A Brief History of the
Medical Reform Group of Ontario
1979 - 1994
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
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
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
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.
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
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
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
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
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
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 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
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
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
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
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.
News Releases 1979 - 1995.
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