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A Brief History of the
Medical Reform Group of Ontario
1979 - 1994

Pre-History

In the autumn of 1978 two members of the house staff at the Toronto Western Hospital, Fred Freedman and Gordon Guyatt, began talking about their alienation from the established medical organizations and the need they perceived for an alternative. The idea for an organization that would represent progressive, socially conscious physicians grew out of their discussions. They circulated a letter describing their idea to other members of the house staff at the Toronto Western, and were pleasantly surprised when ten to fifteen of their colleagues expressed an interest.

The group, supplemented by a few house staff members from other Toronto hospitals, began to meet on a regular basis. They hammered out a preliminary position and sought support through a mailing to over 5,000 Toronto physicians and an advertisement in the Canadian Medical Association Journal. Only a handful of replies were received, and almost half were hostile to the point of being vituperative. However, the mailing attracted a few practising physicians, including John Marshall and Cynthia Carver, into the fold. It was decided that a convention was required to determine whether there was sufficient interest for the group to make a go of it. Held at Hart House in May, 1979, and chaired by John Marshall, the convention was attended by almost sixty people, still mainly medical students and house staff members. Those present agreed on a set of basic principles, and the response left no doubt that the idea of a Medical Reform Group was feasible. A committee, led by John Marshall and Philip Berger, undertook to draft a constitution for the new organization.


The Formation of the MRG


In October, 1979, over 60 young physicians and medical students, largely from Toronto and Hamilton but also from other parts of the province, met in the Hart House Debates Room to ratify the constitution. The structure of the group, with a provincial steering committee, local chapters, and working groups meeting around specific issues, was adopted. The conflict around the issue of whether the group should be restricted to physicians and medical students was highlighted. Pragmatic considerations led to a consensus that the MRG be primarily a physicians' group. The wording of the three basic principles was modified, but their content was confirmed. They are as follows:

1. The universal access of every person to high quality, appropriate health care must be guaranteed. The health care system must be administered in a manner which precludes any monetary or other deterrent to equal care.
2. Health care workers, including physicians, should seek out and recognize the social, economic, occupational, and environmental causes of disease, and be directly involved in their eradication.
3. The health care system should be structured in a manner in which the equally valuable contribution of all health workers is recognized. Both the public and health care workers should have a direct say in resource allocation and in determining the setting in which health care is provided.

The constitution as amended was passed unanimously with, as is described in the minutes of the meeting, "much cheering."

Another notable aspect of this meeting was the establishment of the MRG tradition to back up our positions with a solid understanding of available evidence. The group distributed a fact sheet on the effects of extra billing, citing the experience of user fees in Saskatchewan and the work of economists Barer, Evans, and Stoddart.
Prior to this meeting the MRG had made no public statements, largely because of reluctance of group members to risk subsequent personal reprisals. The first steering committee, which included John Marshall, Cynthia Carver, Debbie Copes, Nick Kates, and Barbara Lent, was willing to put aside these fears and speak publicly for the group. As a result, on November 1, 1979, a bold faced headline on the front page of the Toronto Star announced "125 MDs Break Ranks with the OMA."


The Hall Commission


The short-lived Clark government had appointed Justice Emmett Hall to head a commission to evaluate the state of medical care in Canada, and to make recommendations for changes in the system. While considerable energy within the MRG was being spent on the occupational and environmental disease areas, and a working group was active in the area of women's health, a major initial focus for the MRG was preparing a brief for the Hall Commission. Mike Rachlis, Philip Berger, Bob James, Joel Lexchin, Nick Kates, and Ellen Buchman all made major contributions to the brief, which was presented to Justice Hall in April, 1980, and crystallized our positions around economic issues. The brief included recommendations that were highlighted in the Hall Commission's final report, including ending user fees and health care premiums.

The provincial meeting that followed the presentation of our brief was notable for a change in steering committee members. John Marshall resigned and left shortly thereafter to take up surgical training in the Maritimes, while Brian Gibson and Bob James joined the steering committee. Until he left the steering committee more than three years later, Bob took on a central leadership role, providing major direction for the steering committee, chairing the biennial provincial meetings, and serving as an articulate and well-informed leading spokesman for the group in our media contacts.

