1 In the early 1960s the University of Chicago’s Center for Health Administration as well as Uppsala University’s Department of Social Medicine launched a comparative study of health services in the United States, England, Wales, and Sweden. The project did not include, nor was ever intended to include, a Canadian component, but it nevertheless involved an important Atlantic Canadian connection. One of the project’s lead researchers, Duncan Neuhauser, spent the summer of 1959 as a x-ray assistant for the International Grenfell Association (IGA), a medical-missionary organization that operated in northern Newfoundland and Labrador from the 1890s until the early 1980s. Shortly after leaving Newfoundland, Neuhauser joined Chicago’s Center for Health Administration as a Kellogg Fellow and was hired to investigate health services in Sweden’s northern counties.
2 Although Neuhauser’s findings were not included in the final research publications, he did publish a short article for the IGA magazine Among the Deep Sea Fishers. The article, “Medical Care in Swedish Lapland,” compares rural-remote health care delivery in Lapland and Labrador – two sparsely populated subarctic regions that experienced large-scale industrialization and rural displacement during the 20th century.1 Neuhauser’s article also notes Sweden’s interest in the IGA’s health care model, which differed from other Atlantic Canadian regions but was recognizable to Swedish health administrators. While the IGA operated on the North American periphery, it had deep connections to the metropolitan regions of the American northeast and important parallels to other circumpolar regions such as Greenland and northern Sweden. These linkages are embodied in the career and family of Duncan Neuhauser.
3 There are a number of important similarities between Labrador and Swedish Lapland in the post-Second World War period. This forum contribution considers similarities in climate, state-led industrial development, and the structure and philosophy of health care provision between the two regions. It also examines shared problems with clinician recruitment to rural-remote subarctic spaces, and the impact of industrialization and urbanization on the health and way of life of Indigenous people. While the research on Labrador and the IGA is at a more mature stage, English-language policy documents and secondary materials from Sweden make it clear that the transatlantic north is a fruitful and important avenue for comparative health research.
4 Founded in 1892 by British surgeon and evangelist Wilfred Grenfell, the IGA – until 1914 the Grenfell Mission – was from the beginning more than a medical service. Grenfell wanted to spread his ecumenical faith along the coasts of northern Newfoundland and Labrador, and his rapidly expanding organization soon established cooperative firms, clothing suppliers, floating clinics, travelling libraries, and many other services besides medical ones. After Newfoundland and Labrador joined Canada in 1949, the IGA became a semi-autonomous component of the provincial health system; now financed by provincial and federal grants rather than private philanthropy, the IGA nevertheless remained active in the social and economic affairs of the region.2 As one Newfoundland Department of Health commissioner noted in 1952, the IGA was “more than a hospital service for it maintains an extensive educational and welfare program, operates an unusually successful demonstration farm, maintains a drydock, and has its own supply steamer.”3
5 In the early 20th century the IGA made an exceptional effort to recruit medical students and new graduates from the Ivy League medical schools of the American northeast. These schools offered talent and affluent connections for the IGA, and many of their students were already seeking opportunities to work as physician-missionaries in China and India. By pitching Labrador as North America’s last frontier, the IGA appealed to students seeking adventure closer to home. Jennifer Connor has critiqued the limited historiography on missions in Canada, adding that even historians who have recognized and addressed this gap (however briefly) exclude Newfoundland. In her Grenfell Medical Mission and American Support in Newfoundland and Labrador, Connor examined how Grenfell appealed to young volunteers by urging them to apply their “American traits to useful activity, productivity, economic and even commercial improvement” to the “Anglo-Saxon” people of Labrador.4 By the 1950s the children of this first generation of American volunteers, including Duncan Neuhauser and his brother Hans, were themselves applying for work with the IGA.
6 Neuhauser’s father and mother, Edward and Gernda, met while working for the IGA in the 1930s and they remained involved with the association as executive members of the New England Grenfell Association and Grenfell Association of America respectively.5 Their son Duncan joined the IGA as an x-ray assistant aboard the hospital boat Maraval in 1959 while Hans followed as a general labourer in 1960.6 As late as the 1960s, a volunteer position with the IGA in eastern Canada was a good move for a young American student interested in a medical career, either as a clinician or, as in Duncan Neuhauser’s case, as a health administrator. It provided a unique opportunity to meet accomplished clinicians and other ambitious medical students, and those contacts were maintained by membership in one of the American Grenfell associations.
