Should Doctors Be Rationed?
We can do without butter, sugar, tea, gas, but the sick can’t do without doctors—and there may not be enough to go round
I S THERE a doctor in the house?" The old jest would go very, very flat in hundreds of Canadian towns and villages to(lay, where doctors are as rare as new tires and a thou sand times more essential. Because we're up against the greatest shortage of doctors in civilian life in Canada since the flu epidemic of 1917. And heaveii help us, say boards of health in many hard-hit areas, if an epidemic strikes tomorrow. Why the doctor shortage?
Because your doctor has gone to war. Or else he’s bogged down trying to look after a greater number of patients for the doctors who have gone to war. Or he’s joined the staff of one of the big munitions factories or other war plants where a million Canadians work with machinery and materials that are often dangerous. Or he’s taken advantage of the gaps left in bigger and more desirable centres to move to the city and get established. And the younger men, who might have come out of the universities and started up in fields farther out, are going directly into the armed forces when they graduate. Eighty per cent of them are in uniform when they start their last year.
Take Lucky Lake, Saskatchewan, for example. It’s a farming district in the west of the province, about eighty miles from Saskatoon. Lucky Lake’s population isn’t very big, but you can widen the circle around it to include 7,000 souls, who haven’t a doctor within fifty miles. There used to be five or six in the area.
And Lucky Lake is only one of countless similar areas on the Canadian map from Vancouver Island to the Maritimes.
The shortage in Alberta is so acute it has been suggested that temporary license for civilian practice be granted to doctors stationed there in the armed services. More than half of Alberta’s remaining 380 physicians are over fifty years of age yet there are more than a hundred military age doctors stationed in the province in the Air Force and Army.
Thirty-seven per cent of Manitoba’s medical men under fifty years of age are on active service.
In British Columbia so many doctors have joined up that the Provincial Medical Association thinks it may be necessary to plan their own reallocation of available physicians, and is now trying to muster sufficient authority to do so. The fact that a hundred more doctors want to join the
330 already in the armed forces means that 530 would be left to do the work formerly covered by 860; and the situation, particularly in the Caribou district, has reached emergency proportions.
A survey made in Quebec recently shows that there are more than twelve thousand municipalities, parishes and rural communities which have no doctors.
Nova Scotia is planning an intensive study of group medicine schemes in search of an antidote to the shortage. Halifax and Dartmouth before the war had ninety-two doctors for a population of 70,000. Now they have seventy-one civilian doctors to serve a population of 115,000.
Every province has its distress areas, and if you happen to live in one of them, the whole picture narrows down to this vital point: you, or some of your family are dangerously ill, and you can’t get a doctor.
Who’s to blame and what’s to be done about it?
Priorities On Doctors
WAR IS doctor-snatcher number one. For every thousand men and women in the armed forces, four doctors are needed. Families of the men who go to battle won’t argue with that need. A country which must drain its civilian population of the finest young men and women for fighting must safeguard that most valuable asset with the best possible equipment. Medical care is a big part of that equipment, and the doctor does the top salvage job in the war effort. So the folks back home must get by with what’s left.
Subtract the men needed for war industries afid research, and the country is left with fewer than 7,500 of the 10,000 Canadian doctors who held licenses to practice at the beginning of the war. At that time we had a fairly good proportion— roughly, one doctor to every thousand population. Now the proportion is less than one to every 1,333. True, a few older men are coming back from retirement to fill emergencies. But the hundreds of young men graduated from Canadian universiContinued on page 37
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ties each year are going, with few exceptions, directly into the armed forces. So, not only is our source of supply cut off, but since the universities cannot supply all their needs, even with the six year course telescoped into five, the Army, the Navy and the Air Force will continue to draw from the pool of practicing physicians. To the present strength another eight hundred doctors in uniform are needed by next July. And as the armed forces themselves grow, the Medical Corps will keep pace with them.
Therefore we civilians cannot get any more doctors. In fact, we will have fewer and fewer. Men like Dr. T. C. Routley, who was secretary of the Canadian Medical Association before being loaned to the Government as chairman of the Procurement and Assignment Board, and Dr. J. W. McCutcheon, secretary of the Ontario Medical Association, will tell you that our only hope is in making the best possible use and allocation of the ones we have, and can keep.
