Socialized Medicine Began In Alberta

'Alberta sets the agenda for Canada'
Jean Charest 1996

HEALTH CARE REFORM OR MANAGEMENT REFORM

When we hear about reforming health care in Canada what is the real debate about? Control of hospitals and infrastructure. There is no real challenge to how medicine is taught, or what the aims are of the doctors and their guilds in keeping retrictions on how and who gets taught medicine. As the article by Michael D. Yates points out the crisis in Nursing is not just occuring here, but in the U.S. indeed, Canadian nurses have been cutback by provincial governments for the past decade, they have easily found work in the US, because of the need for front line workers there. So where have the nurses gone here in Canada or in the US when they aren't in the front-line, into management.

In preparing to write this article, I interviewed a Canadian nurse, an activist in her union, with more than thirty years experience. I also read an informative article by Gordon Lafer (“Hospital Speedups and the Fiction of a Nursing Shortage,” Labor Studies Journal 30.1, Spring 2005: 27-46). Lafer tells us that

Nurses may constitute the single most dissatisfied profession in the U.S. . . . When one recent survey asked nurses to describe how they felt at the end of the day, nearly 50 percent reported feeling "exhausted and discouraged." Forty percent felt "powerless to affect change necessary for safe, quality patient care"; 26 percent felt "frightened for [their] patients," and 24 percent felt frightened for themselves. Perhaps most disturbingly, 55 percent of nurses reported that they would not recommend a nursing career to a child or friend. (p. 32)

My Canadian nurse informant gave me chapter-and-verse verification of what Gordon Lafer reports in his article. She reported to me that patient loads (patients are now called "clients") have risen to unconscionable levels. She now works in a long-term patient care facility, where most patients require acute care. Last year there were four Registered Nurses plus some nurses' aides for 32 patients. Today there is one RN for 107 patients. Much of an RN's time is spent filling out forms for funding purposes, and most of the nurses' patient-centered activities are done by less-skilled aides and machines. This means that the nurses' knowledge of their patients, knowledge which can save lives, has been lost. Senior nurses have been laid off or encouraged to take early retirement, and they are either not replaced or replaced with student nurses. This has led to occasional disasters. In the past, student nurses had senior mentors and learned how not to make mistakes. Now they are on their own, and their failure to see warning signs obvious to an experienced nurse costs lives.

Like the colleges, hospitals are top-heavy with highly-paid administrators; when hospitals merge, the number of workers decreases relatively much more than the number of administrators. And as in colleges, administrators are primarily money managers, concerned with the bottom line and not with the health of their "clients."

One final point the Canadian nurse made is that nursing students are now being trained in a system far different than the one in which she was trained. Their expectations are not to become care givers but to become middle managers. So the system creates the people best suited to it. What was will soon be lost forever, unless the nurses' unions and the larger labor movements struggle for change.

Let's Put the Nature of Work on Labor's Agenda: Part Three
by Michael D. Yates

The healthcare reform movement has not addressed the basic fundamental need to completely restructure health care delivery for the good of people and not for profits of the medical establishment and their bueracratic institutions. Medicine, and medical delivery has never been devised by the people who use it or even those who fund it. Medical delivery is part and parcel of the monopoly of the medical establishment, the good old boys who run the Provincial Medical Associaions and the College of Physicians and Surgeons in each province.

The Canadian Medical Association while created in Ontario was to become dominated by the Alberta Medical Association, due to the advanced development here after Alberta became a province.

Which physicians from Alberta have become Canadian Medical Association presidents?
Answer: Drs. H.G. Mackid (1911-12), J.S. McEachern (1934-35), A.E. Archer (1942-43), H. Orr (1950), M.A.R. Young (1957-58), R.M. Parsons (1960-61), R.R. Thomson (1966-67), L. Grisdale (1975-76), T.A. MacPherson (1984-85, R.J. Kennedy (1992-93). All were presidents of the Alberta Medical Association beforehand, except for Dr. H.G. Mackid.

THE SOCIAL HISTORY OF SOCIALIZED MEDICINE IN ALBERTA

The first hospitals in Alberta were private, operated by the Catholic Church. But we the people in Edmonton developed our first public hospital, with an elected board, which was to become the the Royal Alexandera Hospital.

Edmonton Public Hospital at 96th Street and 103A Avenue in 1900.

The public hospital operated until the new Royal Alexandra Hospital opened in 1912.

On the south side, the University of Alberta decided to solve the problem of the sick in rural communities by establishing a medical faculty in 1912. Next year, the Strathcona Hospital opened for business. It became the University of Alberta Hospital in 1922.

100 Years of Medicine in Alberta: The Regions First Hospital

Every civic election until the 1960's when an appointed board took over, saw the election Hospital Board Trustees as well as School Board Trustees, Mayor and City Aldermen. In fact during the 1930's when labour ran city hall aldermen sat on city council and as both school board and hospital trustees.

The first act of the new Alberta Government was to recognize the monopoly of Doctors as a profession and guild in charge of medicine in the province. It was a recognition of their education, training and professional status. And of course their political power, as many were active in the governments of the day and in the ruling political parties. In civil society they were involved in the police forces, the founding of the University of Alberta and in fraternal orders such as the Freemasons, who were highly influential in Alberta's development as a province. They were in fact 'hegemonic' ,as Gramsci called it, within the newly constituted State in Alberta . They had a view of civil society that was based on social need, as a meritocratic order they used their status in society to promote social medicine for the province and the country.

Under the Liberal provincial government 1905-1908, the earliest acts they passed were those recognizing the University of Alberta, the Grand Lodge of Freemasonry, and the formation of the Alberta Medical Association, and the creation of the College of Teachers. Thus the state and civil society became one in Alberta one hundred years ago.

Human progress is our cause, liberty of thought our supreme wish, freedom of conscience our mission, and the guarantee of equal rights to all people everywhere our ultimate goal. -- The Scottish Rite Creed

MACKEY'S FREEMASONRY ENCYCLOPEDIA

Grand Lodge of Manitoba and the Northwest Territories

Northern Light Lodge was granted a Dispensation in 1864 by Brother A. T. Pierson, then Grand Master in Minnesota. The new Lodge was organized at Fort Garry (Winnipeg) with Brother Dr. John Schultz as Worshipful Master but it ceased to exist after a few years' work. When Red River Settlement, as it was then called, became the Province of Manitoba the Grand Lodge of Canada assumed Jurisdiction and chartered Prince Rupert's Lodge, Winnipeg, in December, 1870. Prince Rupert, Lisgar, and Ancient Landmark Lodges held a Convention on May 12, 1875, and formed the Grand Lodge of Manitoba with the Rev. Dr. XV. C. Clarke as Grand Master. Until the Provinces of Alberta and Saskatchewan were established and created Grand Lodges of their own the Grand Lodge of Manitoba controlled the Craft in the Northwest Territories and the Yukon Territory as well as in Manitoba.