7 Duncan Neuhauser may have been motivated to join the IGA for professional reasons, but he also had prior experience in the Canadian north and came from a family interested in northern health affairs. His father, a Pennsylvania medical school graduate and head of the x-ray department at the Boston Children’s Hospital, continued to visit and research circumpolar regions throughout his career. In 1942 the IGA was invited by the United States Army medical service to “send them a speaker on Newfoundland and common diseases in northern countries,” and the elder Neuhauser agreed to do so on its behalf.7 In 1954 Edward Neuhauser travelled to Churchill, Manitoba, aboard the Hudson’s Bay Company ship Rupertsland, taking Duncan with him, and in 1968 participated in a research trip organized by the Danish Health Service to Greenland.8 The photographs of “icebergs, boats, villages, and Greenlanders” that Edward showed during the annual reunion dinner of the New England Grenfell Association would have reminded viewers of their own experiences in Newfoundland and Labrador and mirrored IGA representations of the Canadian northeast. Edward Neuhauser was clearly enamoured with northern life, but viewed his surroundings with clinical southern eyes. He noted, for instance, that huskies were “a major threat to sanitation,” a complaint made by countless IGA personnel frustrated by their inability to dictate terms of living and working in the communities they operated in.9 The IGA and supporters like Edward, nevertheless, cultivated a romantic narrative of its work in “the North,” and its strong institutional brand continued to attract young volunteers well into the postwar period.10
8 Newfoundland and Labrador was changing rapidly when Duncan Neuhauser arrived in the summer of 1959. The former British colony had joined Canada only ten years before in 1949, and a massive infusion of federal money, as well as a large program of military base construction during the Second World War, had changed the built landscape of the new province. There were new highways, airports, hospitals, deep-water ports, mining towns, and a university, and the provincial government was on the verge of an ambitious project to move its most isolated residents into “growth centres” so that health and social services could be centrally located. The growth pole theory of development, which was originally articulated by the French economist François Perroux, had a following in Sweden as well, where policy makers worried that the northern counties were too small to support “sufficiently high quality” public services.11 In Labrador, the Newfoundland government’s concept of growth centres was combined with the activities of private missionaries, corporate consortiums, and military defences. In a remark that echoes Grenfell Mission publicity from the early 20th century, Neuhauser wrote that the IGA would not struggle like its rural Swedish counterparts to recruit nurses because it was still imbued with a “spirit of adventure” and “missionary zeal.”12 But as Neuhauser romanticized the mission volunteer, the IGA aided the provincial and federal governments in the forced relocation of two “isolated” Inuit communities (see below) while global capital transformed Labrador West into a giant centre of mining and hydroelectric power. Iron ore mining at Carol Lake (Labrador City) and, beginning in the 1970s, a massive hydroelectric generating station at Churchill Falls on the Grand River, helped fulfill Newfoundland Premier Joseph R. Smallwood’s vision of Labrador “as a resource to be developed for the sake of Newfoundland.”13 And these were not the only changes. In St. Anthony, former IGA Director Dr. Charles Curtis noted wearily where “there used to be only the Mission pier, now in addition to it, there is the United States Government one and also a Dominion Government pier being built.” Curtis also noted the construction of a new Canadian federal building to house the post office and telegraph office.14
9 The employment opportunities created by this activity lessened the region’s dependence on the IGA for economic and social support. In 1955 the IGA’s Labrador directors noted that the new jobs “pay high wages and residents now have better homes, clothing and food and do not need to hook mats” for the IGA or remain in coastal communities where IGA stations were located.15 Furthermore, IGA fundraising branches throughout North America found it increasingly difficult to “appeal to a philanthropic public to support the health care of a ‘disadvantaged’ people who were now citizens of a wealthy country,” and a “spirit of defeatism” was noted in several branches.16 But while these changes were fatal for other colonial-era organizations like the Moravian Mission in northern Labrador, the IGA found new life as an agent of the provincial and federal states.