This early period of intense MRG activity was also characterized by high profile educational work around occupational health with unions in both Toronto and Hamilton. In the latter city, a group of MRG members, including Ken Burgess, Annalee Yassi, Clyde Hertzman, John Chong, and Ted Haines, were instrumental in the formation of the first workers' occupational health clinic in Canada. While in many ways extremely successful, the clinic's life was cut short before its second anniversary due to a cutback in funds from the Stelco union. However, the clinic was resurrected in 1984 and, due to the efforts of MRG members John Chong and Ted Haines (as well as the clinic director Stan Gray) proved spectacularly successful in the number of referrals, in the outstanding quality of the clinical care delivered, and in their championing of a safe workplace for all Ontario workers. The clinic was subsequently the focus of political battles that eventually led to its demise. John and Ted have continued to take important leadership roles in occupational medicine in Ontario.

In addition to the occupational health work, the MRG was also acting on its policy of working with allied health groups by becoming an active member of the Canadian and Ontario Health Coalitions. The most exciting educational event during this period was a visit by Vincente Navarro, author of "Medicine Under Capitalism", in October, 1980.


A Period of Crisis


The initial burst of energy and enthusiasm that followed the public appearance of the MRG sustained itself for well over a year, but was followed by a period of difficulties that threatened the existence of the group. A gradual decline in the number and productiveness of the working groups, and the lack of dramatic growth in the membership, contributed to a sense of lack of direction. Attempts to address the issues included provincial meetings devoted in part to examining "whence the MRG", and a newsmagazine that failed because of lack of funds. A split in the group was identified between those who believed that abuse of technology and environmental contamination were problems that could be corrected by a change in the social system (Fred Freedman being a leading exponent), and those who felt that technology and industrialization were damaging however they were used (the position espoused by Trevor Hancock). A bigger threat was posed by the group's administrative problems. The immense job of keeping records, preparing and sending mailings, and keeping track of the membership and its dues had been taken care of by Gordon Guyatt during the MRG's pre-history, and subsequently by John Marshall. Although Debby Copes and Brian Gibson had made a monumental effort to keep up with these chores, the steering committee was finding that all their time and energy was being devoted to administrative matters, and despite this the situation was deteriorating. It became clear that hiring a part-time executive secretary was imperative, and the decision to hire Howard Cash was made at a provincial meeting at the South Riverdale Community Health Centre in October 1981. Funding this job required a major increase in income, and with considerable reluctance dues for graduate physicians were increased to $100 per year.

Following this change, the MRG's fortunes improved. The membership lists were reorganized, and regular mailings were established. Most of the membership paid the higher dues, and this assured financial solvency. At a number of meetings members acknowledge the importance of the MRG as a support system for progressive physicians was acknowledged, our common goals recognized, and our significant political voice appreciated.

When considering the resolution of the crisis, the accomplishments of the MRG's first five years are worth bearing in mind. Education of the group was served by regular meetings in Toronto and Hamilton discussing issues such as health care in other countries, occupational medicine, and what we mean by progressive private practice, and by educational sessions at the biennial provincial meetings (with speakers such as health economist Greg Stoddart, political scientists Robert Chernomas, Malcolm Taylor, Vincente Navarro). Invited speaking engagements with a wide variety of community groups allowed the MRG to fill its external educational function. The MRG provided a public service to groups such as occupational health committees in the workplace, and a Hamilton group called the Pro-Hospital Committee fighting for improved health facilities in the city's east region. The MRG formed effective alliances with other individuals and groups working for positive change in the health care system, groups such as the Ontario and Canadian Health Coalitions, pro-choice groups in Toronto including the Physicians for Choice, and the Committee for Responsible Marketing of Pharmaceuticals, as well as broader-based groups including the Coalition Against the Death Penalty.