ALBERTA

(Canada). The Grand Lodge of Manitoba had jurisdiction over the Lodges in the Northwest Territories of Canada but the division of these into Provinces, on September 1, 1905, influenced Medicine Hat Lodge, No. 31, to invoke the oldest Masonic Body, Bow River Lodge, No. 28, to call a preliminary Convention at Calgary on May 25, 1905.

This was followed by another meeting on October 12, 1905, when seventeen lodges were represented by seventy-nine delegates, the Grand Lodge of Alberta was duly organized, and Brother Dr. George MacDonald elected Grand Master and was installed by Grand Master W. G. Scott of the Grand Lodge of Manitoba.

Perfection Lodge in Calgary Perfection Lodge,Calgary, was instituted on the 26 day of June 1894 by M.W.Bro Dr.N.J. Lindsay. The population of Calgary at that time was about 3,000. One of the charter members of Perfection Lodge No. 60, A.F.&A.M., G.R.M. was: Dr. Harry Goodsir Mackid, MD, FACS 1858-1916, who is signed in the lodge book as H.G. McKid (spelling mistake).

The commencement of Dr. Mackid’s practice was significantly augmented by his 1890 appointment as the CPR surgeon for the Calgary division (Regina to Calgary). That same year he joined Dr. Lafferty in a contract with the CPR for medical care during the construction of the Calgary-to-Edmonton railway. This lasted a year or until the railway was completed in 1891. For the next 22 years, Dr. Mackid was the chief CPR surgeon for the entire division until it was split in 1912 and a Regina-based appointment was made.

Dr. Mackid could rightfully be called the Father of Medicine by Rail in Western Canada. He would venture to Medicine Hat or Red Deer to provide emergency care when the patient could not be transported by rail from these centers, Fort MacLeod or Lethbridge.

The senior Mackid led the movement to build hospitals in Calgary. The NWMP built the first hospital in 1877, which consisted of 10 to 13 cot beds, and provided care to everyone. In 1890 Drs. Mackid and Lindsay, with $100 from a Chinese immigrant’s estate and a community canvas undertaken by Bishop Pinkham’s wife, opened the eight-to-12 bed Calgary General “cottage” hospital. Mrs. N. Hoade was matron.

It was only the second NWT incorporated and approved hospital and it opened one year after the Medicine Hat facility. The first admission was a patient with typhoid fever. Three months later, in 1891, Dr. Mackid admitted the first patient to the four-room, six-bed temporary hospital, the next year a three-story, 25-bed Holy Cross Hospital.

Dr. Mackid was appointed coroner for the city of Calgary in 1891. But all too soon Calgary was short of beds again because of its rapid growth. Dr. Mackid helped organize another community group to petition for a larger public general hospital. This led to the construction of the new 30-bed Calgary General Hospital in 1894-95. His wife organized the fundraising campaign to equip it

Pioneer Doctor And Freemason Of The West
Edward Ainslie Braithwaite, M.D., L.M., C.C..
by O.P.Thomas P.D.D.G.M.

When contemplating the history of Western Canada, one of the features that seem to stand out so definitely is the accomplishments that have been achieved as the result of the efforts and initiative of certain individuals. This brief history is based on the life of one of the outstanding pioneers of the west, particularly, Alberta, Dr. Edward Ainslie Braithwaite.

He took his discharge from the N.W.M.P. on May 6, 1892, with the rank of Staff Sergeant and came to live in Edmonton, where he went into practice as a Physician and Surgeon. He was appointed acting surgeon to attend to the personnel of the Northwest Mounted Police detachment at Edmonton. He was made the Health Officer of the Town of Edmonton, and, later, the City of Edmonton, in 1892. He was also a Coroner for the North West Territories at Edmonton, and, upon the formation of the Province of Alberta in 1905, he continued in this capacity, becoming the Chief Coroner and Medical Inspector for the Province of Alberta, in 1932. He retired from this office a year before his death, in 1948. His record of nearly fifty-two years as a coroner is unequalled in Canada. He presided at more than eightthousand inquests. The office or coroner and medical inspector has always been a highly responsible one, and, in the early days, with long trips in the most inclement of weather, as well as the dangers or poor roads and the possibility of becoming lost, a highly hazardous one. This can be realized more if you take into consideration the poor conditions for travel in the large area to the north of Edmonton. It is due in a large measure to the indefatigable work of Dr. Braithwaite that this important branch of medical supervision was established so soundly in the Province of Alberta.

While he was a contract doctor with the N.W.N.P. from his retirement from active service, he was appointed full Honourary Surgeon in the Royal North West Mounted Police with all the rights of that Office, in September, 1911. He served with the N.W.M.P., the R.N,W.M.P. and the R.C.M.P. for almost forty-eight years, having been awarded the Long Service Medal in 1927. His association with the R.C.M.P. extended for a period of 65 years.

In 1892 he entered into Private Practice in Edmonton. It is interesting to note that among the many patients that he had in this city, the first native-born (that is, born in Alberta) Grand Master of the Grand Lodge of Alberta, A.F. & A.M., first saw the light of day with the assistance of Dr. Braithwaite. When this boy grew up he was Master of Edmonton Lodge #7, G.R.A., and had the pleasure and honour of presenting Dr. Braithwaite with his 50-year Jewel. In the early days, with Dr. Whitelaw, who later became the Health Officer for the City of Edmonton when he took over from Dr. Braithwaite, and Dr. Blais, who later became a Senator from Alberta, he used to go to St. Albert, where the first hospital was opened. There was no hospital in Edmonton, itself, for sometime. When the General Hospital was opened in Edmonton he had the first patient who admitted to it. When the rush to the Klondike took place many started out from Edmonton to go there. As the result of this a railway was started to go from Edmonton to the Pacific by way of the Yukon. It was called the Edmonton, Yukon and Pacific. When they started to build it from Strathcona to Edmonton he was appointed Medical Officer. At the time that the Canadian Northern Railway built into Edmonton, in 1905, they decided to buy the E.Y. & P. so as to make a quicker route to Calgary for their passenger service. At the same time, they appointed Dr. Braithwaite as their Medical Officer in Edmonton and he continued in this work until about the time of the First Great War. He was made the first Commissioner of the St. John’s Ambulance for the Province. While he had been a coroner for the Province of Alberta, in 1932 he was made Chief Coroner for the Province, as well as Medical Inspector of Hospitals. Because of his work in the medical field, and his interest in the Dominion Medical Council he was chosen to represent Alberta on this Council. He was active in the Canadian Medical Association, being the President for a term. He enlisted in the Canadian Army Medical Corps at the beginning of the First Great War but was injured shortly afterwards and resumed his practice in Edmonton. During this War period he made it a policy of his not to accept any fees from the family of any enlisted man who came to him for medical services, if this man was overseas.

