First in fear and dread: Cancer control in Saskatchewan, the first decade - 1929-1939.

Abstract

In 1931 Saskatchewan became the first jurisdiction in Canada to introduce a province-wide program for the control of cancer. The program was conceived in 1929 by the cancer committee of the Saskatchewan Medical Association. The provincial government promptly took up the committee's recommendations for centralization of cancer care in two clinics and emphasis on radiotherapy as a mode of treatment. The following year the Saskatchewan Assembly approved The Saskatchewan Cancer Commission Act, as prepared by Health Minister F.D. Munroe, himself a physician. The Regina Cancer Clinic opened at the end of 1931 and the Saskatoon Cancer Clinic at the beginning of 1932. This initial phase of the conception and introduction of cancer control in Saskatchewan is notable for the harmony of agreement among its planners and for the rapidity with which it was introduced. Progress during the remainder of the first decade was much slower, as competing interests and priorities among a larger group of individuals and institutions, together with the Depression, help back the initial momentum. Initially, however, weaknesses accompanied the strengths of the program. Weaknesses included the reluctance of some physicians to cooperate wholeheartedly as they feared the perceived effects of the incursion of a government agency in patient care plus the increasing financial burden placed on the hospitals. The strengths of the program included the existence of the program where none had been present earlier, the availability of a diagnostic and therapeutic service for patients, and a comprehensive system of patient records. In particular, the cancer control program in its first decade was the basis for notable progress in later decades and a model for other jurisdictions.

Full text

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First in Fear and Dread: Cancer
Control in Saskatchewan,
The First Decade-1929-1939
DAVID A. E. SHEPHARD
Abstract. In 1931 Saskatchewan became the first jurisdiction in Canada to intro-
duce a province-wide program for the control of cancer. The program was con-
ceived in 1929 by the cancer committee of the Saskatchewan Medical Association.
The provincial government promptly took up the committee's recommenda-
tions for centralization of cancer care in two clinics and emphasis on radio-
therapy as a mode of treatment. The following year the Saskatchewan Assem-
bly approved The Saskatchewan Cancer Commission Act, as prepared by
Health Minister E D. Munroe, himself a physician. The Regina Cancer Clinic
opened at the end of 1931 and the Saskatoon Cancer Clinic at the beginning of
1932. This initial phase of the conception and introduction of cancer control in
Saskatchewan is notable for the harmony of agreement among its planners
and for the rapidity with which it was introduced. Progress during the remain-
der of the first decade was much slower, as competing interests and priorities
among a larger group of individuals and institutions, together with the Depres-
sion, held back the initial momentum. Initially, however, weaknesses accom-
panied the strengths of the program. Weaknesses included the reluctance of
some physicians to cooperate wholeheartedly as they feared the perceived
effects of the incursion of a government agency in patient care plus the increas-
ing financial burden placed on the hospitals. The strengths of the program
included the existence of the program where none had been present earlier, the
availability of a diagnostic and therapeutic service for patients, and a compre-
hensive system of patient records. In particular, the cancer control program in its
first decade was the basis for notable progress in later decades and a model for
other jurisdictions,
Resume. En 1931, la Saskatchewan devient la premiere jurisdiction canadi-
enne 1 introduire un programme provincial de control du cancer. Ce pro-
gramme fut mis-A-jour en 1929 par le comite du cancer de YAssociation M6dicale
David A. E. Shephard, M.D., PO. Box 31222, Greenville, N.C. 27833-1222

