymptomatic people to detect early tuberculosis while it was still easily curable, and had the lowest tuberculosis death rate in Canada. It was also the first province to have sufficient TB beds: three per TB death. The close relationship between physicians and their communities helped Saskatchewan to be a healthcare leader in this fight against tuberculosis. Payment for the expensive treatment of tuberculosis, which typically required sanatorium stays of one to three years, set a precedent which more than a decade later greatly facilitated T.C. Douglas’ task of introducing medicare.
The next innovation was by the reeve of the RM of McKillop #220, Mathias S. Anderson, who after thirteen years of campaigning consulted with Dr. J.M. Uhrich, Minister of Health, and with Reg Parker, Minister of Municipal Affairs. Together they devised a plan whereby each resident of the RM (1,230 people), the town of Strasbourg (430), and the villages of Bulyea (107) and Silton (70), would receive medical care from Dr. Elden Hitsman, their municipal doctor, and on referral to any medical doctor of their choice in Regina. This free choice of consultant doctor was strikingly different from most other municipal plans, where care was given only by the salaried municipal doctor. Led by Dr. E.K. Sauer, members of the Regina District Medical Society agreed to accept 50% of the provincial schedule of fees as payment in full for medical services rendered to people in the McKillop/Strasbourg district.
A vote taken in the proposed area during the municipal elections of November 1938 passed with a plurality of 96%. Implementation required a special act, the Municipal and Hospital Services Act, referred to by some as the Matt Anderson Act. It was passed quickly by the Legislature in March 1939, and “Health District #1” began operation on June 1, 1939. Before long, similar plans were implemented by the RMs of Caledonia, Chester, Lajord, Lumsden, and Longlaketon. By late 1940, a fledgling doctor-sponsored health insurance plan, Medical Services Incorporated, sent doctors’ bills to the RM McKillop office for services provided by Regina doctors, and the following year to the other five municipalities which had followed the Anderson plan. Municipal leaders and doctors had once again developed an innovative plan to serve the needs of the community.
Within two days of his election in 1944, Premier t.c. Douglas, with the support of his medical advisor, Dr. Hugh MacLean, asked Dr. Henry Sigerist, professor of medical history at Johns Hopkins University, to prepare a report on health care in Saskatchewan. Sigerist’s report, produced after only three weeks of hearings and study, provided the “blueprint” for medical care in Saskatchewan for the next half century. Sigerist’s recommendations included district health regions for preventive medicine, rural health centres of eight to ten maternity beds, universal hospitalization (at a projected cost of $3.60 per person per annum), and the establishment of a medical college at the University of Saskatchewan. Douglas followed MacLean’s advice to assume the health portfolio, so that he as Premier could personally direct the development of health plans.
When the CCF took office in 1944, there was no organized provision of medical care for the province’s indigents. T.C. Douglas quickly reached an amicable, province-wide deal with the medical profession to provide care for the province’s estimated 30,000 indigents, such as widows and the blind, for $9.50 per person per year. The agreement was advantageous to both sides, as the government could budget for a fixed annual sum for the entire province, while the doctors were paid fee-for-service and policed the system.
The Swift Current area was slated to be the demonstration unit for preventive medicine. The RM of Pittville at Hazlet already had a health scheme, devised by William J. Burak, whereby its residents received both medical and hospital care for just under $11 per person per year. Wishing to add the Pittville method of full medical care to the preventive program planned for the southwest, Burak wrote at his own expense to each municipality, town and village, visited each weekly newspaper editor, and called a public meeting to press for a full medical and hospital plan. When a vote of all ratepayers was held on November 26, 1945, a majority voted in favour of a full regional health plan.