Defending Medicare


The next few years saw a continuing struggle over the maintenance of our health care system in which the MRG played a major role. In the spring of 1982 the Ontario Medical Association (OMA) began a series of rotating strikes to support their wage demands. The MRG issued a strong statement of condemnation, and our position against the OMA was widely publicized. In the summer of 1982 five MRG members met with the health minister, Larry Grossman, and discussed our major positions regarding user fees, health premiums, community health centres, and alternative reimbursement systems for physicians. On Mr. Grossman's initiative, the provincial government organized an Ontario Council of Health conference on health care in the 1980's held in April, 1983, to which a large number of groups were invited. The MRG submitted a brief outlining our major positions, and three MRG members attended and played an active role in the conference discussions. The College of Physicians and Surgeons, in a widely publicized brief to the Council of Health conference expressed support of user fees. In an equally publicized rebuke, the MRG pointed out that while the College is mandated to defend the public interest, user fees are contrary to this interest, and that the College had acted undemocratically in not soliciting the views of its members before taking its position.

1984 saw the MRG play a major role in debate over the Canada Health Act. While feeling that the Act may not have gone far enough, the MRG was supportive of its content. MRG members spoke at a number of educational sessions sponsored by the Ontario Health Coalition, presented a submission to the House of Commons health care committee, and countered the misleading statements made by the OMA and the National Citizens Coalition concerning the Canada Health Act. MRG members debated representatives of groups such as the OMA and the Association of Independent Physicians in various public forms and in the media, over the Canada Health Act and the economics of health care in general.

Over this period other major MRG activities included major support of pro-choice activists in Toronto, work that was led by Miriam Garfinkle and Mimi Divinsky; submission of a brief to the Health Professions Review committee emphasizing the need for greater public input in monitoring the performance of the health professions which was prepared by Don Woodside, Paul Rosenburg, and Clyde Hertzman; and submission of an intensively researched brief prepared by Joel Lexchin and Bob Frankfurt to the Eastman Commission on the pharmaceutical industry. This last brief called on the government to abandon plans for legislation that would change the patent act in favour of the multinational sector of the pharmaceutical industry and contrary to the public interest. Joel subsequently published a book entitled "The Real Pushers" examining the role of the pharmaceutical industry in Canada. The MRG also presented a submission to a Canadian Senate committee that examined health care issues not fully addressed by the Canada Health Act.

1984 also saw Ulli Diemer. take over as executive secretary. Ulli was responsible for a number of positive changes, most notably a major upgrading of our newsletter which has since summarized important ongoing developments in health care in Ontario. Since Ulli took over the quality of the newsletter has been consistently outstanding and provided interesting reading for anyone interested in both MRG activities or simply the health care scene in Ontario. Ulli has also done an outstanding job on the organizational aspects of maintaining the group which has provided the steering committee with the time and confidence to continue to address major health issues.


The Maturing of the MRG


When the MRG was formed the members were almost exclusively house staff and medical students; by 1985, over 75% of our membership were practising physicians. By that time the membership included doctors in family practice, internal medicine, surgery, occupational health, and psychiatry. A number of MRG members are involved in academic medicine, to a large extent in areas of clinical epidemiology, public health, and occupational health. The spectrum of our membership, and the areas of expertise spanned, allows us to speak with authority both on issues directly related to clinical practice, as well as areas such as health economics, health technology, and quality of care.

In looking at the nature and attitudes of the MRG in 1985, the results of a study of the group is of interest. James McDermid, a graduate student, approached the Steering Committee and was given permission to survey the MRG membership. Sixty-seven per cent of the membership responded to the survey. The most important findings were that 90% of the group felt that its lobbying function was "very important" in their reasons for joining, and that most would terminate their membership if the MRG stopped lobbying.


The End of Extra Billing: MRG Participation in the Battle


The test of the maturity and credibility of the MRG came with the intense political struggle that accompanied the introduction of the Health Care Accessibility Act. The scene for legislation to end opting out and associated extra charges for patients was set when, in the spring of 1985, Frank Miller's short-lived provincial government was defeated. The MRG contributed to this event by pointing out a contradiction between what Frank Miller was telling the people of Ontario concerning extra billing, and what he was telling the provinces' physicians. The issue received front page coverage a couple of days before the election.

