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David Gagan and Rosemary Gagan, for Patients of Moderate Means: a Social History of the Voluntary Public General Hospital in Canada, 1890-1950.

David Gagan and Rosemary Gagan, For Patients of Moderate Means: A Social History of the Voluntary Public General Hospital in Canada, 1890-1950 (Montreal and Kingston: McGill-Queen's University Press 2002)

AFTER SEVERAL DECADES of lament from Canadian medical historians regarding the lack of an analytical history of Canadian hospital health care, David and Rosemary Gagan have produced a timely and well-argued survey of a major facet of this history: the rise and fall of the secular voluntarist hospital movement. They tell the tale of the transformation of the Canadian public general hospital, in which 19th-century medical charity was reshaped in the fires of scientific medicine and industrial efficiency. In the late 1880s, Canadian urban elites who were dismayed by the poor physical state of the underclass and inspired by philanthropic zeal created charitable institutions to nurse the indigent ill. As these institutions and their sponsoring cities grew in size and capability, however, so too did the aspirations of voluntarist hospital administrators and allopathic physicians.

Gagan and Gagan set the early 1920s as the point by which the medical welfare institution was transformed into a factory to mass-produce health care for all social classes. The charitable mandate, though muted, was still fulfilled, as patients were reconceived as customers whose fees produced enough profits to dispense a grudging, no-frills, "free" service to those who could not pay. Trustees collaborated with doctors to establish hospitals as the centre of the medical economy, using emotional marketing campaigns to attract customers to an expensive panoply of medical and nursing services and promising them "All the Comforts of Home Without the Errors of Love." (42) Along the way, doctors' grip on medical monopoly strengthened as they negotiated the near-exclusive right to use hospitals as their workshops and proving grounds.

In a surprisingly short time, however, in spite of the application of industrial-sector cost-saving measures, exploitation of apprentice nurse labour, and intensive lobbying to increase government funding, the skyrocketing costs of hospitalization overwhelmed the resources of "patients of moderate means," whose cash payments for private rooms and special extras constituted the backbone of hospital revenues. In the crucible of the Great Depression, when income from patients, philanthropists, and municipalities dried up, and newly indigent patients in desperate need filled admitting rooms, many public hospitals found themselves struggling to stay afloat. This resulted, in the authors' analysis, in a "failed vision" of accessible hospital care that met the needs of neither patients nor doctors until its rebirth through universal insurance initiatives beginning in the 1950s.

A key strength of the text is its usefulness in contextualizing current dilemmas regarding health care funding and distribution. What mission should health care institutions and medical knowledge serve in society? Who deserves to benefit from medical expertise and technology? Who should pay, and how much? (181) These dilemmas, the authors demonstrate, remained unresolved through the first half of the twentieth century, and were by no means put to rest by the advent of federal involvement in health care. What was determined between 1890 and 1950, as this book unequivocally shows, was the inadequacy of a health care system that relied primarily upon philanthropic largesse, miserly governmental contributions, and revenue extracted from the already-sick citizen. The cost of illness had to be distributed among the healthy in order to ensure accessibility to care, a realization that inspired many hospital authorities to lead the movement towards health insurance.

The historical evidence laid out by Gagan and Gagan also serves as a critical reminder of the tendency for orthodox medicine and North American society in general to invest heavily in short-term curative technology at the expense of "medico-social," "alternative," and preventive services that might more effectively address the determinants of health and quality of life. Hospital administrators, whose spreadsheets tallied average patient stays, per diem costs, and above all cures, envisioned the hospital's role as "an efficient factory for the production of scientifically mitigated health for public consumption at a fair price commensurate with its value." (11) They strove mightily to divest the community hospital of responsibility for all but financially healthy, acutely ill, and quickly curable patients. Doctors, who had little to gain financially or professionally by the practice of social medicine or the treatment of incurables and indigents, likewise sought to establish the hospital as a site for quick, lucrative, and increasingly specialized procedures. The aged, the insane, and the chronically ill, who were found disproportionately among the indigent, were persona non grata at the "temple of science," especially by the 1930s. (60) In the political economy of health care in the interwar period, the modernized hospital was reserved first for persons whose illness represented an immediate and reversible productive loss to society, or a potential profit to health care providers; those deemed beyond the reach of immediate medical intervention were shunted to under-funded custodial or convalescent care, where such existed.

Gagan and Gagan approach their "social history" with the assertion that "the social realities of the modern hospital became a microcosm of the social structures, processes, and conditions of everyday life." (7) In the service of this institution-as-mirror perspective, they outline the roles and relationships of philanthropists, administrators, physicians, nurses, and patients, theorizing that social relations and divisions outside the hospital shaped relations within it. For example, as the authors explain, a highly-visible legacy of this period of Canadian hospital history was the multi-tiered approach to patient care, in which patients were spatially and administratively segregated according to their social class and sometimes race. Patients from the lowest social rungs could expect to experience similar disadvantages and discriminations inside the hospital as they did in their daily lives. But the hospital, a prestigious institution run by community elites and supported by local and provincial governments, did more than passively reflect outside social structures. Systems of segregation and regulation embedded in hospital architecture, management, and policy (at times subverted by individual health care providers), recreated the ideology of "less eligibility" in the realm of health care and reinforced the notion that social hierarchies were natural and just and fiscally necessary. If hospital authorities imagined their institutions as guardians of Canada's physical and economic health, they also understood it as their public service duty to shore up the existing social order. Superior services available for a fee reassured paying patients that even in times of poor health their respectability and privilege would be upheld; unsavoury public wards, means tests, and "free" second-rate treatments reminded the indigent ill of their dependency and of the deference owed to their benevolent betters. To summarize, Gagan and Gagan seem to theorize segregation in the hospital primarily as a conservative strategy to address the economic pressures caused by the necessity for treating indigent patients. It also needs to be identified as a manifestation of an ideology of class difference predicated upon the idea that the needs and wants and rights of individuals differed according to their social positioning. The significance of this assertion is amplified as we witness the erosion of our idealistic (yet always incomplete) universal access health system in Canada. The neo-liberal claim that the survival of universal access demands free market distribution of the best health care masks an ideology that measures human worth and deservedness in economic terms.

In a history in which the built environment and workplace culture figure so prominently, the absence of images in this book is disappointing. Hospitals in this era produced reams of self-promotional material, much of it in image form, commemorating or announcing various events or public rituals. These productions were part of the deliberate effort by hospital boards to justify the exalted place of their institutions in the community and nation, and to sell their products and services to individuals and governments. Moreover, the social divisions that the authors see reflected in hospital administrative practice appeared most strikingly in the floor plans and decor of buildings like the ornate Private Patients Pavilion at Toronto General, or at the Muskoka tuberculosis hospital with its private and public wards half a mile distant from each other. The lack of photographic material is to some extent offset by a set of statistical tables that well illustrate many of the authors' points, and will be of considerable interest to researchers in the field of hospital history.

All told, For Patients of Moderate Means fills an oft-stated need for a critical survey of a key period in Canadian medical history, synthesizing a large number of smaller studies and older literature. Packed with detail, and drawing from a wide array of primary evidence, the text will undoubtedly prove useful to students of medical and social welfare history, and would serve well as an addition to public policy reading lists.

James M. Wishart

Queen's University
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Author:Wishart, James M.
Publication:Labour/Le Travail
Article Type:Book Review
Date:Mar 22, 2004
Words:1449
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