How can we cope with situations like this one, which developed in Ontario, but could be matched over and over in every province of the Dominion? A farmer who lived three miles from Bala took a very ill child to town for medical attention. He felt it would be impossible to get anyone to come out. There was no doctor in the town. So he drove seventeen miles to Gravenhurst, to find the only remaining doctor ill. He drove on to Orillia, a farther distance of twenty-two and a half miles, and finally, after four hours on the road and a journey of over forty miles, found a doctor. What would have happened if he hadn’t had a set of runnable tires on his old car is unpleasant to conjecture. That, in the province which has a bigger population and more doctors than any other in Canada!
It’s the Villages That Suffer
WHILE overcrowding and bad housing has put an extra load on the remaining doctors in many cities, it is the rural area and the small municipality or village that are suffering lack of medical care most acutely. Halifax, Windsor, Ottawa, Vancouver, Edmonton, Kingston and many other cities are so overcrowded that the Government has stated the housing situation to be one that is “dangerous to health and morale.” Yet by adding burdens to the doctors, hospitals and health services of each community, and cutting down wherever possible on overlapping of services and “luxury” care, the situation in the cities can be met.
But the country districts need more doctors, and need better allocation of the services of their present doctors. In Ontario, although fortyone per cent of the people live in municipalities of less than 1,000 population, only twenty-five per cent of the doctors are said to practice in such areas. Dr. Jean Grégoire, Deputy Minister of Health for Que-
bec, says that forty per cent of the people of that province live outside the towns and cities, yet they get only thirteen per cent of the doctors.
Britain, which has conscripted her doctors as she needed them, and allocated others to the best advantage of the population as a whole, considers that the rural areas need one fifth again as many doctors, per population, as the cities do. This, of course, because of the greater distances to be travelled in the country.
Yet Canada is allowing hundreds of her rural practitioners to be sucked into the cities, other hundreds to enlist, when the proportions are already so heavily weighted in favor of the cities, and when the distances to be travelled are greater than any ever dreamed of in Britain.
Recently the Ontario Medical Association, through its official bulletin, issued an “urgent appeal” to the younger doctors who practice in cities and towns to join up. It said: “The country doctors in Ontario have enlisted very much out of proportion to their numbers and there are few rural areas which can now spare any more.”
But most authorities at the head of government or civilian medical bodies will tell you—although they cannot be quoted officially—that more than an urgent appeal is needed to right the situation at this time. Their suggestions, when given uncensored, are for everything from compulsory selective service to the milder and less effective system of zoning.
Doctors still in private practice have their own points of view. So long as their practice (and livelihood) must be determined by economic interests rather than social need, they must get established to the best advantage. With many doctors leaving the cities for overseas, doctors in outlying areas have an opportunity to come in to the cities and get established. Many of them have children of high school age, and wish to give them the advantages of more cosmopolitan living. Others recall with some bitterness that when they returned from the last war, they had to make a difficult new start, often in rural areas which they are now being criticized for leaving. They will remind you that thirty-five per cent
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of all Canadian doctors were in uniform “last time” and that this service had the highest casualty rate of any branch.
On the other hand, those who are considered to be essential in their areas by the Canadian Medical Procurement and Assignment Board, and are therefore not accepted for military service, feel that they have the right of every Canadian to serve their country on the fighting front, if they so wish. And Navy, Army and Air Force medical authorities point out that with every military hospital in Canada full to the rafters in fall, spring and winter, and the doctors put to other duties in slack times in summer, the armed services are as strenuous as civilian practice, if not more so.
BUT it is the medical men themselves who have taken the first big steps toward a solution. Whether or not that solution is followed to its final conclusions will depend upon the pressure put forward by the people of this country.
In other words, by you.
Here’s how the situation stands at present. Shortly after war broke out, the Canadian Medical Association questionnaired its membership as to their possible service in the armed forces. On the strength of the nine thousand replies received, it offered the services of Canadian doctors to the Government. That was back in 1939.
It was not until last July, three years later, that the Government became really alarmed over the situation arising out of the haphazard enlistment of doctors, and decided to accept that offer.
So an Order in Council was passed calling into being the Canadian Medical Procurement and Assignment Board, with Dr. Routley loaned by the Canadian Medical Association as its chairman. Staffed by representatives of the Medical Association, branches of the armed services, Selective Service, National War Service and Pensions and National Health, its job was to find doctors for the Navy, Army and Air Force without impairing public health services.