He had a long distinguished career in Freemasonry. When he arrived in Edmonton the only Lodge was Edmonton #53, G.R.M. Freemasonry in Edmonton had had a rather hesitant beginning. Saskatchewan Lodge #17 under the Grand Lodge of Manitoba, which took in all the area that is now Manitoba, Saskatchewan and Alberta, had been started before the Riel Rebellion. As the result of this Rebellion and the unsettled conditions around Edmonton they had had to surrender their Charter. When things became more settled, and a steady growth started to take place in Edmonton, another Lodge was formed and is in existence to the present time. This was Edmonton Lodge #53, G.R.M.. In January, 1897, another Lodge was formed on the south bank of the North Saskatchewan River, in Strathcona, a town that had sprung up as the result of the Canadian Pacific Railway running trains into it. This Lodge was also under the Grand Lodge of Manitoba and with the assistance of the members of Edmonton Lodge #53 became Acacia Lodge #66 under the Grand Lodge of Manitoba. It was into Edmonton Lodge #53, G.R.M. that Edward Ainslie Braithwaite was initiated on May 19^th, 1893, passed on July 7, 1893 and received his Third Degree on September 1, 1893. The interest that he showed in Freemasonry in those days abided with him as long as he lived. He was made Master of Edmonton Lodge #53 G.R.M. for the year 1898. In 1899 he was the Grand Steward of the Grand Lodge of Manitoba and was elected the Grand Registrar in 1900. In 1901 he was elected Grand Senior Warden, Deputy Grand Master in 1902, and Grand Master in 1903. He affiliated with Northern Light Lodge #10 in Winnipeg, on November 15, 1906, from Edmonton Lodge #7, G.R.A..

When the Grand Lodge of Alberta was formed in 1905, the year Alberta became a Province, he was the Senior Grand Master of the Grand Lodge of Alberta. He also took an active interest in the Scottish Rite Freemasonry. He had become a member of the Scottish Rite in the Valley of Winnipeg previous to 1904. In 1904 he was a charter member, and the first Thrice Puissant Master of the Lodge of Perfection of the Valley of Edmonton. He was also a charter member of the Mizpah Chapter of the Rose Croix in 1907. In addition to this he was instrumental in the formation of the Alberta Consistory and was the first Commander-in-Chief, in 1910. For his outstanding service to the Scottish Rite he was coroneted 33 degree Honourary Inspector-General at Winnipeg in 1911. He was elected to Active Membership in the Supreme Council at Hamilton in 1918 and on October 25, 1917 was appointed Illustrious Deputy for the Province of Alberta. He held this office until 1945, when he retired because of ill health. At this time he was retired to Past Active Rank. When he passed away, in 1949 he was the oldest member of the Supreme Council for the Dominion of Canada. He was also a member of Al Azhar Temple of the A.A.O.N.M.S..




The Grand Lodge of Alberta, Ancient Free and Accepted Masons was constituted and consecrated on the 12th of October 1905 and was confirmed under an Act of the Province of Alberta passed in the Legislative Assembly in 1908.
At that time, eighteen Lodges withdrew from the jurisdiction of the Grand Lodge of Manitoba, taking with them a combined membership of 1,013. Our daughter Jurisdictions of Saskatchewan and Alberta both of whom are interested in the early development of this Grand Lodge, have each in this Jubilee year [1925] a membership and Lodge Roll in excess of the mother Grand Lodge, the figures in each case being:Grand Lodge of Alberta as at 27th December, 1924, had 130 Lodges with a membership of 12,329.
137767 08-17-91 History of Grand Lodge of Alberta

HEALTH CARE IN ALBERTA A CHRONOLOGY

1905 Alberta's Medical Profession Act passes after Alberta becomes a province.

1906 The College of Physicians and Surgeons of Alberta (CPSA) is formed in Calgary, covering physician licensing and discipline. Shortly after the meeting the Alberta Medical Association (then known as the Canadian Medical Association, Alberta Division) is formed, acting as an educational body. It also is to be involved in standards of medical care and acts in concert with CPSA.

1907 -1908 When the Calgary General Hospital encountered serious financial difficulties in 1907, Dr. Mackid organized a prepaid medical and hospital plan with all the CPR employees at 50 cents per employee, per month in 1908. It covered 3,000-5,000 CPR employees. Although the deductions or amounts varied over the succeeding decades, the plan was continued until MSI took over the contracts in the early 1950’s.

1910-19 At the request of the AMA, CPSA contributes funds to establish a provincial sanatorium for tuberculosis treatment.

University of Alberta (U of A) takes over from CPSA to license physicians during this time of many unqualified and self-styled healers. Within a year of this, the U of A begins instruction of medicine and CPSA offers scholarships.

The public health nursing service is established to carry out preventive health care and public health education at the urging of physicians, concerned with insufficient numbers of physicians in Alberta.

1920-29 AMA recommends physician appointment to the Workmen's Compensation Board (WCB).
CPSA retains licensing and discipline functions and takes over the "business" side -- dues, representing the profession in relation to legislation. The AMA becomes responsible for education and public relations.

A grant to Dr. J.B. Collip's studies helps lead to insulin discovery.

CPSA and CMA sponsor health services investigation.

1940-49 AMA supports prepaid medical care or health insurance. Extensive development by the profession is followed by government-created Medical Services (Alberta) Incorporated (MS(A)I), providing more than 90% of Albertans with prepaid medical care until replaced by compulsory federal medicare in 1969.

80% physicians responding to AMA-conducted referendum favor prepaid medical care.