10 How the IGA retained institutional autonomy after Confederation is unclear, but there were obvious advantages in utilizing the association’s unique knowledge of the region as well as its infrastructure. During the immediate post-Confederation period the IGA remained a powerful regional actor capable of asserting its interests, and it may have been easier and cheaper to simply finance the modernization and expansion of existing services. Whatever the reason, significant federal and provincial investments quickly followed Newfoundland’s union with Canada and this led the IGA to establish “more and more contacts with government departments” as it sought to retain some authority over the acquisition and use of funds.17
11 While Confederation brought many changes to the IGA, one of the most significant was its expansion into the Innu and Inuit communities of northern Labrador – formerly the preserve of the Moravian Mission. With federal funding, new nursing stations were constructed at Makkovik, Hopedale, Davis Inlet, and Nain and in 1952 the IGA “received $61,957 from the federal government to treat Innu and Inuit patients in Grenfell facilities.”18 Unfortunately part of this program involved the discontinuance of health and other social services for the coastline north of Nain and this forced inhabitants there to find new homes further south, where they had no social standing or means of subsistence.19 As well as expanding north, the IGA also grew its presence in central Labrador by building a new hospital near the air base in Happy Valley Goose Bay, where many of the new jobs were being created, and established a medical clinic at Churchill Falls on behalf of the Churchill Falls Labrador Corporation.20 These moves gave the IGA a presence in Labrador’s emergent industrial economy and linked health care in Labrador to a broader program of economic development.
12 Large industrial projects were transforming the landscapes and economic relations of northern Sweden as well. Better health outcomes were explicitly linked to the creation of a new wage labour force, rather than being an adjunct to industrial expansion and community “modernization.” After the Second World War state authorities in northern Sweden pursued the “intensive rationalization” of the older farming and forestry sectors. Just as the Newfoundland government hoped to unlock new economic opportunities by “freeing” labour from the traditional rural fishery and centralizing it in new growth centres, policy analysts in Sweden argued that the establishment of “one to three growth poles in the north” would “by virtue of their own external economies . . . attract additional activities and absorb labour released from agriculture and forestry.”21 However, in northern Sweden the development of mining districts, which began at the turn of the 20th-century, had produced small urban centres long before the popularization of the growth pole theory.22 Indeed, when first ground was broken on mining operations in Labrador West, the underground iron ore mine in Kiruna was already one of the world’s largest.
13 Unlike Labrador, mining in northern Sweden was nationalized in the 1950s and Duncan Neuhauser observed in “Medical Care in Swedish Lapland” that tax revenues generated by the state’s mining company LKAB were used to build roads and finance medical and social services.23 Indeed, after the Second World War, the industrialization of Sweden’s “forest counties” was joined to a national health program that sought to bolster economic productivity as well as provide Swedes with a more uniform standard of medical care. Axel Höjer, the director general of the National Board of Health between 1935 and 1950 and author of the influential 1948 Report Concerning Ambulatory Medical Care in the Country (also known as the Höjer Report) on postwar health reforms, argued that “an efficient and equally distributed health care system was the base for an optimal output in a country trying to adapt its economy to the international market.”24 But if Höjer hoped to leverage Sweden’s economic influence by improving its health care system, Swedish authorities also believed that physical and mental health was linked to full employment. As one Swedish official said, “Work is essential not only to our livelihood and sound physical and mental health, but it also contributes to the economic well-being of the whole population.”25 While ideals of “universalism” and “egalitarianism” guided health and welfare planners, the state’s priority was the rehabilitation of economically unproductive patients to a work-fit condition. The system, as two historians of Swedish health care noted recently, favoured “those who have had the chance to enter the workforce, whilst they are less generous to groups who are outside it for whatever reason.”26
14 One group that was continually at risk of falling “outside” of the Swedish government’s conception of labour and welfare was Sweden’s Sami population. A 1909 Royal Commission Report stated “the herding of reindeers demands that the Lapp has a nomadic way of life,” and protection of the nomadic culture emerged “as the sole and coherent foundation for Swedish Sami policy and the system of Sami rights.” However, in the postwar period, and in line with other “rationalization” efforts, reindeer herding was regarded as a mark of underdevelopment and the nomadic way of life an “obstacle” to modernization. As Sami scholar Ulf Mörkenstam writes, Swedish Sami policy during the 1950s was “incorporated in and aligned with the policy of the full-blown interventionist Swedish welfare state.”27 Herders were expected to be efficient and profitable like any other enterprise or find employment elsewhere.
15 While Neuhauser noted that “increased contact with the modern world has also brought disadvantages such as a higher rate of alcoholism,” he wrote, approvingly, that “most Lapps have given up the hard life of the herders to work for wages alongside the Swedes in the mines, on construction, or similar jobs.”28 Neuhauser was likely unaware that Sami workers were not accepted as citizens and workers with equal rights but “defined as deviant and marginal” for leaving reindeer herding behind.29 Northern Sweden’s Sami population was further burdened by the enclosure, alteration, and destruction of land caused by the construction of railway lines, mines and mining towns, hydroelectric dams, and reservoirs. Confronted with large-scale industrial displacement and state-legislated identity boundaries, it is little wonder that Sami communities struggled with problems of alcohol and other health issues rooted in social dislocation.