The Conservatives were replaced by a Liberal minority which could govern only with NDP support. It didn't take the government long to suggest that they would introduce legislation to end extra billing. In preparation, they organized a series of public forums to raise awareness about the proposed legislation. MRG members participated, along with members of the Liberal caucus, as panellists in a number of these forums. The public forums included the first of what was to be a long series of exchanges between MRG spokespersons and OMA representatives and sympathizers, exchanges that were sometimes acrimonious, and always intense.

The struggle escalated when the legislation, then called Bill 94, was introduced in December 1985, and the OMA first talked about the possibility of a strike in response to the legislation. The next few months saw the issue in the headlines almost every day, with progressively increasing physician militancy. Initially, the OMA refused to negotiate with the government; when closed-door negotiation began in March 1986 there was a total deadlock. The first physicians' rotating strikes began in February. In late May, the OMA called a full strike of Ontario physicians. When the government was undeterred, the OMA introduced further sanctions and organized major reductions in the service of a number of emergency departments in hospitals throughout Ontario. The legislation was finally passed on June 20, but the strike continued in full force for another week. Physician support for the strike began to erode by the end of the month, and the strike was called off in early July.

The MRG was spectacularly effective in presenting its position in support of the legislation. With each major event in the drama, the media described both the OMA position and the MRG reaction. This was true of newspapers, radio, and television. The MRG was included in special news presentations about the extra billing legislation and the doctors' response (such as a segment of CTV's "W5"), and our position was presented in major published articles in the Globe and Mail and Toronto Star (op-ed pieces in both), the Hamilton Spectator, and the London Free Press.

There were a number of reasons for this success. First was regular contact maintained by Michael Rachlis and Phil Berger in Toronto, and Gordon Guyatt in Hamilton, with the media people involved in covering the story. Mike and Phil were particularly outstanding in co-ordinating our contact with the media. Second, the steering committee members and other MRG members dealing with the press were in regular contact (often daily), planning strategy and ensuring a consistent, logically and politically sound response to ongoing developments. Third, we had fully researched the issues prior to the legislations being introduced and were, for example, able to rebut, citing empirical evidence, the claim that user charges decreased health care costs. Our data base and the close co-ordination of our response facilitated the fourth major element in our success: the calm, articulate, and closely reasoned responses that we were able to offer to the media. This was true not only of the primary spokespersons (Mike, Phil, and Gordon) but also of others who presented our position: Don Woodside, Bob James, Mimi Divinsky, Doug Sider, Bob Frankford and, in London, Barbara Lent.

The impact of the MRG in the struggle can only be a matter of speculation. However, we destroyed the myth of the unanimity of the medical profession in a very visible and repeated fashion. This may have had an important psychological effect both on the profession and on the government in holding firm on the legislation. We repeatedly pointed out fallacious arguments the OMA was using: that extra billing was an effective way to control costs; that patients didn't suffer as a result of extra billing; that extra billing was a mechanism to reward superior physicians; that physician autonomy in practice would be compromised by the legislation. Credible challenges to these points could only have come from within the profession, and our responses compromised the OMA's ability to spread misinformation. Our effectiveness was such that quite early in the battle the OMA refused to participate in any debates with the MRG, or any panels or news programs if a member of the MRG were to be present. We also gained a great deal of credibility with the government, and also with the Conservative opposition. For example, an intervention by Mike Rachlis played an important role in avoiding further delay in passing the Health Care Accessibility Act.

One testimony to our impact was an editorial that appeared in Ontario Medicine, the OMA's official journal, after the strike was over. It castigated the media for its coverage of the MRG. One section of the editorial provides a good description of the MRG's effectiveness: "Perhaps the most disturbing breach of journalism ethics evident in some of the news media, particularly the Toronto Star, the Globe and Mail and the CBC, is their insistence on including, with virtually every comment by the O.M.A., a contrary statement by the Medical Reform Group...It isn't so much their statements that rankles (sic), but the fact that such an insignificant rump group is given "equal time" with the recognized representatives of Ontario's 18,000 physicians." Four years after the event a CMA representative, in a statement published in the CMAJ, still referred to the MRG during this period as being, "darlings of the media".