MEDICAL FAQS ABOUT ALBERTA

When was the first medical school west of Winnipeg organized and when did it become a full four-year MD granting program?
Answer: At the University of Alberta in 1913. A full MD program started in 1921 with the first graduates receiving their MDs in 1925.

What doctor in Canada first raised the concept of initiating a form of medicare (State Medical Insurance) similar to that introduced by Lloyd George in Britain before WWI?
Answer: Dr. A.R. Munroe of Edmonton. He raised the subject at the 1914 Canadian Medical Association meeting.

By whom and when was the first free VD clinic started in Canada?
Answer: By Dr. H. Orr, in Alberta, in 1920.

When was the first free polio rehabilitation program established in Canada?
Answer: In Alberta in 1938.

When was the first free cancer services program established in Canada?
Answer: In Alberta in 1941.

What five medical schools in Canada received a half million dollars or $1 million upgrading Rockefeller grants in 1920? Which medical school still has its grant?
Answer: Toronto, McGill, Dalhousie, Laval, Manitoba and Alberta. The University of Alberta received $500,000, conditional upon the establishment of a full six year Faculty of Medicine program and the granting of MDs. The capital funds were received in 1923. The grant still exists.

When and where was the first continuous voluntary prepaid medical insurance program - open to all members of the community - established and operated?
Answer: In Cardston in March 1932. Drs. J.K. Mulloy and M. Brayton were the physicians. The Trustees were Messrs. N.E. Tanner, E.W. Hinman and D.O. Wight. It was replicated with modifications in Lamont by Drs. Archer et al in 1933 under the "Di Bochza" program. The Alberta Government supported and agreed to subsidize a prepayment insurance program in 1935 and again in 1942. The former died because the UFA government was defeated. The latter was not acted upon because of a pending national program, which was first discussed at the federal/provincial post-WWII conference of 1944.

What was the largest hospital ever built at one time in North America?
Answer: Foothills Hospital (766 beds) in 1960-66.

What was the largest hospital ever destroyed at one time?
Answer: Calgary General Hospital in 1998 (1000 beds).

100 Years of Medicine in Alberta: Medical History On The Prairies

Frontiers of Medicine: A History of Medical Education and Research at the University of Alberta. Publisher: University of Alberta Press. Place of Publication: Edmonton. Publication Year: 1990. Page Number: iii.
A History of Medical Education and Research at the University of Alberta
In 1913, Dr. Henry Marshall Tory established the University of Alberta medical school with a single faculty member and only 27 students. This is the story of the faculty's progress from these modest beginnings to the world-class facilities and education it offers today.

CHAPTER I
The Early Years 1913-1921IN 1912, a group of twenty-five science students at the fledgling University of Alberta signed a petition requesting the Senate to institute a faculty of medicine. Henry Marshall Tory, president of the university, presented the petition to the Senate at its meeting in April of that year and gave it his complete support. Medical practitioners arriving in the rapidly developing West, he said, preferred to settle in the larger urban centres, and those settlers who lived in small communities and rural areas had little access to a physician. If the farming families in the outlying districts were to receive adequate medical care, then it was necessary to train doctors in Alberta. Those who had been raised here understood the needs of the people of the province, and after their training would return and settle in the local communities in which they had lived. Tory's persuasive arguments, coupled with the students' petition, led the Senate to agree to the establishment of a medical school as soon as faculty members and a curriculum could be put in place.For President Tory, the introduction of a medical school within the framework of the University of Alberta was a long-cherished dream, and he had been laying the groundwork for several years. Tory's concept of a provincial university included the early introduction of professional faculties, so that young Albertans could be trained in the professions without incurring the expense of travelling to eastern universities. Before he accepted the position of president of the new university, Tory discussed the subject in detail with representatives of the provincial government and received their approval for the concept.A university act was among the bills passed at the first sitting of Alberta's Legislature.

CHAPTER 2
The Years of Struggle
The twenties and the thirties

THE YEARS immediately following the war were exciting ones for the young school, even though fraught with tension, problems and concern about its future. There were high points: the Class A rating, the opening of the Medical Building, an endowment of half a million dollars from the Rockefeller Foundation, the extension of the programme to a full-degree course, and the pride and excitement of having one of its own faculty members involved with the dramatic discovery of insulin.

Several major events took place during this postwar period to solidify and strengthen the role of the Faculty of Medicine within the framework of the University of Alberta. Construction of a building specifically for the school itself spelled stability and progress, as did the appointment of new faculty members, some on a full-time basis. When the Department of National Defence gave up its lease on the Strathcona Hospital in 1922, Tory's vision of a university teaching hospital was finally realized. Changes in the curriculum at Toronto's and McGill's medical schools necessitated changes in Alberta's curriculum as well, and gradually the clinical years were added to the programme. The first class to earn an M.D. ( Alberta) graduated in 1925.

All these developments will be explored in this chapter, but first they have to be set within the framework of the political and economic situation in Alberta. In 1921, Albertans went to the polls and elected a new government, a " farmers' government." As is their wont, when Albertans decide to change governments, they do so decisively. In this instance, they replaced the Liberals with the United Farmers of Alberta, a pseudopolitical party that won thirty-eight seats in a sixty-one-seat legislature.

Review Essay Aspects of Canadian Medical Education*

Teachers of Medicine presents local material on a topic
that deserves more attention than it has received, namely the growth
of internship and residency training in Canada. After sketching how
internships emerged in Canadian hospitals, the authors report what
took place in each hospital in their city. They attribute the introduction
of internships in Calgary (and presumably elsewhere in North
America) to the impetus given by the American College of Surgeons in
establishing standards of hospital accreditation after World War I. The
implication is that community hospitals received accreditation and
cheap labor while the interns obtained clinical experience with minimal
systematic education. Internships came slowly to Calgary despite
a provincial ruling, in 1930, that every community hospital should
have house staff in proportion to the bed size of the hospital. In 1934,
the Calgary General Hospital could not respond to a request from the
University of Alberta in Edmonton to take some of their graduates as
interns because the medical staff was not "organized well enough to
mount a satisfactory experience for novice doctors. The next year the
Holy Cross Hospital had the first intern to come to Calgary. The
General did not have a viable internship program until the 1950s.
Before the medical school developed in the 1960s it was not always
easy for Calgary to attract medical graduates from the University of
Alberta and other Canadian medical schools. When the University of
l Calgary established its medical school, and residency education
flourished under the aegis of the Royal College of Physicians and
Surgeons of Canada, full internship and residency programs sprang
up in the Calgary teaching hospitals. The development of each of the
specialties is described briefly. The most innovative residency was that
in family medicine started by Dr. John Corley before the medical school
was in operation. His program had an important influence on what
happened across the country as this new specialty emerged. The
involvement of the Royal College in specialty training changed a local,
laissez-faire approach to one of conformity with increasingly strict
national standards. What happened in Calgary epitomized the changing
scene across the country.