16 One part of the “hard life” of the Sami noted by Neuhauser was the production of handicrafts for supplemental income. These handicrafts, Neuhauser observed, “are a similar high quality to those of the Grenfell Mission,” but it is not clear if there was a similar obligation on the part of the producers to work for access to health and social services as well as cash as was the case in Labrador.30 Who commissioned their production and why remains unknown, but the IGA had maintained a handicrafts industry since 1906, when it convinced ceramist Jesse Luther, who combined handicrafts with occupational therapy at New York’s Butler Hospital, to develop a similar program in St. Anthony.31
17 Labrador’s Inuit and Innu communities were similarly affected by the development of large-scale mining and hydroelectric projects. While Inuit and Innu communities were forcibly relocated to growth centres and permanent settlements, their labour was not welcomed on the new industrial sites while poor transportation links between Labrador West and the coast created a further barrier to employment.32 Like northern Sweden, alcohol abuse became widespread in Labrador’s Indigenous communities; but rather than recognizing it as one consequence of massive social disruption, IGA officials such as Dr. Anthony Paddon leaned on racialized and colonial explanations. As Paddon remarked at an award dinner in 1977, the postwar years “brought practically unlimited alcohol to Labrador, to a people with little or no experience of it . . . .”33 Indeed, while the IGA had become “modern” in appearance, with mobile x-ray units, aircraft, radio-telephones and, in 1966, a new hospital ship, clinicians and volunteers were still motivated by a colonial-missionary ethos reminiscent of the late 19th century. Writing of a vacancy at the Davis Inlet nursing station, for example, Dr. Charles Curtis enthused that it would be “a very interesting and challenging job to work with these Indians and go into the country with them. It is probably the last ‘pioneer’ job we have got on the Grenfell Mission.”34
18 Tuberculosis was another disease worsened by poverty and social inequality, and Neuhauser wrote that both Labrador and Lapland were “cursed” with it.35 Testing for tuberculosis in Labrador and Lapland was complicated by vast distances, small populations, and unreliable transportation links that were frequently severed by severe weather. To overcome these challenges, health authorities undertook “mass tuberculosis surveys” using mobile platforms that could move x-ray equipment and access even the remotest populations. As we will see below, in both regions little sympathy was shown for residents who were unwilling or uncomfortable participants.
19 From 1940 to 1970 the National Swedish Board of Health screened people in all of the country’s counties for pulmonary tuberculosis – around 90 per cent of the population during a 30-year period. In order to access remote areas, Sweden’s Mass Radiography Centre, a department of the Board of Health in Stockholm, deployed buses equipped with x-ray equipment and technical staff, and enlisted county authorities to gather communities together. The specially built buses were “not only sites for taking the images but also a means of transporting the x-ray images to the Mass Radiography Centre in Stockholm . . . a “centre of calculation” where the data were collected, processed, and analysed.” Photographs and positive descriptions of the surveys were also published in photography magazines with national circulation, and people who refused or hesitated to participate – pejoratively labelled “objectors” – were condemned as public health threats and irresponsible parents. Opposition to the surveys began to grow in the 1960s and the insensitivity of the mass examination system towards individual needs soon rendered it “out of date.”36 In 1970 the Mass Radiography Centre was closed.