The Saskatchewan government, manoeuvred by Burak into initiating a more comprehensive scheme than the preventive medicine program it had planned, passed an Order-in-Council on December 11. The region’s hospitalization and health care scheme took effect on July 1, 1946—a full two years before Great Britain’s “cradle to the grave” health care plan was implemented. Within the Swift Current Health Region (Saskatchewan’s Health Region #1) the residents felt empowered, and the region assembled statistical data on the costs of health care that were unrivalled in Canada. The regional scheme flowered when Dr. Vince Matthews, the public health officer, provided seamless integration of preventive work and medical care, a first in Canada. There was a high level of rapport between the local administration, the constituent municipalities, patients, and physicians: Stewart Robertson, the administrator, Dr. Vince Matthews, and Dr. Cas Wolan, president of the district medical association, met informally most days for coffee. In 1951, Swift Current created the first regional hospital board in Canada.
In 1945, Saskatchewan became the first province to provide capital grants for hospital construction. Federal funding became available for such purposes in 1948, but the province lost out by having already spent most of its hospital construction funds, which thereby did not qualify for federal matching. Next came provincial hospitalization, capably organized by an American, Dr. Fred D. Mott, a McGill medical graduate who had married a Winnipeg girl. Mott was lured away from his public health position in the United States, where he had assisted low-income farmers and migratory workers. He masterminded an efficient province-wide hospital plan with low overhead; the nominal fee of $5 per Saskatchewan resident covered 70% of the provincial hospital expenses in the first year (1947). Almost all doctors welcomed the new freedom to admit patients to hospital without concern for ability to pay.
Saskatchewan was a leader in psychiatric concepts and practice in many ways. In 1908, Dr. David Low of Regina recommended small, humane psychiatric hospitals, but his forward-thinking advice was overruled on the advice of a Toronto psychiatrist. Instead, two large institutions were built in North Battleford and Weyburn. At the former, Dr. J.W. MacNeill did his best to administer the large complex as compassionately as possible. He removed the bars from windows, forbade the use of mechanical restraints, substituted the word “hospital” for “asylum,” provided meaningful therapeutic work on the farm and grounds of the North Battleford Hospital, and treated patients as human beings with illnesses in need of help. A 500-hour psychiatric nurse training program was developed at Weyburn in 1947.
Led by Dr. Sam Lawson, the Saskatchewan Plan, a comprehensive proposal for all phases of emotional or mental treatment to be given within a health region, without recourse to a remote large mental hospital, was developed in the 1950s. A team would provide continuity of care within each region. Between 1960 and 1963, Dr. D.G. McKerracher at University Hospital, Saskatoon, showed that all types of mentally ill patients, including some psychotics, could be cared for in a small open psychiatric ward in that hospital, where selected, interested family practitioners were allowed to treat their own patients. Drs. Abram Hoffer and Humphrey Osmond, who incidentally coined the word “psychedelic,” were among the first to explore the biochemical basis of mental disease, and experimented with hallucinogens and nicotinic acid in treatment.
As part of an effort to catch up with other provinces in offering radium treatment of cancer, Saskatchewan went even farther and established the first cancer control agency in Canada in 1930. This agency set up, in Regina and Saskatoon, the first government-sponsored cancer clinics in North America; this public service later evolved into a position at the forefront of world clinical radiation science. In 1945, the Saskatchewan Cancer Commission and the University of Saskatchewan jointly hired Dr. Harold Johns, Canada’s first full-time cancer physicist; in 1949, Johns began the first concerted clinical use of the high-energy betatron in the world. Given funding and carte blanche approval by Premier Douglas, Dr. Johns and Dr. Allan Blair, radiation therapist in Regina, next developed treatment with a new modality, cobalt-60. Dr. Johns and graduate student Sylvia Fedoruk, later chancellor of the University and subsequently Saskatchewan’s Lieutenant-Governor, calibrated the cobalt machine in eleven weeks. The first patient was treated on November 8, 1951, for an advanced carcinoma of the cervix, deemed unlikely to be cured by any treatment regimen previously known. The patient received a precise dose to an exact area, was cured, and lived to the age of 90.