It is clear that in the extra billing crisis the MRG fulfilled, in an outstanding fashion, the role of political lobbying that the majority of the membership see as its primary mission.


The MRG After the Health Care Accessibility Act


In the aftermath of the doctors' strike, the MRG continued its lobbying activity in other areas. A political alliance, including the MRG (led by Joel Lexchin and Bob Frankford), was unable to prevent the Mulroney government from passing amendments to the Patent Act. This legislation extended the patent length, a move made in response to pressure from the multinational pharmaceutical manufacturers. A happier conclusion followed the activities of the pro-choice movement, in which the MRG (led by Mimi Divinsky and Miriam Garfinkle) has participated for a number of years, when the Supreme Court of Canada struck down legislation limiting women's right to abortion. Free-standing abortion clinics such as those established by Dr. Henry Morgentaler were, for the first time, legal. The prominent role in this struggle played by MRG member Nikki Colodny is worth noting.

The Ontario government struck a committee to examine privatization within the health care system. Our brief to the committee pointed out that private medicine in the United States was considerably more expensive than public medicine in Canada, and explained the reasons. Other MRG submissions during this time period included briefs to the Evans Committee on health care, and the Schwartz Commission on Legislation for the Health Professions. Brian Hutchison, Pat Smith, and Catherine Oliver were the major contributors to a superb, carefully researched, and powerfully argued brief to the Task Force on the Implementation of Midwifery in Toronto. The MRG presentation to this group was very well received, and the recommendations of the Task Force was consistent with the MRG's position that midwifery has an important potential role in Ontario.

December 1986 marked the beginning of a new phase for the MRG Newsletter. Haresh Kirpalani began a leading role in editing the Newsletter, soliciting "think pieces" and discussions of controversial issues from the membership. This increased the interest and value of the Newsletter, which was renamed "Medical Reform".

In 1987 MRG concern with the growing number of Canadians with Acquired Immune Deficiency Syndrome led to the formation of an MRG AIDS working group. This working group brought issues to do with confidentiality, education, and drug treatment to the MRG, and has been active in the community.


The MRG and Resource Allocation


The evolution of the MRG in the 1988 to 1990 period was profoundly influenced by the changing political environment. Cost control in the health care system became the major priority of the provincial government. Fee increases to physicians were essentially put on hold, and the OMA responded by a campaign that suggested that government funding constraints were compromising the quality of care. Episodes suggesting suboptimal care (patients waiting excessively long periods for cardiac surgery, an intensive care unit bed not being found for a woman who subsequently died) began appearing with increasing frequency in the press.

These developments suggested that if the MRG was to make a significant contribution to the most important current debates, a focus on issues of resource allocation was required. This position was initially taken most forcefully by Michael Rachlis. Michael's own career was evolving, and his publication of "Second Opinion", a critique of the Canadian health care system, elicited widespread interest. Michael became famous, and it is hardly an exaggeration to say that any conference or meeting on health care was incomplete with his participation as a keynote speaker. He was widely quoted in the lay press as an alternative voice from that of organized medicine. His statements stressed the extent to which health was determined by factors outside of health care, and the inefficiencies in the delivery of health care.

In the meanwhile, the MRG was responding to Michael's suggestion that resource allocation was the primary current issue in the system. In the latter part of 1988 a resource allocation working group was formed. The major players in this effort included Andy Oxman, Haresh Kirpalani, Rosana Pellizari, and Gordon Guyatt. In its efforts to achieve a coherent position, the working group struggled with what proved to be a series of complex issues. Early in its deliberations, a discomfort with the position Michael Rachlis was taking in public was noted. Some MRG members felt that excessive stress on the limits of health care in achieving health, and on the inefficiencies in the system, could provide support for forces (currently very strong) that would be inclined to reduce health care expenditures to the point where high quality care for all would be compromised.