That board was given the power to refuse enlistment to practicing physicians and surgeons who were considered essential in their own districts; and already many such have been turned down. However, the farsighted and alert Dr. Routley took his chance to make what he calls “the greatest stocktaking and inventory of health resources ever done in any country.” Today his committee has under way a mammoth survey of the medical profession, the fighting forces, public health services, hospitals, nursing, dentistry, medical schools, medical research, industry, urban municipalities and rural municipalities and services such as the Red Cross and the Victorian Order of Nurses. When the findings are all put together and sorted out in proContinued on inside back cover
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vinces and areas, the Canadian health picture will be complete for inspection and diagnosis, both for now and for a possible sudden emergency. For the committee hopes to work out a “skeleton” health service which would care for the country in case of actual fighting in Canada, as well as a longer-view solution to the whole problem of medical care in war and peace.
For the long view, health insurance is looked upon by the medical profession as a possible solution; not only to civilian needs, but to the employment problems of the profession after the war. State medicine is favored more in civilian and socialist groups than in the profession, and complete control of the profession by the State is as moot a question as any other state control in a democracy.
And while these plans are being discussed and debated, this is the new year of 1943, there are no doctors in Lucky Lake, Saskatchewan, and an epidemic may break out at any time there or in any other of the doctorless areas of the country.
SO IMMEDIATE solutions, or at least palliatives, are being considered. Medical authorities are generally agreed that some form of at least mild rationing is now necessary to spread the supply of doctors around. The Placement and Assignment Board can keep men out of the Army, but it cannot direct them to new and more important fields than the ones in which they labor. Compulsory selective service would place doctors in essential posts, but the Government has indicated that any measure to this effect would immediately be labelled as class legislation, and meet with plenty of trouble.
The Canadian Red Cross has a good scheme for Community Doctor Services which is already working successfully in some Ontario points and could be extended nationally. The Red Cross, if requested, will go into a community, set up and administer the Community Services.
Members of the community voluntarily become subscribers for themselves and their families and guarantee the doctor four thousand dollars a year. This sum is made up from subscribers’ fees, private practice fees of residents who are not subscribers, municipal contributions for health officer services, and fees for coroner services. The Red Cross surveys the community which wishes the service, and sets subscribers’ fees at a rate necessary to finance the plan.
The Ontario Medical Association has suggested zoning for emergency calls and says “there is no reason why a doctor should go fifteen miles and use up good tires and gasoline if a lady who faints lives only a mile from another doctor. The county society executives (Medical Association) can map out the zones. When the zones are made definite, a copy should be given to each doctor, to the
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telephone offices, the fire halls and the police stations.”
This scheme could be applied later for ordinary day visits too. Another point the Association suggests is doing away with “luxury care,” and says this on the subject:
“Neuroses are less common in wartime for the simple reason that most people are working. They have less time to think about themselves and their various organs. There will still be some who demand unnecessary attention; but the question should be, not ‘Does the patient want me?’ but ‘Does he need me?’ Luxury medical care is out for the duration.” Finally, the Association suggests that doctors be transferred from cities to rural areas. “Retired practitioners could be persuaded to volunteer for this emergency; or the Red Cross Community Plan used ; or the Medical Procurement and Assignment Board given authority to make transfers and allow subsidies in poorer communities.”
BRITAIN has already taken such authority, and has transferred many doctors from one area to another. Britain can do that, for the system of recruitment is compulsory. It was decided in the first year of war that enlistment of doctors on a voluntary basis did not work. So today Britain has legislation so that she can decide how many doctors she needs for the armed services, and how many she must leave behind, and where they are most needed. She keeps one civilian doctor on hand for every 3,000 people in the cities, one for every 2,400 in rural areas. Besides that, emergency hospitals and the doctors who operate them are used in raidless periods for the treatment of chronic civilian cases and operations other than emergencies.
Finally, Britain has given her medical men confidence in whatever move she deems necessary by providing an excellent and judicious system of appeals. She has also protected the practices of those men who are serving in the armed forces. In Britain the stay-at-home doctor who takes over the warrior doctor’s practice must bank half the fees received from patients of the absent doctor, to be returned to him or his heirs after the war; and he must also agree not to treat any of his “adopted” patients for one year after the warrior doctor’s return to his practice.
This system, with zoning of calls and restrictions to the public on the services of medical men to avoid overlapping, is keeping Britishers healthy and well cared for in spite of the drain on the medical profession.
It looks as though Canada would have to head for something similar if we are to keep our home front as well as our battle front toeing the health line.