Yet for most of history, an asylum bed was never the norm. The overwhelming majority of people with severe disabilities, cognitive differences, and chronic illnesses never set foot inside an institution. Care was anchored in daily life—provided for at home by families, neighbors, religious charities, and local networks. Residential institutions were for those whose support needs exceeded what could be provided at home or who had no family or private funding.

When institutions did step in, placement had less to do with modern diagnostic categories than with practicality. Medical and legal codes recognized rough distinctions like lunacy (acquired, fluctuating disturbances) and idiocy (congenital impairments), but real-world institutionalization was rarely about clinical precision. Instead, it was driven by a complex web of behavior, supervision, labor capacity, and administrative convenience.

When you examine admission ledgers from the medieval era through the mid-twentieth century, a clear pattern emerges across the Western world: a vast portion of institutionalized residents suffered from physical, metabolic, or social dependencies—none of which we would classify as psychiatric illness today.

General paraylsis of the insane

A major source of patients in psychiatric facilities – up to 25% in some places – were patients with general paralysis of the insane (GPI). GPI was a progressive and ultimately fatal disorder marked by slurred speech, tremors, and ataxia alongside severe cognitive deterioration, grand delusions, and dementia. From the 1820s, doctors knew the symptoms and screened incoming patients for early indicators long before paralysis set in.

The association between GPI and syphilis was discovered in the late 1880s and confirmed in the early 1900s. This was one of the first major pieces of evidence that a condition considered a psychiatric illness might actually have a specific infectious cause. In 1927, Julius Wagner-Jauregg won the Nobel prize for inducing remissions in 1/3 to 1/2 of early-stage GPI patients with induced malaria infections. The widespread availability of penicillin in the 1940s effectively eliminated GPI.

Alcohol related disorders

Before the late 18th century, alcohol consumption in Western societies consisted primarily of low-ABV fermented beverages like cider, beer, and light wines. In the late 1700s, industrial grain processing made high-proof distilled spirits like whiskey, gin, rum cheaper than clean drinking water. By the 1820s and 1830s, annual per-capita alcohol consumption reached historical peaks. Alcohol withdrawal could cause life-threatening delirium, seizures, and visual/auditory hallucinosis. Long-term use could lead to psychiatric and cognitive symptoms leading to placement in residential institutions.

As state mental hospitals opened across North America and Europe after around 1850, alcohol-related diagnoses accounted for up to 20% of all public asylum admissions. Some asylums opened “inebriate wards.”

Nutritional deficiencies

People noticed that a certain percentage of urban patients with psychiatric symptoms sent to rural asylums quickly recovered. This is because deficiencies of niacin/B3 (pellagra), B12, thiamine/B1 (Wernicke-Korsakoff syndrome), and folate/B9 can all cause psychiatric symptoms.

This recovery was, of course, dependent on the availability of fresh foods. Unfortunately, over time, larger institutions began selling their agricultural produce to raise funds, rather than using them to feed residents. Institutional diets became deficient. Between 1915 and 1926, Joseph Goldberger gathered increasingly compelling proof that pellagra was a dietary deficiency which could be cured with brewer’s yeast, fresh meat, or milk. Public asylum administrators in the American south, where pellagra was most common, actively fought Goldberger’s findings.

By the 1930s, vitamins could be cheaply synthesized. The US government mandated the fortification of refined flour, cornmeal, and bread in the early 1940s. Institutional diets were thus automatically corrected for thiamine, niacin, riboflavin, and iron deficiencies, without requiring administrators to change their meal plans.

Epilepsy

Many asylums housed large numbers of epileptic patients, and some institutions eventually created separate “epileptic colonies” because there were simply so many of them.

Many epilepsies, especially temporal lobe epilepsy, can produce psychiatric symptoms before, during, after, or between seizures. Patients might hear voices, see things that aren’t there, experience intense fear, feel like things are unreal, or have religious or mystical feelings. After a cluster of seizures, some patients can experience hallucinations, paranoia, delusions, agitation, and mania. Chronic epilepsy can lead to memory problems, cognitive loss, depression, anxiety, and emotional instability. Many seizures don’t involve dramatic convulsions.

In the 1860s and 1870s, John Hughlings Jackson gathered evidence that epilepsy was caused by localized, excessive electrical discharges in the cerebral cortex. By the 1890s, dedicated neurological institutes and specialized epilepsy colonies were established separate from general psychiatric asylums. However, I’ve come across accounts of epileptic patients in psychiatric hospitals in the 1960s.