For the next 18 months, issues of resource allocation became the focus for the MRG semi-annual meetings. In the spring of 1989, the Friday night session at the semi-annual meeting was framed as a debate between Michael and Gordon Guyatt. While well-attended and interesting, the debate was a disappointment in that a clear delineation of the areas of controversy and disagreement did not emerge. The subsequent meeting provided the forum for a general discussion of issues of resource allocation.

Following the meeting, the resource allocation group further developed their position with a series of "think pieces", each accompanied by a resolution, which were published in "Medical Reform". These resolutions were debated at the semi-annual meeting in the autumn of 1989 and largely endorsed by those attending.

The activities of the Resource Allocation Working Group did little to dispel the sense of lack of direction within the group. Steering Committee membership was falling, and public statements by the MRG were virtually absent. The autumn semi-annual meeting was poorly attended, and the position of the Resource Allocation Working Group appeared poorly understood by many members; the clear consensus the working group had been hoping for had not emerged. This led to a sense of crisis, and an expanded meeting of the Steering Committee was held at Haresh Kirpalani's in January 1990. The issue on the table was "should the MRG disband". It was pointed out that membership had been well maintained, and many who had been polled informally were very upset at the thought of the group disbanding. There was an unequivocal decision that the group should continue, though clear solutions to the problems of lack of energy and direction were not forthcoming.

The Steering Committee decided that fundamental disagreement about resource allocation issues remained, and required resolution if the group MRG were to move ahead. At the Spring semi-annual meeting the discussion was initially organized around a debate between Ralph Sutherland (taking the position that health care was a minor contributor to health, that resources should be shifted outside of the health care system to other social expenditures, that two-tiered medicine should be accepted, and that "capping" was a useful cost containment strategy) and Gordon Guyatt (taking the position of the resource allocation working group), followed by small group discussions around how the MRG should respond to specific issues appearing in the press. The Resource Allocation Working Group had further clarified its position. The concept of "Thatcherism", an attempt to cut social and medical spending and drive the system toward a two-tiered structure reliant on private funds, and the need to defend against Thatcherism, appeared helpful in communication the working group's concerns.

The result of the discussion was a discovery that despite some fundamental differences in viewpoint, there was a great deal of agreement, and that a clear response that represented the MRG's view to issues currently appearing in the press could be easily formulated. This consensus aided MRG representatives in their subsequent statements to the media.


The MRG, 1990 and After

MRG activities in this period are organized according to major themes.

The Organization of Primary Care
Bob James, Joel Lexchin, and Fred Freedman led a Primary Care Working Group which formulated what they called a "HUB" model of the delivery of primary care. The proposed HUB would be a physical office community with a computerised data base summarizing the health status of the local community, would have some mechanism of community input, would be a focus of continuing medical education, and would be involved in community outreach, in part through provision of nurse practitioner and social services. Each HUB would serve three to six primary care practices and would provide information to the District Health Council. The MRG discussed the model at the semi-annual meeting in October, 1990, and there was considerable support for the ideas. While the group did not take the model farther, the discussion advanced MRG thinking in primary care.

The issue of the organization of primary care arose again in 1992. Here the focus was physician reimbursement, with the Resource Allocation group doing the background work. Their proposals were debated an the autumn semi-annual meeting in November 1992. We reached a consensus on the advantages and disadvantages of the various funding mechanisms and a final position that harked back to our founding principles.
i) The political, social, and economic causes of ill-health should be recognized, and strategies to deal with these causes should be integrated into our health interventions.
ii) The power and autonomy of non-physician health workers should increase.

Capitation and salary arrangements are essentially compatible with these goals, whereas fee for service is not. The MRG therefore supports a major change in the structure of the current health-care system to one in which the primary mechanisms for reimbursement of primary health care delivery would be capitation and salary.

Since the organization and reimbursement mechanisms of primary care are likely to be an area of increasing focus, this resolution gave MRG spokespeople a clear position to present in public statements and debates.


