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Health care in Québec in the second half of the 20th century
By Mathieu Pigeon, under the supervision of Dominique Marquis, internship director, Université du Québec à Montréal
Medicine and health care have undergone tremendous change since the start of the 20th century. Thanks to a number of major medical discoveries, progress has been made in hygiene, scientific knowledge and technology. In the second half of the 20th century, many Western countries set up universal public health care systems. As a result, the public in Québec and the rest of Canada now benefit from free health care and social services.
Before the 1960s, even though health was a provincial responsibility, the Québec State was virtually absent from the health care field, abandoning it to the private sector. The State took care only of the destitute, leaving most Quebeckers without any form of social protection. Religious orders played a major role in providing health care and running most Québec hospitals. Public information and vaccination campaigns were often organized by municipalities. Beginning in the very early years of the 20th century, municipalities became very concerned with public hygiene, especially in old working-class neighbourhoods, where sewer and water-supply services were inadequate and people often lived in overcrowded, unsanitary conditions. The establishment in 1911 of Gouttes de lait, or milk stations, which provided mothers with advice as well as quality milk for their babies, was a good example of the initiatives authorities took to improve the overall health of their citizens. At the dawn of the 1960s, almost half of all Quebeckers had no private medical insurance and so could not afford a lengthy stay in hospital or an expensive operation.
Québec in better health
Despite the shortcomings of the Québec health care system, sanitary conditions improved greatly in Québec after World War II (1939-1945). Whereas in 1941, tuberculosis was killing close to 81 of every 1,000 people, by 1961, deaths from this disease had dropped to just 7 per 1,000. This progress was due in part to advances in medical research and new technologies, including the widespread use of antibiotics. Such innovations meant that doctors and nurses required more extensive training. The postwar period also saw a great deal of hospital construction in Québec, with the number of establishments more than doubling between 1945 and 1960. By the end of this period, most medicine was being practised in hospitals. One of the most telling examples of this new trend was the medicalization of childbirth. The number of women giving birth in hospital soared from just 16% in 1940 to over 98% by 1965.
New role for the State
The reforms of the Quiet Revolution, inspired by the concept of the welfare state, brought radical change to the Québec health care system. The government took on a greater role in several areas of society, including health care and social services, in an effort to reduce social inequality. The Boucher Study Committee on Public Assistance, set up by Liberal Premier Jean Lesage (1912-1980), recommended increased State intervention in health care when it submitted its report in 1963.
On coming to power in 1960, the provincial Liberal government wasted no time before taking action. In 1961 Québec joined the federal hospital insurance program, which was a first step toward establishing a public health care system. In 1966 the federal government continued its reforms, setting up a shared-cost health insurance program.
Concerned about ensuring its autonomy in the health care sector, the Québec government decided not to join this new program. Instead, that same year, it established the Castonguay-Nepveu Commission to ascertain the situation of health care and social welfare in Québec and examine the question of whether the province should establish its own health insurance program. The Castonguay-Nepveu Report proposed a complete overhaul of Québec's health care system. The commissioners recommended establishing a comprehensive health care system that would take into account the relationship between social conditions and health. They also recommended that the system be fully managed and funded by the State and that all care and services be universal and free of charge. Brought in by the Liberal government under Robert Bourassa (1933-1996), the Health Insurance Act was passed in July 1970. The resulting program covering all care and services constituted the backbone of the new Québec health care system. These reforms also focussed on improving social conditions, free access to care, and prevention. To achieve these objectives, Québec introduced a range of social policies in the 1970s and established a number of facilities, such as CLSCs (local community service centres), to strengthen the health care network.
Doctors' expertise lies at the heart of the progress made in health care. Recognition of their know-how grew throughout the 20th century, as people resorted less and less to quacks and non-scientific treatment. As early as 1909, future doctors were being put through a specific five-year training program that included study of the most recent scientific discoveries. In the 1940s, the many advances in medical science forced doctors to specialize. Since the 1960s and the progressive establishment of a public health care system, the State has exercised greater supervisory control over medical practice and physician training. Today, doctors must complete at least six years of training and have access to continuing education.
While doctors are a fundamental component of the health care system, the work performed by nurses is just as essential. The first French-speaking lay nurses entered the job market in the 1940s. Still, members of religious orders constituted the majority of hospital staff until the early 1960s. It was the religious orders who taught in the nursing schools affiliated with hospitals. Another option open to French-speaking students was the Institut Marguerite d'Youville, founded in 1934, which was run by the Grey Nuns and offered more advanced training in nursing. Québec's English-speaking universities had been running nursing programs since the first half of the 20th century. Following on from the reforms in the Québec education system in the 1960s, the State took over responsibility for nurses' training to ensure quality standards were maintained in health care throughout Québec. The college (cégep) nursing program replaced the training provided in nursing schools, while the Institut Marguerite d'Youville became affiliated with the Université de Montréal and began to offer a university-level program in nursing. These two educational career paths still exist today.
The political and social environment of the Quiet Revolution was more favourable to Québec workers. The public health system became the largest employer in the province, and the people who worked in it made substantial gains when large numbers of them joined unions. The main Québec union federations, such as the Confederation of National Trade Unions (CNTU), the Québec Federation of Labour (QFL) and the Centrale des syndicats du Québec (CSQ), are significant players in the Québec health care sector. In addition, certain professionals such as general practitioners and nurses are represented by professional associations or unions that defend the specific interests of their groups.
Since the 1980s, Québec, like many Western societies, has seen the costs of funding its public health care system skyrocket. This situation is due essentially to the aging of the population, overconsumption of health care services, the costs of medication and new treatments, and the continual need to upgrade facilities and equipment. In the late 1980s, the Québec government began reorganizing the health care system by shifting to ambulatory care in an effort to cut spending. Some health care institutions were closed or amalgamated, while others were assigned new functions. Some budget cuts have affected the quality of the services provided to patients. Despite the cuts, health care now accounts for 45% of the provincial budget, and this percentage should continue to climb because of the aging population. One of the solutions put forward to solve this problem is to allow the private sector a larger role in delivering health care. But that option represents a major decision for Québec society, as it calls into question a fundamental principle of the reforms of the 1960s and '70s, which was to provide health care free of charge.
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Université de Sherbrooke, Bilan du siècle, http://www.bilan.usherb.ca/
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