20 At the same time as the Board of Health was preparing to shutter the Mass Radiography Centre, IGA authorities were planning an ambitious summer survey of Indigenous communities in northern Labrador. The preferred technology of the IGA was one personally experienced by Neuhauser: the >hospital ship. As an x-ray assistant aboard the Maraval in 1959 Neuhauser participated in one of the IGA’s first mass surveys of the Labrador coast, which was conducted in conjunction with the Newfoundland Tuberculosis Association vessel Christmas Seal. While Neuhauser seemed more interested in the recreational fishing opportunities of the survey, he did note that “people of the coast are often reluctant to be the first to do anything,” mistaking unease at the prospect of being tested for tuberculosis with some innate sense of social conservatism.37
21 In 1966 the IGA took ownership of the Strathcona III, a new ship equipped with an ice-reinforced hull, shallow keel, and complete x-ray clinic. Specifically designed for the shallow waterways of the Labrador coast, the Strathcona III could visit difficult harbours and track the summer fishing camps established by Inuit communities in the summer. These camps were the focus of the 1970 mass survey, and those who showed signs positive for tuberculosis were immediately removed from the area, either aboard the ship or possibly by aircraft, to a distant sanatorium in Labrador West. The Strathcona III supplemented the small number of nursing stations maintained by the IGA in northern Labrador, and Dr. Paddon’s comment that “to the Eskimo, and to the Indians of Davis Inlet, the ship is the symbol of the IGA” is perhaps reflective of the Strathcona III’s ability to track mobile population groups.38
22 Like the buses used in Sweden, the Strathcona III could both produce x-ray images and transport them back to a research centre for further evaluation, in this case St. Anthony, thus enabling a centralized system of rural oversight. Clinicians aboard the Strathcona III also used the same (dehumanizing) language of war as their Swedish counterparts, describing tuberculosis as an “enemy” to be “eradicated,” and they did not seriously consider the objections or fears of the people being tested.39 Indeed, in a further parallel to Swedish surveys, a photographer was assigned to take images of the Strathcona III, northern landscapes, and patients being x-rayed, images that were subsequently published in Among the Deep Sea Fishers (ADSF). But, unlike Sweden, mass surveys did not end in 1970, and while evidence suggests that Inuit and Innu communities feared and resisted mass x-ray surveys – one clinician complained that “everyone somehow manages to be off in the country” when the x-ray team arrives – there are no indications that the IGA was aware of (or cared for) their concerns.40
23 At the end of his article Neuhauser wrote that the Swedish health officers “were very interested in the activities of the Grenfell Mission” and “were particularly impressed with the wide range of social and economic activities” of the mission. Neuhauser described the IGA’s work as a “total welfare” approach, and it was a system that was at least outwardly recognizable to Swedish administrators.41 The IGA was more than strictly a medical service, and was actively involved in a range of social and economic programs, including infrastructure projects, education, and the regulation of alcohol consumption. The IGA’s “broad view,” Paddon explained, included public health “at the community level as well as the professional one” and “more health education – specifically adapted to our own environmental and community needs – these can do more for a good state of health and of lifestyle than the medical profession alone.”42 But this “very broad view” was also shaped by racial prejudices that painted Indigenous peoples as hostile, sedentary, and exploitative. One IGA report warned “The Eskimo, with the active assistance of the Province, was lapsing into an increasingly xenophobic view of the White Man, a conviction that he is owed a living.”43 Additionally, while the IGA aspired to a totalizing model of health care and economic development, the government of Newfoundland was primarily interested in what benefits the island could accrue from the industrialization of Labrador. In this context, the IGA was as much a tool to facilitate natural resource development and population centralization.
24 The Swedish government’s approach to its northern counties appears to be similar, with the modernizing potential of its abundant natural resources frustrated by the social upheaval inflicted on Indigenous and settler people by large-scale extractive industries. In both Labrador and Lapland, rural inhabitants, and Indigenous inhabitants in particular, were described as backwards, difficult to service, obstacles to progress, and even threats to public health and economic development. Ludvig Nordström’s 1938 book and radio series Dirty Sweden, for example, painted “a dark picture of the spiritual, physical and material stays and conditions” of the Swedish – and mainly rural – population at the end of the 1930s – an image similar to the narrative of “graft, hunger, dole and disease” deployed by pro-Confederation campaigners in Newfoundland during the late 1940s.44 While social conditions were undoubtedly severe in parts of Labrador and Lapland at this time, the rhetoric of despair and backwardness was easily deployed to justify a wider scale of displacement and harm in rural-remote regions that had limited representation.
25 While both Labrador and Lapland are commonly understood as frontiers or peripheral spaces, both regions were connected to a broader transatlantic medical network – personified here by Duncan Neuhauser. Both are thinly populated and subarctic regions with a significant Indigenous presence and both, from the perspective of the Newfoundland and Swedish governments, held enormous natural resource potential. Moreover, the provision of health services in both areas were shaped by the displacement of older economic activities by heavy industry, rural population loss, persistent poverty, and similar theories of regional economic development. Thanks in part to the IGA’s long history in Labrador, and Newfoundland’s late entry into Canadian Confederation, health care provision in Labrador followed a different trajectory from other Canadian provinces, and, by the 1970s was, in many respects, more akin to that of northern Sweden.