The MRG and American Health Care

The late 1980's saw a ferment in the American health care system predicated on the realization of huge inequalities and uncontrolled cost. By 1989 there was a great deal of interest among Americans about the Canadian health care system. Progressive groups in the United States looked for informed Canadian physicians to educate them, and their constituents, about how health care in Canada works. The MRG spend considerable energy filling this role. Gordon Guyatt and Haresh Kirpalani prepared a rigorously documented summary of the relative merits of the two systems with respect to coverage, patient satisfaction, physician satisfaction, health status, and costs. They prepared a slide show which was taken on the road by MRG speakers. MRG members participated in conferences on health care in Canada and the United States, such as the Pugh foundation conference in Toronto in May 1990. MRG members presented talks to labour and community coalitions (such as Maine's Citizens for Affordable Health Care or Massachussetts' Health Care for All), and physicians' groups. The American physicians' group advocating a universal single-payer system, the Physicians for a National Health Policy, saw the MRG and as an important ally, and obtained MRG participation in press conferences and symposia. The most exciting endeavour was a 12 city series of presentations to the press, radio talk shows, community groups, labour groups, and politicians organized by the Democratic Socialists of America in the summer of 1991. MRG representatives spoke side by side with Canadian labour activists and NDP politicians heavily involved in health care.

MRG members who participated in the tour included Mimi Divinsky, Rosana Pellizari, Haresh Kirpalani, Gordon Guyatt, and Don Woodside. The cities they visited included New York, Chicago, Washington, Philadelphia, Hartford, and several west coast cities. It was a tremendously experience for the participants, and the enthusiasm they met was very exciting.

The MRG was also active in rebutting distorted impressions of Canadian health care being presented in the American press. Of note were two letters published in the New England Journal of Medicine, one in June 1990 in response to an article by Adam Linton (N Engl J Med 1990 Jun 7;322(23):1675-6), and the other in November 1992 in response to a letter from a disaffected Canadian physician reporting derogatory anecdotal comments about Canadian Health Care delivery (N Engl J Med 1992 Nov 26;327(22):1603).

The MRG and the Ontario NDP Government
The election of the NDP government in 1990 meant a sympathetic ear for the group in the provincial parliament. The MRG, in meetings with Health Ministers Evelyn Gigantes (December 1990) and France Lankin (December 1991) and Deputy Minister Michael Decter (autumn 1992) emphasized positions worked out by the Resource Allocation group. These included the dangers of excessive cost cutting, the need for decisions to be made democratically, and on the basis of evidence, and the areas in which costs could appropriately be constrained (excessive physician use of diagnostic tests, in part through increased use of independent health facilities and getting diagnostic test facilities out of physicians' offices; licensing of health technologies; and restriction of funding for unproven procedures). The MRG, represented by Phil Berger, had a positive influence the method in which the new health cards were introduced at the beginning of 1992. At the invitation of the government, the MRG participated in a National Conference on Physician Management in June 1992. Through contacts with Frances Lankin's Executive Assistant Sue Colley, the MRG provided comments on a number of the Health Minister's speeches, and made a number of nominations to Ministry working committees. Mimi Divinsky and Rosanna Pellizari were able to represent the MRG position concerning proposed delisting of procedures -- that delisting be done only after careful consideration of the underlying principles, public debate, and with provision for services still being covered where legitimate -- directly to Ministry personnel. The were able to reinforce the Ministry's understanding that delisting will not help deal with the province's health care problems.

MRG Internal Matters
In June of 1990 the CMAJ published an article which presented a rather unflattering picture of the MRG searching for a purpose. Ralph Sutherland was particularly negative about the group. However, many took the view that such major publicity was better than no publicity at all, and the steering committee had a chance to reply in a letter to the editor.

