A man and an idea (1939-1944)
Multiple factors, including the economic difficulties faced by many French Canadians, the Quebec government's non-intervention policy and the broad‑based consensus on clergy-supported nationalism, account for the fact that so many private initiatives began working to address the problems facing workers, farmers and the middle class. Previously, in the areas of social services and insurance, which sought to provide protection against life's uncertainties (sickness, unemployment, old age, etc.), government programs were few and far between and were mostly provided at the federal level. Related legislation included the Old Age Pensions Act (1926), the Unemployment Insurance Act (1941) and the Family Allowance Act (1944). Only public assistance (1921) and aid for mothers in need (1937) had drawn the attention of the provincial government. Everything else was left up to private initiatives or public charity.
Quebec had yet to embrace the role of state intervention. The Church, through its support and charitable organizations, did what it could, although the task it faced was daunting despite continual calls for citizens to take part in its social initiatives. At that time, the state saw its function as a strictly auxiliary one.
Furthermore, French Canadian nationalists—a not inconsiderable group—took a dim view of calls for state intervention. They feared that action by Quebec would provide the federal government with an enticing opportunity to encroach on the province's fragile autonomy. Had it not already attempted to do so during the Depression?
52 Avenue des Oblats
Dr. Tremblay's office
Against that backdrop, how should one qualify a project, albeit privately operated, designed to reduce social inequalities in the face of life's uncertainties? Dr. Jacques Tremblay turned out to be the driving force behind one such project; it involved the creation of a tiny health cooperative in the Saint‑Sauveur district of Quebec City.
At that time, Dr. Tremblay was practicing medicine and general surgery in Saint‑Sauveur, a working-class district of Quebec City. He also worked as a forensic physician, which enabled him to boost his income while charging lower fees to his far-from-wealthy clientele.
The precarious circumstances of doctors working in underprivileged neighbourhoods underscored the more widespread problem of access to healthcare. Dr. Tremblay summarized the dilemma in these words:
Doctors and patients, regardless of what one might think, have a similar relationship to that of producers and consumers. And so it is impossible for their relationship to be any different in the medical field than it is in the economic sphere. How does the modern economy operate? It is based on the supremacy of capital, along with a disdain for labour and cutthroat competition, all of which have led to a host of unacceptable outcomes. The poor are begging amidst abundance and dying of hunger alongside a table piled high with food. It is the same in the medical field, where we see medical practitioners and specialists on one side, admirably equipped to fight disease and awaiting patients who never appear. On the other side are members of the public, who have myriad needs but are unable to afford the care they should receive. Both sides need each other but they cannot come to an agreement.1
Drawing a connection between economic difficulties and medical problems, Dr. Tremblay denounced not only traditional medical practices, but also the adverse effects of the capitalist economy. Fears that the state might interfere only served to strengthen his convictions.
In this context, an original way of preventing disease and distributing healthcare was needed. So what was the solution championed by Dr. Tremblay? Needless to say, it stemmed from his involvement in various organizations advocating cooperation, such as the Société Saint-Jean-Baptiste and the powerful (and secretive) Ordre de Jacques-Cartier. It was understandable for Dr. Tremblay to opt for the cooperative formula, which offered all the benefits of private initiative, but replaced unacceptable competition with collaboration.
An idea takes shape
A book by Dr. Michael A. Shadid2, founder of a cooperative hospital in Elk City, Oklahoma, also served to strengthen Dr. Jacques Tremblay's convictions3 while shedding new light on his own cooperative project. Once he had finished Dr. Shadid's book, Dr. Tremblay began a period of extensive research aimed at adapting the cooperative formula to the medical field. In Quebec, no research had been conducted in this area, so his thinking was shaped by various "foreign" experiments, primarily in America and English Canada. Canadian Doctor magazine also helped him stay up to date on new developments.
The first task at hand was to encourage people to determine the availability of healthcare services... before the state stepped in! In 1940, Dr. Tremblay began writing articles and giving talks on cooperative medicine. His excellent relationship with the Archbishop of Rimouski, Mgr. Courchesne, facilitated contacts with bishops around the province.4 He also paid visits to chambers of commerce, municipal medical associations, union organizations and cooperatives of all kinds. The Société Saint-Jean-Baptiste, in which he played an active role, also provided him with a valuable forum. In 1942, Dr. Tremblay spoke on the topic of cooperative medicine at the third general cooperators convention. His remarks were published in the official proceedings, as well as in a separate brochure.
Essentially, Dr. Tremblay decried the gap between technological progress in the medical field and the real fight against disease, which involved prevention as well as care. According to the argument he put forward, the current system should be replaced by cooperative medicine, which was located midway between state-sponsored medicine, which encroached on doctors' professional autonomy, and individual-based medicine, which in his words "no longer meets the needs of our century".