Physical conditions

Today, we usually think of a stroke as causing physical paralysis or speech loss, but vascular events and acquired brain injuries frequently trigger profound behavioral changes, like sudden mood swings, impulsivity, aggression, delusions, and mania. Without modern brain imaging, doctors had no way to distinguish these structural brain injuries from primary psychiatric illness.

A huge range of physical, metabolic, and infectious conditions produced symptoms that looked like “madness”:

• Infections & structural issues: Tuberculous meningitis (tuberculosis of the brain) often presented as rapid-onset insanity, usually proving fatal within a few months. Conditions like normal pressure hydrocephalus or a chronic subdural hematoma—sometimes from a forgotten, minor head bump—steadily destroyed memory and executive function under the guise of progressive insanity.

• Metabolic & endocrine crises: When a person went into severe liver failure, toxins that the liver would normally clear built up in the bloodstream and flooded the brain. Asylum doctors regularly misattributed this toxic encephalopathy to chronic alcoholism or mania. Severe drops in thyroid hormone could trigger acute paranoia and deep memory loss, while untreated diabetes caused extreme blood sugar spikes and crashes that looked like violent delirium.

• Neurodegenerative & autoimmune disorders: With Parkinson’s disease, executive dysfunction, severe depression, and paranoia can show up years before the classic hand tremors ever start. As the disease advances, it can also cause hallucinations and delusions.

Even today, people with brain tumors, autoimmune encephalitis, lupus, or severe sleep apnea are still at risk of having physical illnesses misdiagnosed as purely psychiatric.

Poverty

Scandals at the end of the state asylum age in the late 20th century uncovered a pattern of systemic misclassification: individuals were routinely labeled with mental or physical disabilities as a last-resort strategy by local officials to secure state or federal funding for basic room and board for the impoverished. These modern diagnostic reclassification scandals, however, were not a new phenomenon; they continued a centuries-old administrative tradition. Even as specialized facilities developed throughout the 19th and 20th centuries, institutional placement consistently depended less on diagnostic precision than on municipal budget streams, legal settlement status, and simple bed availability.

This administrative flexibility made asylums convenient catch-all repositories for populations that municipal authorities found economically burdensome or socially inconvenient. Single, widowed, or non-conforming women were particularly vulnerable to institutional commitment. Under broad, subjective diagnostic categories like “moral insanity,” “hysteria,” or “erotomania,” people who could not function in society could be placed in residential institutions.

Intellectual and developmental disabilities

Historically, communities often viewed people with intellectual and developmental disabilities (IDD) as “innocents,” individuals lacking moral agency or the capacity for sin. Because of this view, there was a shared understanding that local communities had a responsibility to support them. When occasional in-kind help or informal respite wasn’t enough, communities tried to place the person with extended family or a neighboring household. People with IDD who could perform simple manual labor were usually only institutionalized after severe social upheaval—like losing all surviving family who could care for them. Early institutions were small, local, and enmeshed in town life; someone was only confined if there was an urgent safety concern.

This landscape shifted dramatically with the rise of industrialization and the eugenics movement. Modern factory work demanded standardized, fast-paced labor, making it much harder to integrate people with developmental differences into local economies. At the same time, pseudo-scientific theories about “hereditary degeneration” and crime convinced state legislatures to fund massive custodial facilities designed for lifelong segregation to prevent reproduction. By the early-to-mid 20th century, doctors routinely counseled parents of newborns with visible disabilities to institutionalize them immediately and pretend the baby had died.

For families who wanted to keep their children at home, the system offered almost no help: public support often required surrendering legal custody, and children with IDD were excluded from public schools and basic pediatric services. This institutional setup left poor and middle-income families with virtually no choice.

Age related dementia

Aging parents transferred land, housing, or businesses to adult children or tenants in exchange for lifetime housing, food, and basic care. Local manorial and civic courts acted as legal enforcers: if adult children neglected their duties, courts could reassign the contract and assets to another relative or steward. When individuals exhibited severe cognitive or behavioral decline, families had to manage them at home or they risked the courts assigning their contract to someone else.

People could purchase a corrody, a legal contract granting a permanent room, food, and care within a monastery or priory. While monasteries accommodated physical frailty in their infirmaries, people with high support needs had to hire additional help. Maintenance agreements could be cancelled for uncooperative, wandering, or aggressive residents.

For those without land or family, medieval almshouses and hospitals offered residential care. Elderly individuals comprised the majority of permanent residents in these facilities. However, admission was not universal. Most almshouses had behavioral requirements. People with advanced dementia could be denied admission or discharged back to their families. People with extremely difficult to manage behaviors might be kept in the gaol, although this was due to the lack of any other option.

