The existence of the Canadian Medicare system is often a point of national pride, exemplifying a supposed national belief in the right to health care. Narratives of its development typically begin with Tommy Douglas and the origins of provincial policy in Saskatchewan, cumulating in the passage of the Hospital Insurance and Diagnostic Services Act (HIDS) in 1957, the Medical Care Act in 1966 and finally the Canada Health Act in 1984. Although the politicians and political debates that led to the eventual implementation of a Canadian Medicare program are discussed at length in the literature, the individual stories of doctors and nurses who participated in the development of this system do not often feature. Even rarer are the perspectives of the many foreign-born doctors who arrived en mass during the 1960s and 1970s. Foreign Practices addresses this silence by supplementing the traditional narrative of Canadian Medicare with an analysis of the impact of foreign trained doctors on the shape of Canadian medical practice. By integrating a discussion of international medical migration within major policy developments in the 1950s–1970s, the authors have succeeded in transforming the traditional story of Medicare as a home-grown national system, into the story of a system that was shaped by an entangled web of forces, including immigration, globalisation, domestic demand and the transformative efforts of individual doctors.
The book follows a roughly chronological procession, commencing in the immediate post-war period and highlighting early medical immigration patterns largely influenced by the 1952 Immigration Act. This act encouraged immigration from individuals who could easily assimilate into Canadian culture, engendering an influx of trained physicians from the British Isles. By the end of the decade, medical immigration increasingly included doctors from former British colonies, including South Africa, Kenya, India and New Zealand. In the first chapter of this book, Mullally and Wright outline a persistent deficit in the number of Canadian-trained physicians and a growing demand for medical services in post-war Canadian society. This was compounded by both economic and demographic growth, exacerbating the deficit in rural areas where populations were geographically dispersed. In response to this need, the famous first step towards universal health insurance was implemented by the Co-operative Commonwealth Federation (Farmer-Labour-Socialist) Government in Saskatchewan, and it would seem ‘inevitable’ that a federal system would eventually follow (p. 47). The federal approach to a hospital insurance scheme is outlined in depth in the third chapter, following a discussion of the increased immigration of British doctors ‘fleeing’ the British National Health System in hopes of finding more lucrative careers in Canada. Throughout, the diverse perceptions, concerns and anxieties felt by physicians towards socialised medicine remain in the forefront of the analysis, emphasizing how the shift to Medicare was far from smooth, and centring the individual in a story that is often impersonal.
The impact of international events on the Canadian medical landscape shines through in the first five chapters, as concerns over domestic British medical policy provide a push away from the British Isles, and the looming conflict in Vietnam directed many away from the United States. Other conflicts also stimulated medical migration, with the Prague Spring, the conflict over the Suez Canal, civil war in Pakistan and the struggle for control of Taiwan pushing many people away from their homelands. However, the authors frequently refocus the macroanalysis back onto the micronarratives, interweaving the personal journeys of many individual physicians and their own experiences of migration and settlement into the discussions of these transnational events. The stories of medically trained individuals were gathered through many oral interviews, and their inclusion sets this work apart from other works on the development of Medicare by de-essentialising the grand narrative of a national system.
The influx of medically trained immigrants was domestically encouraged by the refocusing of immigration policy in favour of attracting ‘highly skilled manpower’ through a points-based system. While this successfully increased medical immigration to the country, it would be condemned as a global ‘brain drain’ of skilled individuals by Western countries, especially the United States, the United Kingdom and Canada. This international discourse is the focus of Chapter 6 of the monograph, highlighting the criticisms levelled at industrialised countries which had absorbed nearly 90% of the world’s migrant physicians (p. 160). In Canada, this enabled the supplementation of rural and remote health regions with a growing foreign workforce of medical professionals. Two full chapters of the book provide intimate case studies of the development of unique health cultures in rural areas, with Chapter 8 comparing the examples of two resource towns: Sault Ste. Marie, Ontario, and Thompson, Manitoba. The discussion finishes once again with domestic policy review of the novel incentive policies passed in the 1970s to relocate physicians towards underserved areas of the country.
Mullally and Wright employed comprehensive research methods for this work, with quantitative data forming a core part of the evidence. Using the Canadian Medical Directory, the annual returns of the federal Department of Immigration and Citizenship, multiple published reports from medical journals and an abundance of popular news and media resources, the authors compiled a substantial database regarding migrant doctors, their countries of origin, counties of study, location of settlement and general demographic information. The statistics that emerged from these data provide a solid foundation for their assertations about the influx and outflow of medically trained individuals and highlight the quantitative impact of a ‘brain gain’ on Canadian medical practice and policy. However, the true strength of the work is the combined approach which supplements the hard statistics and policy discussions with the personal stories of men and women which were collected through oral interviews over several years. A glance through the sources demonstrates that this work was years in the making, and the authors took care to follow up on leads and contact numerous external individuals for added insight. One minor limitation to the qualitative content is the high ratio of male voices, which at times overshadows the contributions and experiences of foreign female medical professionals.
Nonetheless, this is a significant work of history which does much to reconceptualise the narratives told about Canadian Medicare. Through its exploration of the ways that foreign-trained doctors settled into Canadian structures of medicine and subsequently moulded those structures over the course of the 1960s and 1970s, Foreign Practices provides a new framing for the national Medicare system, one which recognises the contributions of immigrant medical workers and marries the national belief of a home-grown system, with a multilayered transnational understanding.
