The following is an excerpt from McMaster Children’s Hospital: Celebrating the first 25 years, ISBN 0969743564, 9780969743569. The book was launched on October 16, with copies available through the university stores and select booksellers.
What’s past is prologue
The origins of pediatric care in Hamilton
by Glen Herbert
In his address at the dedication ceremony, Dr. Peter Dent mentioned that “We were originally designated as a Children’s Hospital at Chedoke back in 1960 … there have been a lot of changes since then.” True as that statement was, there were likely few in the audience who had any clear idea of what he was talking about. The fact was this wasn’t the first time that a children’s hospital had been attempted in Hamilton. The precursor began thirty years earlier when Dr. Hugo Ewart, superintendent of the Mountain Sanatorium, started hatching plans to repurpose the aging hospital on the hill. It was a bold idea given that most people at the time failed to see the need for a pediatric hospital. Perhaps because of that context, Ewart’s approach, at least initially, could appear veiled and reluctant. In a letter to his board dated November 26, 1958, he wrote, “You have probably been interested in the report in the press, that we are considering converting the Wilcox Building to a children’s hospital and have wondered what is happening at the Mountain Sanatorium.” No doubt the board would have been very interested, if not a bit miffed that the public became aware of the plan via the media before they did.
The urge to refocus the institution came from a problem we don’t see much of these days: empty beds and a declining patient load. The Sanatorium had been created in 1906 as a centre for the treatment of tuberculosis. With the development of the antibiotic streptomycin in 1946, mortality rates from TB plummeted. Tuberculosis wards, an enduring symbol of the Victorian age, were becoming a thing of the past, the Mountain Sanatorium among them. Suggestions around the restructuring of the facility as a children’s hospital were met with quiet conservatism—many felt that the respite from tuberculosis would prove to be momentary—which was perhaps why Ewart felt he needed to handle his board with kid gloves.
Health care in a changing world
Efforts to proceed with caution proved to be the right approach. From the moment the plan became public it was surrounded by controversy, both within and without the confines of the Sanatorium boardroom. On March 5, 1957, the Hamilton Spectator newspaper ran a story that began like a potboiler: “A chill wind is blowing across the large, modern wing of the Mountain Sanatorium, where it is planned to establish a children’s hospital for Hamilton and district.” That ominous description foreshadowed the kind of debate that would surround efforts at providing children’s acute care in Hamilton then as well as in the coming decades.
In Ewart’s time, there was a two-tiered health system, with open hospitals—those to which community doctors could admit and attend to their own patients—and closed or private hospitals, which had a dedicated medical staff and where community physicians were not able to attend their patients once admitted.
From the outset, Ewart had to walk a very fine line. The Sanatorium had been a private hospital, one that operated for profit, and the board, Ewart rightly assumed, wanted to keep things as close to that model as possible. It was the fiscal health of the institution, and a desire to maintain the Sanatorium staff—rather than a desire to provide better care for children—that ultimately guided him the most. “After a good deal of thought,” Ewart wrote to his board, “I am convinced that the children’s hospital which is being proposed must be open.” Children would be admitted as charges of the community and cared for by community physicians.
It was the grandest moment in all of Ewart’s correspondences, though very quickly the moral high ground fell from beneath him. In 1957, the Hospital Insurance and Diagnostic Services Act was passed, a plan for provincial and federal governments to reimburse one half of the cost of health care and services, and universal health care would follow in the next decade.
Ewart, nevertheless, forged ahead. On December 9, 1960, the hospital was opened as the Chedoke General and Children’s Hospital. Invitations were printed, tea and a tour of the facility was given to members of the public who attended the opening. The Mayor spoke, as did the Minister of Health for the province of Ontario. The ribbon-cutting honours were handled by Dr. A. D. Unsworth, a community leader who, in 1906, had become the Hamilton Health Association’s first superintendent.
It was a brief moment in which the controversy died away, though any air of celebration was to be short-lived. Because of the changing face of health care in Canada, the new hospital quickly became irrelevant and, ultimately, entirely ignored. By the time it should have been celebrating its tenth anniversary, the Children’s Hospital at Chedoke had quietly vanished. The facility was renamed Chedoke Hospitals in 1971 and the pediatric beds and staff were amalgamated with those at McMaster University Medical Centre.
More than anything, the episode was a learning experience. Clearly, if there was ever going to be a children’s hospital in Hamilton, its creation would require a very different approach and be based on a very different set of goals and expectations.
Championing a cause
One of the problems that Dr. Hugo Ewart faced was that of perception. Even into the 1970s, the need for a children’s hospital wasn’t at all clear to those outside the at times rarefied world of pediatric care. Most parents, and perhaps most community physicians as well, didn’t see a need for dedicated children’s services. Medicine was about medicine, the thinking went, not age. A surgeon who could take out the appendix of a 50-year-old, it was presumed, could just as easily take one out of a five-year-old. To have both adult and pediatric services often appeared redundant to those where were less immersed in it.