By the mid-to-late 1700s, elderly residents made up 25% to 40% of the general workhouse population. Workhouses were not medicalized. Mentally impaired elders (often cataloged in parish ledgers under terms like dotage, fatuity, or frenzy) were housed indiscriminately alongside younger destitute individuals, criminals, and the acutely ill. Workhouse masters frequently relied on physical restraints (chains, locked attics, or cellar cells) or paid local keepers to house disruptive individuals off-site.

By the late 1800s, workhouses were creating wards for the elderly and disabled. Workhouses had evolved into long-stay institutions where up to half of long-term beds were occupied by infirm elders suffering from age-related cognitive impairment.

Mid-to-late 19th-century public psychiatric hospitals saw an explosion in elderly admissions. While asylums had been created to treat acute, curable mental illness, by the end of the 1800s they had become de facto public nursing homes. People whose dementia symptoms involved aggression, wandering, and incontinence were most likely to end up in a residential institution because their families could not provide for them safely at home.

By the 1950s, up to 35% of all US psychiatric hospital admissions were diagnosed with conditions now recognized as dementia; among institutionalized patients aged 65 and older, that proportion reached up to 75%.

Institutional death rates

Mortality rates among older patients diagnosed with “senile psychosis” were extremely high. In some institutions, as many as 80% died within three years of admission. While this sounds like evidence that the asylum itself was fatal, admission typically occurred only after families had exhausted themselves keeping someone home as long as possible. Many elderly residents arrived in advanced stages of dementia, severe physical frailty, or terminal illness. In that respect, the pattern resembles modern long-term care populations, where admission frequently occurs late in the course of a progressive disease rather than at its onset. Residents of contemporary nursing homes have similar statistics, despite improved sanitation, nutrition, and advanced treatment options.

Large numbers of residents suffered from progressive neurological, infectious, and metabolic disorders that physicians could neither diagnose nor treat. Nutrition posed another serious challenge. Institutional diets frequently relied on inexpensive staples such as bread, porridge, potatoes, and preserved foods. When diets lacked sufficient vitamins and protein, nutritional deficiencies could worsen confusion, cognitive impairment, physical weakness, and susceptibility to disease. Tuberculosis, pneumonia, dysentery, and other infectious diseases spread easily through crowded wards filled with frail and medically vulnerable residents.

On top of all that, as modern medicine developed, doctors routinely subjected patients to deeply alarming “treatments.” Medical historian Andrew Scull recounts how celebrated psychiatric cures were often built on coercion, physical trauma, and dubious (or outright fraudulent) claims. His research illustrates how the institutional psychiatric establishment repeatedly embraced aggressive procedures to project medical authority and the illusion of progress.

The role of residential care

Prior to the late 18th century, communities accommodated a spectrum of human capacity, acknowledging that individuals were born with different abilities, acquired disabilities over time, and grew frail with age. All residents were expected to contribute labor however they could, while the broader community carried the moral and legal duty to support those who required it.

People with disabilities, chronic illnesses, dementia, or mental health conditions have always mostly lived in ordinary homes. Care was usually provided by family members, neighbors, paid servants, religious communities, or other local households. Communities and charities often preferred to provide food, clothing, fuel, cash assistance, or respite support rather than remove someone from their home. When a family could no longer cope on its own, the first solution was often placement with relatives, local clergy, foster families, or boarding homes rather than an institution.

Many residents were admitted to institutions not because they were considered dangerous or insane, but because they required a level of supervision that no household could reliably provide. People who wandered, experienced frequent seizures, required constant nursing, or could not safely be left alone often overwhelmed even devoted families. Admission records are filled with families who had successfully cared for a relative for decades before a financial crisis, bereavement, illness, exhaustion, or intensifying care needs forced them to seek outside help.

The rise of industrialization increased the pressure on families. Rural households had often been able to incorporate people with varying levels of ability into agricultural work and domestic production. Urban industrial life left less room for this flexibility. Homes became smaller, work moved outside the household, and family members spent long hours in factories and workshops. Caring for someone requiring constant supervision became significantly more difficult. As a result, institutions increasingly absorbed people whose needs had not changed, but whose families’ capacity to support them had.

From the 17th to the 19th century, support for the poor was usually administered at the parish or municipal level. Every person had a legal “settlement,” typically based on birth, property ownership, marriage, or lengthy residence. This settlement determined which community was financially responsible if that person became dependent on public support. As a result, a willing relative could not always legally take in a disabled family member, which required the posting of a bond and a guarantee that the person would not create a disturbance. When people were not granted permission to cross parish boundaries, people who might otherwise have lived with extended family or friends could instead end up in workhouses, hospitals, or municipal institutions.

