I want to highlight here a decisive aspect of the thought and work of Jean Rochon, Quebec Minister of Health from 1994 to 1998, recently deceased: the fragile and nevertheless necessary balance between the exclusively biological causes of the disease and causes related to the social and physical environment. Quebec owes Jean Rochon, for a large part at least, the decentralization and, subsequently, the CLSCs, day surgery, the law on tobacco, drug insurance. There is a link between these various choices which must be taken into account in the umpteenth reform which is currently being drafted. This link appears clearly in the work of the masters of Jean Rochon, starting with that of the British epidemiologist Archibald Cochrane.
At the start of the 1970s, Ivan Illich published The medical nemesis, an essay that shook the medical world: the notion of iatrogenic disease, that is to say caused by medicine itself, reached for the first time a large public at the same time as the warnings against an excessive medicalization in this sense that it converges too many resources towards hospitals in defiance of environmental determinants.
The two main sources of Illich were Archibald Cochrane and René Dubos. Besides Jean Rochon himself, doctor of public health from Harvard since 1973, they are the first lecturers that I wanted to invite when, in 1975, I organized, for the review Criterion, an international conference entitled “For a new medical contract”. But how to join and convince these two world luminaries. A phone call was enough for me in the case of René Dubos, who told me that he knew Cochrane well. But to convince the latter to receive me in Cardiff for an interview which would be published in Criterion before the conference, I needed another intermediary even closer to the teacher: Jean Rochon.
Cochrane had devoted much of his life to patient research into the disease of miners in his region while helping, after 1945, to found the British public health system, the NHS. He was one of the pioneers of the evidence-based medicine that is so often talked about in these times of pandemic. The expression “randomized trial” for RCT (Randomized Controlled Trial) is forever associated with his name. We understand why in the light of this passage from the interview he gave me:
CRITERION: “Could you give some examples of results obtained with the RCT? “
ALC: “I could give you dozens. Here are a few. Dr. David Sackett of McMaster University in Canada did important work including the Burlington Experiment in which he demonstrated that the control group treated by nurses performed as well as the control group treated by nurses. doctors. It was primary care. A similar study in Cardiff with a group of older people showed that treatment given by people without specialist training was as effective as that given by doctors. Heart disease has also been studied in Cardiff. In one case, the patients were 60 years of age and over. Group A was treated in hospital, group B at home. The results were better for those treated at home. “
Jean Rochon believed that, in order to achieve its ends, any reform of health services must be based on an explicit and widely shared conception of health, a condition which did not seem to him to be fulfilled in 1975, a few years after a reform to which he had himself. even contributed. Is the same condition more fulfilled at this time? We can judge by this excerpt from Jean Rochon’s lecture at the Orford conference:
“Where are we in the effort to clarify valid assumptions for ‘health science’? Since the work of Galen, we first used a mechanistic concept of health, namely the harmonious functioning of the human body. The disease therefore becomes a biologically normal disorder that can be corrected when the cause is identified.
The elimination of the cause of the disease necessarily depends on biological, chemical and surgical means. This notion, which is still predominant today, characterizes the clinical approach to health problems. Around the middle of the 19th centurye century, the reports of Chadwick in England and Shattuck in the United States resumed and generalized the recognition of social factors as the causes of several health problems. This development has made it possible to identify situations that are both complex and generate disease. This orientation emphasizes the interactions between individuals and their physical and social environment. Health is no longer just the functioning of an organism, but involves a notion of organic integrity and of the organism’s balance with its environment. Solutions to health problems are no longer limited to removing the cause, but also aim to adapt the individual to his environment by seeking a new balance. This notion of health is currently characteristic of the social approach to health problems. “
Archibald Cochrane combined the rigor of the statistician with the compassion of the Samaritan. We find the same paradox in the life and work of several great contemporary physicians. Jean Rochon was one of them. Would he have followed Cochrane to his conception of the criteria for entering medical school: “Intelligence would only be my first criterion for 10% of the places available.” For the 90% of the other places, my first criterion would be kindness. Intelligence, which is called intelligence, is of primary importance only to those who are heading into research. “