Once Alberta became a province it set the agenda for public health care, for promoting Medicare in Canada as well as establishing medical training programs, and helping to maintain the Canadian Medical Association. First under the Liberal provincial government in 1912, and then under the populist farmer worker alliance of the UFA (United Farmers of Alberta) government till 1935, public medicine in Alberta was seen as a necessity for this largely rural province.

Socialized Medicine originated in Alberta. Even under the later right wing government of Social Credit under both Premiers Bill Aberhart and Ernest Manning (Prestons daddy) socialized medicine was seen as a necessity and promoted by the government. Albertans demanded it and we got it.

And what was good for Alberta eventually became good for the whole country when Tommy Douglas, Leader of the left wing CCF, Premier of Saskatchewan, and Freemason introduced a single payer public medicare system in his province.

But Douglas developed this system into Saskatchewan after Alberta had set up our own MSI program in 1944.

Alberta and Saskatchewan waited for the Federal Government to introduce a national program after WWII as promised by the then Liberal government, but none occurred.

Alberta maintained its private public insurance program while Tommy Douglas developed the first single payer social model in North America. The model was originally developed in the United States and lobbied for there by the labour movement.

1947
Under Tommy Douglas (regarded as the founder of Canada’s health care system), Saskatchewan was the first province to establish a public health care system, insuring hospital care for its population. As North America's first socialist government, Douglas and the Cooperative Commonwealth Federation (CCF) promoted a Canada-wide Medicare program.

The Alberta program was an early form of public private partnership, since it still did not cover 100% of all Albertans and was supplied by a private insurer associated with the AMA. It was setup with government funding, it still charged Albertans as a modified user pay system. Nonetheless it was the first public Medicare program in Canada until Douglas introduced modern 100% government based socialized Medicare to Saskatchewan in 1961.

Douglas's number one concern was the creation of Medicare. Saskatchewan became the centre of a hard-fought struggle between the government, the North American medical establishment, and the province's physicians, who brought things to a head with the doctors' strike. The doctors believed their best interests were not being met, and they feared a significant loss of income. Despite these setbacks, Douglas managed to resolve the strike, clearing the way for Medicare in Saskatchewan. Many had doubted the feasibility of Medicare, but Douglas showed Canada how it could work—that the doctors could be brought onside, and that through careful financial planning, enough money could be set aside to set up a universal system. Proving it was possible on the provincial scale cleared the way for a national Medicare program.

While Douglas is often described as the "father of Medicare" in Canada, the Saskatchewan program was finally launched by his successor, Woodrow Lloyd, in 1962. After seeing the success of the Saskatchewan experiment, Prime Minister Lester Pearson and the other provinces agreed to the creation of a national Medicare program in 1967.

The dispute between the Alberta Model of MSI with its user pay system and Douglas’s single payer 100% government funded model continued through the sixties. And it is still with us today as Alberta is one of the few provinces that charges health care premiums.

Once again proving that user pay philosophy of the right wing remains intact here. Whether Socreds or Conservatives, they grudgingly accepted a national Medicare program, but they still insisted on the Alberta way of doing it, they never gave up their MSI ideology.

Led by Tommy Douglas’ Co-operative Commonwealth Federation government (the precursor to the modern New Democratic Party), Saskatchewan became the first province in Canada to adopt public hospital insurance in 1946. Governments in other provinces, including British Columbia and Alberta, soon followed suit. One element which facilitated these new programs was the federal government's National Health Grants Program of 1948, created by Paul Martin Sr., to assist provinces through public health grants and hospital construction.

During the 1950s, two parallel developments in health insurance occurred in Canada. First, in 1951, the Trans Canada Medical Service (TCMS) developed seven insurance plans overseen by provincial affiliates of the Canadian Medical Association. By 1955, the TCMS plans had two million beneficiaries across Canada. Second, governments continued to develop public hospital insurance.

Prime Minister Louis St-Laurent was hesitant to extend federal involvement in health care B in part, due to resistance on jurisdictional grounds by Quebec, but also from many other provinces, including Ontario's Progressive Conservative Premier Leslie Frost, who sought federal funds to help pay for provincial hospital plans. Despite the misgivings of insurers and medical lobby groups, the House of Commons unanimously passed the Hospital Insurance and Diagnostic Services Act in 1957. The federal government would now share in the costs of provincial hospital insurance and diagnostic services. The program came into effect on July 1, 1958, and by the end of 1961, every province in Canada had adopted a public hospital insurance plan.

Once again, Saskatchewan led the way in public insurance programs for medical care. In late 1961, Saskatchewan Premier Woodrow Lloyd introduced a medical care bill to the provincial legislature. North America's first public medical insurance went into effect on July 1, 1962. However, the day made history for another reason: a doctor's strike was launched to protest the plan. A key reasons for the strike was the physicians' fear of universal, mandatory medical insurance which excluded the possibility of practitioners opting out of the program. At the strike's end, a clause was included in the legislation whereby physicians were given the choice to opt out of the public plan. Ontario, BC and Alberta also developed medical insurance plans, but they were created on the principal of voluntary insurance

Exhibit - Public Health Insurance Throught History - 1987-2002

Alberta hospitals were behind the formation of the Alberta Blue Cross Plan in 1948. Under an Act of the Alberta Legislature, the Associated Hospitals of Alberta (AHA) was incorporated and permitted to establish a voluntary, pre-paid, not-for-profit Blue Cross plan.

The Plan essentially served as an extension of Alberta's hospital sector, offering a province-wide hospital care plan for working Albertans. It gave patients affordable coverage for needed hospital services. At the same time, Alberta hospitals gained greater financial security because the Plan paid patient bills.

Continual innovation has marked the history of Alberta Blue Cross since 1948. With the introduction of Medicare in the late 1960s, Albertans no longer needed basic hospital coverage, but they wanted other, supplementary, coverage. Alberta Blue Cross responded with benefit plans for services such as prescription drugs, ambulance service, home nursing and health-related appliances.