In February of 1991 the MRG sent a letter to the Prime Minister, noting the heroic action of steering committee member Robbie Chase in participating in formation of the international peace camp in Saudi Arabia, and suggesting that war was not the best response to the crisis. The steering committee was subsequently criticized for the not including wider consultation with MRG members, though there was a split in the group on the appropriateness of the steering committee's action. The incident led to two long-standing active MRG members not renewing their memberships.

In August of 1991 the MRG decided to change the format of semi-annual meetings. Recognizing the increasing competing demands in the lives of the members, semi-annual meetings were subsequently held on weekday evenings and were seen as opportunities for members to participate in debate on the most relevant current issues, rather than educational sessions which would require a large attendance to be successful.

One issue addressed in the first such meeting, in October, 1991, was whether, in response to the OMA and the Ontario government agreeing to Rand formula for Ontario physicians, the MRG should become a section of the OMA. The decisions was to reject this course, and to continue to stand on our own.

Steering Committee members at the beginning of 1990 included Bob James, Mimi Divinsky, Rosanna Pellizari, Haresh Kirpalani, Bob Frankford, Don Woodside, and Robbie Chase. Jim Sugiyama, although not attending steering committee meetings, was in charge of membership. Bob James stepped down from the Steering Committee after his second stint in April of 1990. Gordon Guyatt began a second tenure on the Steering Committee in June, 1990, and Murray Enkin joined for the first time in November, 1990. John Frank started a second stint on the steering committee in January 1991 and stayed active for over a year. Bob Frankford resigned from the Steering Committee after being elected as an NDP member of parliament. Don Woodside left the committee in the summer of 1991, Andy Oxman in the summer of 1992, and John Frank at the end of 1992. Vera Tarman and Chris Jinot joined the steering Committee in August, 1992.

The Pharmaceutical Industry
Led by Joel Lexchin, the MRG continued to be very active in fighting the interests of multinational drug companies. Joel sat on a committee of the Royal College of Physicians and Surgeons charged with developing guidelines for interaction between physicians and the industry to which Rosana Pellizari and Gordon Guyatt made, on behalf of the MRG, a submission. Joel led the MRG in joining with Canadian Health Coalition to submit a brief to the government opposing Bill C-91, which would further extend the patent life of products produced by the multinational companies. Gordon Guyatt, on behalf of the MRG, published a major editorial on the "Commentary" page of the Globe and Mail in January, 1993. The editorial pointed out inaccuracies and spurious arguments raised by a McGill Emeritus Professor who, in a previously featured editorial in the Globe and Mail, had suggested that science supports C-91.

Gordon Guyatt, in his role as Residency Director of the Internal Medicine Program at McMaster introduced Guidelines to eliminate both receipt of industry largesse (including drug lunches) by residents and attendance by industry representatives at resident educational events. The Guidelines were inspired by his work and contacts with the MRG.

Working with other Groups
The MRG continued to play an active role with the Canadian Health Coalition and played a particularly important part in the revival of the Ontario Health Coalition. Haresh Kirpalani was very influential in helping set the direction of the new OHC. Particularly important were the well-formulated policies coming out of the documents produced by the Resource Allocation Working Group. The OHC was aware of the importance of stressing the need for alternative services, and thus new resource commitments, if resources to hospital and other high technology services were to be cut.

The Public Face of the MRG
In February of 1992 McMaster University notified all faculty that they should bill patients without health cards directly. A group of MRG McMaster faculty took on the administration over this issue, and ended up having them rescind the initial directive.

In 1994, the Steering Committee decided we needed to be much more active. We set a goal of having a press release at least once each month, with the result that our media profile rose immediately.
The MRG was active in radio, television, and the newspapers on a number of issues. These included the threat to universal health care by reduction of transfer payments from the federal government, the great benefits of Canadian versus American health care, and the threat of reintroduction of user fees. Venues included radio interviews, letters and op-ed pieces in the Globe and Mail, the Toronto Star, and the Hamilton Spectator, and magazine articles. MRG spokespeople representing the group included Mimi Divinsky, Haresh Kirpalani, Gordon Guyatt, Rosanna Pellizari, Don Woodside, and Bob James.


MRG News Releases 1979 - 1995.

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