Summary from a brochure published by the Conseil supérieur de la Coopération, "La médecine coopérative" by Dr. Jacques Tremblay
Cooperative medicine: core principles
Medical cooperatives would be "transformed", i.e., they would operate as private voluntary non-profit organizations supported by people seeking medical services. Cooperative medicine has four core principles:
- "Team-based medical practice", which delivers better care to patients by bringing together a group of specialists, thereby saving time and energy.
- "Preventive medicine", which seeks to maintain health (rather than treating avoidable diseases at great expense) and focuses on prevention (rather than costly treatments).
- "Periodic payment", which applies to all members (the healthy as well as the sick). Each member is asked to make an equal contribution towards the total cost of medical care. This ensures that each member receives the appropriate care and frees doctors from having to worry about unpaid bills and fee collection.
- "Democratic control", which applies to how the cooperative is managed, and not to the diagnostic and treatment methods selected or prescribed by doctors. Healthcare consumers can choose from among the doctors working in the cooperative, just as they would in the private sector.
The choice of the middle classes
In Dr. Tremblay's view, the cooperative health system was geared towards the middle classes. For one thing, the poor would continue to be supported by the state, which would carry out its fundamental auxiliary role; meanwhile, the very rich would continue to pay for their own healthcare.5
Insofar as the broad lines of Dr. Tremblay's position adhered to clerical and nationalist ideology, it is understandable that various interconnected groups involved with social problems voiced their approval. They included cooperators, clergy members, Catholic union members and workers involved in social organizations. Their support was a matter of "common sense"—meaning that they endorsed Dr. Tremblay's fight against state intervention, which they were quick to associate with the dangers of socialism and centralizing federalism. But they also endorsed Dr. Tremblay's calls for citizen independence and for all social classes to work together. The limitations of Dr. Tremblay's proposed solution, however, became evident as soon as it came time for action. Even though his solution adhered to traditional ideology, it posed a threat to another deeply entrenched value: established medical practices, or the status quo.
Thinking things over
Dr. Tremblay's voluminous correspondence is a testament to the warm welcome he and his ideas received. In 1944, the Arvida aluminum workers union organized a health insurance fund based on his ideas, while at the same time the Val-d'Or Junior Chamber of Commerce, together with a group of doctors and cooperators, attempted to set up a cooperative hospital.6
Notwithstanding these initiatives, enthusiasm alone was rarely enough to yield satisfactory results. In any event, it soon became clear that Dr. Tremblay's proposed solutions would be met with the medical profession's full-scale resistance. This was illustrated in the remarks officially introducing him at the cooperators' third annual convention in 1942, at which he was a guest speaker:
Dr. Jacques Tremblay, a man of renown, always surprises us with his perseverance and dedication to cooperative medicine. Doctors generally avoid this issue lest they upset their colleagues.
Dr. Tremblay is one of the few individuals seeking to make the field of medicine (as opposed to medical practitioners) more socially committed: this lends all the more weight to his words.7
Convincing the medical profession of the merits of cooperative medicine was no mean feat. The pioneering nature of Dr. Tremblay's analysis, particularly as seen by other doctors, taken together with his criticisms of individual-focused medicine and unequal access to health care, as well as the traditional nature of his proposed solution, influenced the welcome his project received. Nevertheless, his visionary and idealistic project eventually took shape as the Coopérative de Santé de Québec [Quebec City health cooperative], which would serve to determine whether his ideals would lead to a viable institution.
Next chpater : The founding of the Coopérative de Santé de Québec (1944)
- Tremblay, Jacques. La médecine coopérative (Quebec City, Conseil supérieur de la coopération, 1942, p. 41.).
- Shadid, Dr. Michael. Principles of Cooperative Medicine. (New Deal Printing Co., Oklahoma, USA, 129 pp. Quoted in Ensemble, vol. 1, no. 6, June 1940, p. 30).
- Interview with Dr. Tremblay (pp. 2-3). Cf. also J. Tremblay. La Coopération médicale (Ensemble, vol. 1, no. 6, pp. 24-26).
- Dr. Tremblay's membership in the Ordre de Jacques-Cartier probably had some bearing on the welcome he received since many clergy members also belonged to the Ordre. See Raymond Laliberté, L'O.J.C. ou l'utopie d'un césarisme laurentien (Quebec City, doctoral thesis, Université Laval, 1980, p. 39).
- A summary of Dr. Tremblay's brochure titled "La médecine coopérative" is provided under the An Idea Takes Shape section.
- Cf. Canadian Doctor magazine, June 1944, and "Un projet d'hôpital coopératif" (Ensemble, vol. 2, no. 4, April 1942, pp. 23-24).
- Tremblay, Jacques. "La médecine coopérative", presented by Philippe Lessard, in L'Assurance-Mutuelle (Conseil supérieur de la coopération, Quebec City, 1942, p. 172).