Since the early 1970s, Alberta Blue Cross has administered Alberta Government-sponsored supplementary health benefit programs. These important programs for =seniors and Albertans who did not have coverage available through an employer.

To meet customer demands in the '70s and '80s, Alberta Blue Cross added coverage for dental care, vision care, outside Canada emergency medical, disability and life insurance—resulting in a full line of health benefit products.

By the 1990s, less than one per cent of Alberta Blue Cross business related to hospital claims. Changes in Alberta's health care system further rendered irrelevant the original legislation governing the operation of the Alberta Blue Cross Plan. In response, the Alberta government replaced the outdated governance legislation with a new stand-alone act, the ABC Benefits Corporation Act, effective December 1, 1996. ABC Benefits Corporation continues the operation of the Alberta Blue Cross Plan.

HEALTH CARE IN CANADA

The single payer Canadian Health System is the result of a protracted battle in the post war years between business groups and the medical profession on one side and the people on the other. The people won a resounding victory. The health system is consequently highly valued and attempts to meddle with it are politically sensitive. Canadians are well aware of the situation south of the border.

While private care was not prohibited and continued in a small number of areas all Canadians had equitable access to services paid for by taxes. Canada does not have for-profit acute care hospitals, although the 'for-profits' do exist in the long-term care sector. Canada has a system which is a Single-Payer system; "publicly-funded, publicly-administered, and publicly-Accountable. "

Also see:

The Birth of Medicare CBC ARCHIVES

Phoney Health Care Reform:
The Neo Liberal Agenda of Outsourcing and Privatization

THE DIFFERENTIAL IMPACT OF HEALTH CARE PRIVATIZATION ON WOMEN IN ALBERTA

Privatization of The Canadian Health Care System

Not Yet and Hopefully Never

by Donna Wilson, RN, PhD
Associate Professor, Faculty of Nursing,
University of Alberta, Edmonton, Alberta T6G 2G3
donna.wilson@ualberta.ca

Alberta under the Social Credit party of Ernest Manning, fought to maintain the two tier private insurance program against Tommy Douglas's single payer form of medicare, even after the Federal Government accepted it as the national program. During the reign of the Progressive Conservatives of Peter Lougheed an unprecidented expansion of the public service as well as a construction boom in hospital and long term care facilities occurred. It reflected the wealth of the oil boom of the seventies in the province and the political accumen of the Lougheed gang in getting rural and seniors votes.

With the oil crisis in 1984 and the crash in the market the Getty Government faced a crisis in building and staffing infrastructure. Further attempts at diversification by the government led to many startling business failures. The government became scandal ridden. In came Ralph Klein and the Calgary/Southern Alberta right wing, with their neo-liberal agenda and Alberta became a laboratory for privatization and market models of public service delivery.

The Klein government closed and blew up hospitals, transformed rural hospitals into long term care facilities, privatized laundry services in Edmonton and Calgary Hospitals (giving the contract to Tory insiders), reduced funding for univeristies resulting in a decline in training of nurses and doctors, laid off hospital staff, and of course froze wages and benefits forcing those not laid off to look for work elsewhere. They also consolidated the hospitals into districts, removed control from boards and appointed their own lackies to the new District Boards.

What the Lougheed government had built the Klein government renovated, causing long serious and long term damage. Currently the lack of doctors and nurses in this province and across the country is a result of the decisions of 1995. In that year the Federal Government under Fianace Minister Paul Martin also adopted the neo-liberal model and reduced transfer payments to the provinces to reduce its debt. The federal government also embraced the Reinventing government model prevalent in the U.S. which promoted the contracting out of government services and the development of Private Public Partnerships (P3's).

The result of this move to the right provincially and Federally left public health care seriously undermined, as the right hoped in order to 'level the playing field' in order to introduce a market driven model of for profit health delivery in Alberta. The old hospitals in Calgary that weren't blown up were sold at fire sale prices to private medical companies, which again had ties to the Tory government.

Health boards were stocked with former Tory ministers. And new delivery models of health care became the reform agenda of the government, including its disatorous attempt to intorduce fullscale privatization with Bill 11. Mass protests stalled the bill but the Federal Government was in no position to oppose it since it had abdicated its fiscal responsibilty for health care with its cuts.

For the last decade the Klein government has driven the agenda of Health Care Reform in Canada, and its model is that of private public insurance (MSI) combined with public funding for private service delivery.

In the past two years the Klein government and its supporters on the right ( The Fraser Institute and Preston Manning and Mike Harris) has realized its reliance on the American model is a political deadend in Canada. So now they are looking to Europe for P3 models to emulate.

But the fact remains it was their very attack on the public funding and delivery of medical services that created the problem in the first place. While claiming to have to spend billions in providing public health care, the reason is that they are rebuilding a social infrastructure that they blew up during the Klein Revolution and the Martin Budget of 1995.

The money is not the problem, as America's increasing costs for medicine prove, it is the failure of the government to develop a wide based public healthcare system that includes coverage for pharmaceuticals, dentistry, alternative delivery, etc. that is resulting in increased costs. Like the reform of public education and other so called reforms of the right these are not driven by cost considerations but by the ideology of privatization at all costs.



Real Health Care Reform: The Proletarianization of Medicine

Wednesday, February 8, 1989

Much to learn from cost-efficient HMOs

Andrew Coyne

Health care is a classic case of ''producer capture'': a system run more in the interests of providers than of patients or taxpayers. Competition is limited by the various professional cartels within the medical industry, through ''recommended'' fee schedules, restrictions on the numbers of new doctors, a licensed monopoly in broad areas of medical practice, and prohibitions on advertising so strict as to make even the use of bold type in the Yellow Pages an offence.

The object of reform should not, however, merely be to break the doctors' cartel. It is not doctors' incomes, first, that are at issue, since they are but a fraction of the total health bill. Nor is competition much use so long as consumers have vastly less knowledge than their physicians about the care they need. Who is the patient to object if the doctor recommends an expensive course of treatment, especially in an emergency? ALTERNATIVE MODEL

Most doctors are paid on a fee-for-service basis, which makes the pound of cure more interesting than the ounce of prevention. Yet it is not enough, either, simply to proletarianize the physicians. Putting doctors on salary would remove any direct incentive to waste. But it would not encourage them to seek out the lowest- cost treatment, when the costs of expensive new procedures, so entrancing to the profession, can be passed on without question to the public insurer.