Not every resident entered unwillingly. Throughout the 18th, 19th, and early 20th centuries, some people sought admission voluntarily or asked relatives to arrange it. For individuals struggling with severe depression, psychosis, alcoholism, epilepsy, or physical frailty, an institution could offer something difficult to obtain elsewhere: regular meals, shelter, medical attention, protection from self-harm, and relief from the demands of everyday life. Case records occasionally describe residents returning after discharge or requesting to remain because they felt safer inside than they did in the community.

Types of residential facilities

The names given to residential institutions reveal how societies understood dependency, disability, illness, and poverty. Over time, the purpose of these facilities gradually shifted. Early institutions focused on hospitality, charity, and religious obligation, sheltering a broad mix of travelers, the poor, the sick, the elderly, and people with disabilities under one roof.

Beginning in the early modern period, governments became increasingly concerned with managing poverty, disorder, and social dependency, leading to the creation of poorhouses, workhouses, and specialized facilities for particular groups. By the nineteenth century, reformers and physicians promoted the idea that institutions could actively treat, educate, rehabilitate, or cure their residents, resulting in asylums, training schools, and other specialized establishments.

During the late nineteenth and early twentieth centuries, many of these facilities evolved into large state-run systems focused less on treatment and more on long-term custodial care and segregation. Modern nursing homes, rehabilitation centers, and disability services emerged from this same history. The changing terminology reflects a broader shift from faith-based charity, to municipal poor relief, to medical treatment, and finally to the complex mix of healthcare, social services, and long-term support that exists today.

• Xenodochium: A Late Antique and early Christian hostel established to provide basic shelter, food, and protection to traveling strangers, pilgrims, the poor, and the disabled.

• Hospital: A medieval religious or civic refuge providing shelter, meals, medical care, and spiritual care to the poor, sick, disabled, elderly, and travelers.

  • In the late 18th century, advances in clinical medicine, pathology, and antiseptic surgery transformed hospitals into specialized centers for physician-led diagnosis and acute bodily treatment.

• Hospice / Guesthouse: A monastic lodging situated along trade or pilgrimage routes that offered food, rest, and care to weary travelers, the disabled, and the terminally ill.

  • The term hospice began narrowing in the mid-19th century to describe residential homes specifically caring for the incurable and dying.

• Almshouse (introduced in the 14th century): A charitably endowed residential home providing permanent housing and basic maintenance for the destitute or qualifying elderly, widowed, or physically disabled.

• Madhouse (16th & 17th centuries): A privately or publicly run facility focused on the care for and management of people exhibiting severe psychiatric disturbance, referred to as the “raving mad.”

• Workhouse / Poorhouse (17th-19th centuries): A municipal or parish facility offering basic room and board to the impoverished in exchange for strict, mandatory manual labor designed to discourage pauperism.

  • In the US, almshouse and poorhouse were used almost interchangeably for public municipal facilities, whereas in Britain, almshouses were private/charitable and workhouses were parish/union tax-funded.

• Asylum (introduced in the 1790s): A specialized residential retreat initially designed to cure mental illness through structured moral treatment and serene environments, which later evolved into large state-run custodial institutions.

• Training School (1840s-1880s): A specialized residential educational institution created to provide sensory training, basic literacy, and practical skills to children with intellectual and developmental disabilities.

• State Colony / Institution (1880s-1990s): A massive, self-contained state campus designed for the permanent custodial segregation and agricultural labor of individuals with chronic mental illnesses or developmental disabilities.

• Nursing Home (introduced in the 1930s): A commercial or non-profit residential facility providing long-term personal assistance, skilled nursing care, and daily support for frail elderly adults or individuals with chronic physical impairments.

Community integration

From the medieval era through the 17th century, Western residential care operated on a domestic scale. Almshouses, monastic infirmaries, and early town workhouses sheltered small populations—typically between six and 36 individuals—functioning as extended, parish-level households. Though governed by monastic-style rules, meal schedules, and moral codes, these early facilities were physically and socially porous. Residents routinely ran errands in town, worked as local day laborers, and interacted with vendors on facility grounds, while community members used institutional chapels and halls.

By the 18th century, this civic integration diverged. In major urban centers, institutions like London’s Bethlem allowed paying members of the public to tour wards—a voyeuristic practice that, despite its ethical flaws, kept care spaces visible. Simultaneously, parish systems began formally dividing the “deserving poor” (the aged, infirm, and widowed) from the “undeserving poor” (able-bodied individuals deemed idle). Because local jurisdictions lacked the resources to create and maintain separate facilities, both groups were routinely funneled into increasingly punitive workhouses designed to deter reliance on public relief through compulsory labor and strict regimentation.