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324
DAVID A.E. SHEPHARD
du Saskatchewan. Le gouvernement provincial se prend en main les recom-
mendations du comite et centralise les soins des cancereux dans deux cliniques
et insiste sur la radiotherapie comme mode de traitement. L'annee suivante
l'Assembl6e provinciale approuve la "Saskatchewan Cancer Commission Act,"
preparee par le ministre de la sant6, le docteur ED. Monroe. La clinique du
cancer de Regina ouvre ses portes B la fin de l'annee 1931 et la clinique du can-
cer de Saskatoon au debut de 1932.
La periode de debut, a partir de la conception a la mise B jour du control du
cancer au Saskatchewan est remarquable par la rapidit6 de son introduction et
par l'harmonie parmis le planificateurs. Par la suite, le progrb ralenti durant la
prernibe decennie. Les priorities et les interets divers des grosses institutions et
d'individus font concurrence, ainsi que la periode de la Grande Depression,
les deux s'unissent pour ralentir le mouvement.
Neamoins, il y avait de faiblesses qui accompagnent les richesses du pro-
gramme au debut. Celles-ci comprend le refus de certains medecins de cooper&
de tout coeur, de peur de l'intevention gouvernementale dans les soins des
malades et B cause du fardeau financier impose sur les hopitaux. Les richesses
du programme etaient sa presence ou nu1 existait auparavent et l'acces a des
services diagnostiques et thkrapeutiques pour la malades cancereux et finale-
ment un systeme de dossiers medicales complets. En particulier, durant la pre-
miere decennie, le programme de control du cancer semi de fondation pour les
progres remarquables par la suite et ne meme temps servi de modele pour les
autres provinces.
INTRODUCTION
The opening of two cancer clinics in Saskatchewan in the early 1930s ush-
ered in a new phase in health care in the province, and indeed in Canada
as a whole. The first jurisdidion in the nation to develop a province-wide
cancer control program, Saskatchewan had long been in the vanguard of
liberal ideas on health care.1 The cancer control program was a further
manifestation of the coooperative approach to health care that had earlier
spawned the municipal funding of general practitioners and union hos-
pitals2 and then, over the next six decades, a tuberculosis control pro-
gram, regional heath care and finally, in 1962, province-wide Medicare.3
The conception in 1929 and the introduction in 1931 of cancer control
in Saskatchewan resulted from a productive relationship among a small
group of physicians, the provincial medical association, and the gov-
ernment. The start-up phase took less than two years. Development in
the first decade, however, was slower, as competing interests and prior-
ities during the Depression held back the promising progress that had
been made in the first year. Even so, a solid foundation was laid, and the
cancer control program in Saskatchewan became of interest to other
jurisdictions that were developing their own programs. The purpose of
this paper is to delineate the components of the program, discuss its
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First in Fear and Dread: Cancer Control in Saskatchewan
325
strengths and weaknesses, and evaluate the accomplishments of its first
decade.
BACKGROUND: THE RISING MORTALITY OF CANCER IN WESTERN
COUNTRIES
Early in the 20th century, statistical analyses suggested that the mortal-
ity from cancer in Western countries had increased alarmingly in the
previous few decades. Concern led, in 1926, to an international confer-
ence at Lake Mohonk, New York.4 This conference focused the attention
of physicians on a disease that was less obviously associated with social
factors than was tuberculosis, which may explain the more prominent
role of physicians, compared to lay persons, in the control of cancer
than in the control of tuberculosis. At the Lake Mohonk conference can-
cer mortality rates in different countries were discussed and ideas for
control of the disease shared. The cancer mortality (per 100,000 inhabi-
tants) in Holland, for example, had been 34 in 1867 but 112 in 1924;s in
Italy it had been 42.2 in 1889 but 67.5 in 1917;6 and in England a similar
trend was apparent from 1920 to 1925 when the recorded deaths from
cancer increased by between 30 and 40 per million population.7 Cancer
was now usurping the position of tuberculosis as the captain of the men
of death. In England, for example, in 1884 the annual mortality had been
257 for tuberculosis and 56 for cancer, while in 1925 the figures were 104
and 133, respectively! The situation was similar in Denmark, where in
1922 tuberculosis mortality had been 9.5 as opposed to 14.2 for cancer?
It was also pointed out that effective diagnosis and treatment of can-
cer was not a job for one person, but required the cooperation of patient,
general practitioner, specialist, and pathologist.10 A logical development
was therefore the creation of cancer clinics and organizations dedicated
to the investigation and therapy of cancer. This had occurred in France.
The French Association for the Study of Cancer had been formed in
1908, the Franco-Anglo-American League for the Control of Cancer in
1918, and the Radium Institute of Paris in 1919,11 while cancer clinics
had been established across the country in the 1920s.12
I
THE SASKATCHEWAN RESPONSE TO THE RISING MORTALITY OF CANCER
In the second half of the 1920s, some physicians in Saskatchewan, aware
of the apparent increase in cancer mortality, reviewed the situation in the
province. A report by the Department of Health revealed that the death
rate in 1905 had been 8.8 per 100,000 but 45.1 in 1926)s while the newly
formed cancer committee of the Saskatchewan Medical Association
(SMA) found that the mortality in 1928 was 55.2.14 The trend in mortality
from cancer was, therefore, indeed increasing, as it was elsewhere. It