Coyne as usual throws a red herring in which is the cost of treatment which is set by either specialists wages, or by high cost pharmacutecal costs. Drug costs skyrocketed because Coynes pals in the Mulroney government allowed drug companies a twenty year patent monopoly on their drugs thwarting a free market in generic based drugs.

However the proletarianization of medicine is exactly what we need. And it would work and be the most radical real reform we could do to socialized medicine in Canada. One that the great Canadian Communist Doctor Norman Bethune advocated back during the Spanish Civil War and one he attempted to implement in revolutionary China with Mao during the war against Japan.

Bethune himself clashed with the English Ruling Class Masonic Monopoly that controled medicine in Canada. He developed open heart surgery during WWI when the medical establishment shyed away from it. He developed transfusion units and the modern MASH units in the Spanish Civil War. His proletarian approach to medicine, was frowned upon by the parlour phsycians that controled medicine in Canada.

Had we had open training for medical professionals instead of the current guild monopoly by the doctors associations we would not have been in the crisis we are for a shortage in medical staff:

Waiting lists, staff shortages, public-private health care top concerns: CMA

Julia Necheff

Canadian Press

Monday, August 15, 2005

"Right now, things in medicine in Canada are not particularly rosy," said Dr. Albert Schumacher, the association's out-going president.

"We're confronted with very significant wait times which, in some instances, are unfortunately increasing every day . . . for core procedures - hips, knees, hearts, cataracts."

An even bigger issue from the profession's standpoint, for both the short and long term, is the shortage of health-care professionals - the main reason behind the long wait lists, Schumacher said.

"We need to move our country to a goal of self-sufficiency in the supply of doctors, nurses and other health-care professionals. We've been too long plundering from other countries that can ill-afford to lose people."

The system is struggling to recover from deficit cuts by governments in the 1990s.

Nurses were laid off. And funding cuts filtered down to universities, which in turn cut medical enrolments, said Schumacher.

Canada now ranks lowest among industrialized nations in the world in terms of its self-sufficiency in supplying health professionals, said the general practitioner from Windsor, Ont.

Even though medical schools are scrambling to increase enrolments again, it will only take the country to 80 per cent self-sufficiency, he added.

Financial Survey: Young doctors face a steep climb

"Break their Haughty Power"

Says a line in the union song Solidarity Forever, in order to do so we need to look at making medicine truly socialized. That would mean breaking the monopoly of the College of Physicians and Surgeons, and the Canadian Medical Association. When Alberta first became a province, the British/American medical interests founded the University of Alberta and the College of Physians and Surgeons, making their establishment the first acts of the provincial legislature. This guarnteed their guild monopoly that has existed for 100 years.

It is time that we remodled social medicine not to be the prevue of the elite but be proletarianized, reducing the restrictions and monopoly on who can become doctors, paying them a salary, and creating community medical clinics where a series of on salary services are provided, including psychiatric, specialists, dentists, etc.

Mr. Jeannot Castonguay (Madawaska—Restigouche, Lib.): Mr. Speaker, I listened with a great deal of interest to the presentations of the two hon. members who just spoke. I think we can agree that currently in Canada doctors are providing excellent services.

We also know that the majority of these doctors are private entrepreneurs. They are paid a fee for service, and if they do not work, they are not remunerated. If they do work, they are. It is up to them to take care of their own fringe benefits.

My colleague is simply suggesting that we stop this type of practice in Canada and that all doctors should be salaried public workers. I wonder if we would receive better care that way. Would the cost be any different?

[English]

Mr. Dick Proctor: Mr. Speaker, I certainly think people who work in the profession feel that if we had doctors paid on a salaried basis, it would help matters. I worked in the department of health in the province of Saskatchewan before coming to this place. One thing the department was working on was exactly that. It was trying to get doctors off of a fee for service arrangement and onto an annual salary.

I am pleased to say that I belong to the Regina community clinic on Winnipeg Street in Regina. There are roughly half a dozen doctors there and they are all on a salaried basis. Progressive governments that are looking for choices on this would like to see more doctors on salary rather than on a fee for service basis so we can try to reign in some of the costs.

When Mr. Romanow was the premier of the province of Saskatchewan, he used to say that the province could spend 100% of its money on health care and it still would not be enough. Of course there had to be money to pay down the debt left over from Grant Devine and for education, roads and a number of other things. However, this has become a juggernaut over the last 10 years that has grabbed provinces like Saskatchewan and most others in the country, and it will not let go because of the rising costs.

I have less concern overall about the doctors on a fee for service basis than I have on private MRIs. Inevitably, built into those private MRIs will have to be a profit motive. That is our concern. We want to limit and reduce the for profit delivery rather than see it escalate in the years to come.

Mrs. Lynne Yelich (Blackstrap, CPC): Mr. Speaker, I really have to wonder if the two members who spoke before are really from Saskatchewan. What I heard was incredible. They are talking about trying to debate health care. Health care is what we should be debating. All I heard was a rant. I do not believe they are really concerned about health care one iota. If they were, they would go home and try to access our health care. It is not always accessible to those with real health problems.

I can tell about a person who went in for a knee operation. He was quite healthy and was told to have both knees operated on at the same time. He had both done at the same time and never came out of the hospital. I can tell about a person who had to go back into the hospital to have a limb re-broken. What about the workmen's compensation patients who go to Calgary for MRIs because our province does not have an MRI machine available for Saskatchewan workmen's compensation clients?

That is why nobody wants to participate in this debate. It is sickening.

Mr. Dick Proctor: Mr. Speaker, one hardly knows where to start on that. I would just repeat what I said a minute ago. When provinces are carrying 84¢ of the dollar and the federal government is only putting in 16¢, it is very difficult for provinces like Saskatchewan, with a million people and a small taxpayer base, to do all that.

However, perhaps the member for Blackstrap could make some of those approaches to the health minister across the way and point out some of the realities with which governments are dealing.

Section B: Vital Statistics and Health

R.D. Fraser, Queen's University

Statistics in the tables of Section B are in two divisions. Series Bl-81 contain data on vital statistics and series B82-543 on health. Data on social welfare, formerly contained in this section, are presented separately in Section C.