Why was Saskatchewan the leader in so many areas of health? Why did a member of Parliament from Prince Albert, John Diefenbaker, appoint in 1961 Mr. Justice Emmett Hall, Chief Justice of Saskatchewan , to head up the Royal Commission on Health Services, which recommended universal medical care for the rest of Canada? Why was a former Premier of Saskatchewan, Roy Romanow, chosen to lead the one-man Royal Commission on the Future of Health Care in Canada, which reported in November 2002? In fact, the province got off to a slow start. In the 1890s, a resident of what is now Saskatchewan had to go west to Medicine Hat or Calgary, or east to Brandon or Winnipeg, to obtain hospital care and to see most medical specialists other than surgeons. But there was unlimited faith in future prospects: when, in the early years of the 20th century, small hospitals were built, a number of them quickly developed nursing training schools. Medical practitioners settled in almost every town and village with a population of 200, and their lives intertwined with their chosen community. Their dedication gained them much respect, providing them with authority and community support to suggest and introduce many health care innovations.
There were six main elements that contributed to Saskatchewan’s pre-eminence in the healthcare field. First, the visionaries mentioned above acted as catalysts. Second, the citizens showed a co-operative spirit, trust, and a willingness to help one another that was perhaps developed to a higher and more practical degree than in any other province. Rarely did people have surplus cash, but there was an abundance of good will, of trust in one another, a willingness to help, and a sense that lives could be improved through communal effort. Mutual co-operation among 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; and the same philosophy applied to creating and nurturing community services and institutions.
Third, municipal politicians were forward-thinking and innovative, using the municipal structure to full advantage. The manager, then known as the secretary-treasurer, knew every farm and every farmer; he might or might not have a “stenographer” and a man to run a road grader and do odd jobs. The hospital was managed by the nursing matron, who would also rush a bedpan to a patient in need. Things were done efficiently, with a tremendous “bang for the buck.” Survivors of the Depression, severe drought, and dust storms of the Dirty Thirties, Saskatchewan’s residents were more frugal than many other groups, and much effort was voluntary—without pay. Fourth, rather than appointing commissions whose reports often gathered dust where they were shelved, provincial governments responded quickly to needs, often passing appropriate legislation at the next session of the Legislature.
Fifth, medical doctors in general were altruistic, with service to sick patients as their primary goal and money only a by-product. In private practice, through the 1930s, doctors collected for less than half of their services. Except for holidays and an occasional refresher course, most were on call 24 hours a day, seven days a week. Queues were non-existent. Hospitals were patient-oriented and lacked multiple layers of bureaucracy. Through the 1950s, it was the rule (as it was in Great Britain, at least until the 1970s) that once a patient’s name was placed on the morning’s operating “slate,” the doctors and nurses stayed until every surgery was completed, even if they ran into difficulty and ran several hours late. No one was “bumped.” A patient requiring a consultation with a specialist was almost always seen that same week. If there were no beds in the wards, the patient was promptly placed in a bed in a hospital ward corridor. Laboratory and x-ray examinations were done and reported within the week. Sixth, economic hardship, particularly during the 1930s, meant that virtually everyone was in the same predicament: there was rarely a discretionary dollar to spend, but most people did not perceive themselves as poor. An egalitarian spirit of co-operation and altruism formed the cohesive social fabric that helped to drive Saskatchewan’s leadership role.
C. Stuart Houston et John A. Boan
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——. 2003. “A Medical Historian Looks at the Romanow Report,” Saskatchewan Law Review 66: 539–547.
Johnson, A.W. 2004. Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961. Toronto: University of Toronto Press.
McLeod, T.H. and I. McLeod. 1987. Tommy Douglas: The Road to Jerusalem. Edmonton: Hurtig.
Romanow, R. 2002. Building on Values: The Future of Health Care in Canada. Saskatoon: Commission on the Future of Health Care in Canada.