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DAVID A.E. SHEPHARD
was through concern over these findings that cancer control in
Saskatchewan developed. Before the events leading to this program are
described it may be well to answer the question as to why the first
province-wide cancer control program should have developed in
Saskatchewan rather than elsewhere in Canada.
When the SMA cancer committee was struck in 1929, several pro-
grams designed to protect and preserve the health of Saskatchewan cit-
izens had existed for a decade and a half. Though the ideas behind these
various programs were liberal in themselves, the soil into which the
seeds of these ideas were sown had to be receptive, and it was the
response on the part of the people of Saskatchewan that explains the ger-
mination of those ideas. Underlying this response was a social collec-
tivism that embraced social, cultural, economic, and political factors that,
together may be included under the rubric of a philosophy of coopera-
tiveness.15 Stuart Houston has summarized the practical aspects of this
philosophy in suggesting that "house raising, barn raising and the build-
ing of community amenities such as schools and rinks made it logical for
more sophisticated developments to occur." l6 The European immigrant
farmers who came to the territory that became Saskatchewan in 1905
were rugged individualists but also communally minded, as they had to
be-particularly in winter-to survive on the bleak prairies of their
adopted homeland. These traits informed the early development of
health care. It is therefore not surprising that in 1930, following the
emphasis placed by Saskatchewan physicians on the problem of the
increasing mortality from cancer, Hon. E D. Munroe, Minister of Public
Health in Saskatchewan and himself a physician, should feel able to call
on the "hearty and sincere co-operation of all citizens in the attack" on
cancer that was about to be launched.17
DEVELOPMENT OF THE SASKATCHEWAN CANCER CONTROL PROGRAM
I
The cancer committee of the SMA first met in November 1929. Initially,
its members included R. H. MacDonald and Earle Shepley, of Saska-
toon, T . M. Leask of Moose Jaw, and C. M. Henry and E. B. Alport, of
Regina. Later, they were joined by Drs. W, L. Lindsay (Dean of the two-
year preclinical College of Medicine at the University of Saskatchewan);
Professor E. L. Harrington (Department of Physics, University of
Saskatchewan); R. C. Riley and D. S. Johnstone of Regina; and J. E.
Bloomer of Moose Jaw. It was the deliberations of this committee that
generated the ideas and momentum that were essential to the program.
The committee reviewed advances in the management of cancer and
made recommendations.18 The main one was for a provincial program
for the study and treatment of cancer. Recommended elements of the
program were the following:

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First in Fear and Dread: Cancer Control in Saskatchewan
327
Treatment should be centralized, with two consultative clinics, in
which a pathologist, a surgeon, a radium therapist, and an internist
would have diagnostic roles, while the referring physician would
take action on treatment;
The relationship between attending physician and patient should be
protected and undisturbed;
Directors competent in the use of radium should be in charge of
each centre;
A radium emanation plant should be situated at the University of
Saskatchewan, directed by the professor of physics, with radium
needles or radon being under the direction of a qualified radium
therapist;
Treatment should be charged for; and
Reporting of cases should be voluntary.
These recommendations were included in the definitive program.
Another recommendation, which was not fulfilled until later, was that a
Canadian Society for the Control of Cancer be formed.
For his part, Health Minister Munroe's primary task was to draft leg-
islation that would provide the basis in law for the various elements of a
cancer control program. In undertaking this task he received invaluable
information and advice from members of the cancer committee. Partic-
ularly helpful was Dr. Earle Shepley, who kept Munroe informed about
the many aspects of cancer control that would have to be built into the
Saskatchewan program. Shepley's advice, and in general that of his col-
leagues, was appreciated by Munroe, who sought "the sympathetic co-
operation of the medical profession."lg
The Saskatchewan Cancer Commission Act, 1930
Munroe spent the early part of 1930 preparing Bill 33, which was to lead
to both The Saskatchewan Cancer Commission Act of March 1930 and the
Saskatchewan Cancer Commission. His work is reflected in the docu-
ment titled "The Cancer Problem in Saskatchewan," a comprehensive
and well-researched paper that was the basis for his address to the
Saskatchewan Assembly on 17 March 1930.20 Munroe called for the cre-
ation of a provincial body that would coordinate the attack on cancer. He
identified several aspects of the cancer problem. One was the increase in
the incidence of cancer; another was the "insidious" nature of the early
symptoms, which underlined the need for education of the public on the
importance of early examination and diagnosis-and for an adequate
and efficient diagnostic and treatment service. In a geographically large
but sparsely populated province these various aspects of the cancer
problem bespoke difficulties and a daunting challenge. Munroe's solu-
tion, which was thus far recognized by only a few in Saskatchewan, was
I