The principal sources for vital statistics (series B1-81) are: Statistics Canada, Vital Statistics, 1921 to 1970, (Ottawa, Queen's Printer); Statistics Canada, Vital Statistics, vol. I, Births; vol. II, Marriages and Divorces; vol. III, Deaths; all three volumes published annually since 1971 (Ottawa, Queen's Printer). Additional sources on historical series are given in the first edition of Historical Statistics of Canada, p. 30.

The principal sources for health (series B82-543) are: Department of National Health and Welfare, Canada Health Manpower Inventory, annual (Ottawa, Department of National Health and Welfare); Statistics Canada, Hospital Statistics, vols. I-VII, (Ottawa, Queen's Printer); Statistics Canada, Mental Health Statistics, vols. I-III, annual (Ottawa, Queen's Printer); Department of National Health and Welfare, National Health Expenditures in Canada, 1960-1973, updated every two years (Ottawa, Department of National Health and Welfare).

Doctors, Inc

ON docs can now join the rest of Canada and incorporate
their practices. Here's how to get in on the tax savings

By Craig Silverman

Temporary guardian angels

Hospitalists look after your inpatients when you can't.
Who are these docs-for-hire?

A clinic of one's own

A doc and his community take on the physician shortage and build themselves a clinic

Even the right wing so called Free Market Think Tank the AIMS institute recognizes that the doctors historic monopoly in Canada needs to be busted up in order to truly have medicare reform. The proletarianization of modern medicine is their reccomendation through the use of Nurse Practicioners. But of courtse their whole point is not to create a socialized community clinic model of delivery but a MacDonalds style franchise of private sector delivery of services......

DOCTORS HAVE TO MAKE A LIVING TOO: THE MICROECONOMICS OF PHYSICIAN PRACTICE

November 2002

AIMS Health Care Reform

Background Paper #6

Atlantic Institute for Market Studies

The Atlantic Institute for Market Studies (AIMS) is an independent, non-partisan, social and economic policy

think tank based in Halifax. The Institute was founded by a group of Atlantic Canadians to broaden the

debate about the realistic options available to build our economy.

AIMS was incorporated as a non-profit corporation under Part II of the Canada Corporations Act, and was

granted charitable registration by Revenue Canada as of October 3, 1994.

The American evidence indicates that, over a certain range of services, nurse practitioners (NPs) can

deliver a comparable quality of care and are cheaper to train than MDs. However, the cost of educating a provider is not the primary determinant of how much they get paid.

The ultimate determinant of how much a provider earns is the value of the services they provide. If NP services are equivalent to MD services, the price NPs get paid for each service will rise to equal that of

an MD providing the same service. This is what has happened in the US, to the point where many proponents

of NPs acknowledge that they have lost their cost advantage over MDs. According to one salary survey, turned up by an internet search, the average American NP salary is about US$60,000, almost Can$90,000. That’s less than an MD earns but it’s not cheap and, unless Canadian salaries are in the same general range, a lot of the NPs we train here will head straight for the American market.

A second factor at play is equal pay for work of equal value. If NP services are of comparable quality to MD services, NPs have every right to expect to be paid as much, on a per-service basis, as an MD would be paid for providing them. If that isn’t the case at first, one good pay equity lawsuit will make it so.

Regardless of what it costs to train an NP, it will cost the system as much to have those primary care services provided by NPs as it would to have them provided by MDs. Is it likely that NPPs could fit into Medicare as additional inputs into GPs offices? There is an example closer to home than the US since most Canadian dentists use hygienists and assistants to perform basic

preventive dental tasks. While the dentist could do cleanings, his time is undoubtedly better spent at more demanding tasks. In many cases, the patient won’t see the dentist, only the hygienist or assistant. Because the dentist can bill for the services his staff provides under his supervision (even if supervision often means being in the next room, available should problems arise), it is profitable for him to employ

them. As a result, the typical general practice dentist’s time is probably more efficiently allocated than is the typical GP’s time.

The real solution to Medicare reform lies neither with the return of the old MSI model as the Alberta government is currently promoting as its third way,
Firm chosen to do private health insurance review, nor the bandaid solutions offered by reforms to the Canada Health Act. Real reform would be to create community health clinics based on the Boyle McCauley Model below.

This model was also developed in Saskatchewan but once the Canada Health Act was passed the community health clinic model was shelved in favour of doctors as private businessmen on the government payroll, the billing process.

We need to put doctors on salary, widening the abilities of nurse practioners to be GP's, especially in remote communities, we need to break their haughty power and monopoly. End their control over university medical departments with their outmoded archaic practices of training Doctors over seven or eight years, but only those students who have a high GPA.

Open it up to a four year GP course drop the GPA requirements, and make it an apprenceship system where you begin as a Nurse Practioner, move to a GP then specialize. We need to end the hazing process where by new interns spend thirty six hour shifts in Hospital emergency rooms.

We need to combine in health clinics doctors, NP's, massage therapists, chiropractors and natropaths as well as pharmacists and dentists.

Dentistry is not covered by the Canada Health Act, and again is a monopoly controlled by those who certify and approve those who can become dentists. Boyle McCauley includes dentists in its clinic in the inner city.

And we need to insure that all university trained doctors and dentists serve a two year indentured service on salary in rural and northern communities, and inner cities as their social service to the community. This would then lessen the crisis these communities face in having medical services delivered.

To break the medical monopoly would be to expand social medicine to community colleges and technical schools with two year, three year and four year programs, with universities training specialists.

About the Boyle McCauley Health Centre

The Boyle McCauley Health Centre has been serving the population of the inner city for over twenty years and is constantly growing and changing.

Mission Statement

The community-owned Boyle McCauley Health Centre responds to the unique needs of Edmonton's inner city. Along with Capital Health and other stakeholders, we improve the health of individuals and the community by providing a range of primary health and health promotion services to those with limited access.

Our Vision

We are recognized as a model of excellence and innovation in providing accessible primary health care and health promotion services in Edmonton's inner city.

BHMC Background Information

The Boyle McCauley Health Centre and Society: the BMHC is a non-profit, charitable organization, run by the Board of Directors of the BMHC Society. The Board members are elected at the Annual General Meeting of the Society for a two-year term and can serve a total of three consecutive terms. The Board of Directors is responsible for hiring the Executive Director. The Executive Director is responsible for hiring all staff and for the overall day-to-day running of the Health Centre.

The Health cCentre is funded on a global basis by the Capital Health Authority and by charitable donations. Staff physicians are remunerated at a flat rate and do not bill Alberta Health Care or any other agency for the services they provide at the Health Centre.