Those within the growing field of child health, however, were beginning to hold a longer view of the opportunities and the responsibilities that pediatric care could represent. In 1973, Dr. Angus MacMillan, then chair of the Department of Pediatrics at McMaster University, was asked by the Hamilton-Wentworth District Health Council, an agency of the provincial Ministry of Health, to report on the needs of the pediatric population in the Hamilton region. “Ideally,” he would write in his report, “the Hamilton community should look to the development of a child health program based on a thorough understanding of the needs of the children in this community as it might relate to the District and Region.”
While there were pediatric services throughout the Hamilton hospitals, they lacked a unified vision and therefore a unified application of care. Pediatric services were spread across the five Hamilton hospitals operating at that time: St. Joseph’s Hospital, Hamilton General, Henderson General, Chedoke General, and McMaster University Medical Centre. The placement of those services didn’t follow an internal logic and was developed independent of any overarching plan. All but the Henderson had pediatric inpatient beds, although that hospital was the centre for neonatal care. Of those with pediatric beds, Chedoke had the least, despite the fact that it was the centre for long-term care of chronically ill children.
In comparison, McMaster University Medical Centre could easily appear a poor cousin. Few of the pediatric beds that were available there were actually in use. No pediatric emergency visits were reported there in 1972 (the year on which MacMillan’s report was based), while Hamilton General reported more than 14,000 and St. Joseph’s Hospital reported close to 10,000.
MacMillan argued that children could be better served within an exclusively pediatric environment, which he defined as a single unit of 100 beds, with a staff trained in the care of children, and a robust program of outpatient clinical services. The unit, he said, should be situated in an academic centre (specifically McMaster University) so that research and teaching could occur alongside clinical work. In all, what he was suggesting was a global restructuring of the pediatric care in the city, and to locate the bulk of it at McMaster University Medical Centre.
From the outset, his report didn’t gain many fans. “It caused considerable outrage in the community,” MacMillan recalled recently. “There were complaints of disruptive and inconvenient logistics, interference in physicians’ practices, control issues, religious issues, choice issues.” Even as he put the finishing touches on the report—the document is palpably passionate and canny in its recommendations—MacMillan knew that the political realities within the city simply wouldn’t allow many of the things he was suggesting. In a story that ran in the Hamilton Spectator, he was quoted as saying of the document he authored that, “it’s a valid report but you’re crazy if you expect it to happen. It just won’t go politically.” Such a statement underscores MacMillan’s perspective at the time. He wasn’t thinking of Band-Aid fixes, or triaging what could be done first and what should be left for later. Instead he chose to use the moment to engage in some blue-sky thinking toward imagining and outlining the best possible case for the city in the long term.
He knew that the context, nevertheless, presented a range of significant challenges. Having worked in both settings, MacMillan was intimately aware of the conceptual divide between the secular approach of Chedoke-McMaster, and the religion-based approach of St. Joseph’s Hospital. Sister Ann Marshall, superior general of the Sisters of St. Joseph of Hamilton, noted publicly that if the proposal went through, St. Joseph’s Hospital would no longer be able to function as its board intended. She worried to a Spectator reporter that, with a restructuring of pediatric services, St. Joseph’s Hospital “would not be able to influence policies with which we work,” including policies around abortion, euthanasia, and genetics.
On the other side of the ledger, one of the most vocal proponents of the amalgamation of children’s services was Dr. Alvin Zipursky, the founding chief of the department of pediatrics, a position he would take up again in 1978 after a six-year hiatus. In a letter to MacMillan, Zipursky wrote “I believe we must not settle for the progress that has occurred, but rather look to the tremendous opportunities that lie before us. Because of the unique character of McMaster and of the development that has occurred to date, these opportunities are also responsibilities to ourselves, to our community, to our students, to our country and to health care of children.”[1]
It was clear to Zipursky that, one way or another, things had to change, and he accepted a second term as chair and chief in part to encourage them. The department had expanded to the point at which it became evident that, among other things, the residency program was being unduly stretched between St. Joseph’s Hospital and the Medical Centre. (St. Joseph’s Hospital established a partnership with McMaster in 1969 in order to take part in the nascent medical program.) “It was very difficult to maintain both of these [locations],” recalls Zipursky, “and I made the point at that time that we could no longer have residents at St. Joseph’s Hospital.”
“That became a cause celebre. … They had big meetings about how terrible Zipursky was and so forth. And I kind of weathered the storm, and it wasn’t very nice. It was a very difficult time. … It got to be quite nasty.”
MacMillan recalls that the most frequent argument came from physicians who feared that the changes would be detrimental to their practices, and would recast their role within the community. “But that’s not the important thing. The important thing is child welfare [and] the quality of the work we’d done. … I said that the importance of it is that we have a unit that serves children, not necessarily physicians.” After a chuckle, he continues, “But I didn’t think you could have had excellence in care and teaching if you tried to do it in a lesser way.” By lesser way he meant choosing a path of least resistance and making any range of compromises, such as accepting smaller units, a less controlled environment, and fewer standards. To work, MacMillan maintained vocally in the press and at public meetings, that it had to be the whole hog. “And for all the objections that were made, there was one thing that people didn’t mention: providing the best care for children.” A mandate had been set and plans, if haltingly, were beginning to move forward.
[1] emphasis in the original
Glen Herbert 