In response to these harsh conditions, late eighteenth- and early nineteenth-century reformers codified “moral treatment.” This movement sought to reclaim structured openness by framing family-style living and community participation as therapeutic. To ensure superintendents could personally know every resident, reformers capped ideal facility capacities at 250, with managing families usually living on site.

This small-scale model collapsed between the 1850s and 1930s under the pressure of rapid urbanization, mass immigration, and growing populations of people needing long-term care. Viewed by taxpayers as an economically burdensome class rather than vulnerable neighbors, residents were increasingly managed through cost-containment measures. Rather than funding small, local asylums, state legislatures repeatedly expanded existing sites with multi-story ward blocks and vast agricultural units. By the mid-20th century, mid-sized regional facilities had morphed into sprawling, isolated administrative cities housing 5,000 to 13,000 residents. Relocated to distant rural land, these mega-institutions ended daily community integration and replaced household care with centralized, clockwork routines.

Ultimately, the history of institutional care is not a story about a single diagnosis, a single type of facility, or a single group of people. It is the history of how families and communities responded when a person’s support needs exceeded what a household could safely manage.

Many of the residents who filled historical asylums, almshouses, workhouses, and psychiatric hospitals were defined less by psychiatric illness than by three broad, overlapping categories of vulnerability:

• Physical dependencies: Structural brain injuries, strokes, Parkinson’s disease, severe epilepsy, and the physical frailties of aging that required round-the-clock nursing care or supervision beyond a family’s capacity.

• Metabolic dependencies: Systemic physiological disruptions (such as pellagra, B12 deficiencies, neurosyphilis, liver failure, and severe endocrine crises) that altered brain function and behavior in ways that mimic psychiatric illness.

• Social dependencies: The acute economic vulnerabilities born of destitution, legal settlement restrictions, and the loss of surviving family networks, often compounded by public funding streams and broader economic realities.

Some residents entered these facilities voluntarily, some were placed by exhausted or desperate families, and others were committed through legal processes. Conditions ranged from deeply compassionate to systematically neglectful, allowing institutions to function simultaneously as places of refuge, medical treatment, custodial holding, and social control.

Understanding this complexity helps us move beyond simple narratives of either benevolent care or wholesale abuse. It reminds us that the central challenge of residential care has remained remarkably consistent across centuries: how to provide safety, dignity, supervision, and support to people with significant dependencies while preserving as much autonomy and community connection as possible.

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The pitch of the care village is that they’re basically the opposite of a nursing home. The media loves them and whenever there’s an article people eagerly share it. Imagine a place where people with dementia can walk to a cafe, run errands, or relax in a garden without needing special permission. Imagine a place where autistic adults can live in homes designed around their sensory needs, work in meaningful roles, and participate in community life without being overwhelmed. These villages start from the premise that people with cognitive disabilities are ordinary people who need beauty, routine, autonomy, and belonging, not just supervision and medical care. They are neighborhoods built around human needs rather than institutional convenience. They feature walkable streets, gardens, cafés, and homes clustered around courtyards. The village is engineered to be safe, predictable, and supportive for people whose disabilities make ordinary environments overwhelming or dangerous.

A dementia village is designed specifically for people living with Alzheimer’s or other forms of dementia. Residents live in small households of six to eight people, each with a lifestyle theme so the environment feels intuitively recognizable. The entire village is enclosed for safety, but inside the perimeter residents can walk freely. Staff are present everywhere, appearing in the role of shopkeepers, neighbors, and café workers.

An IDD village often includes small homes, vocational workshops, sensory‑friendly spaces, and predictable routines. Some are farm‑based, where residents care for animals or gardens; others resemble small towns with craft studios, bakeries, or greenhouses. The goal is to create an environment where sensory overload is minimized, social expectations are clear, and support is woven into the fabric of life. Staff are embedded in the community, offering guidance and structure without dominating the environment.

Care villages tend to work best for people whose disabilities make ordinary community life exhausting, unsafe, or dependent on constant supervision — but who still have rich inner lives, preferences, relationships, and capacities that flourish when the environment is predictable and orderly. Many are nonverbal yet cognitively sophisticated, capable of complex reasoning, humor, emotional nuance, and deep connection. What limits them in the outside world is the sheer amount of scaffolding required to navigate their communication differences. In a village, that scaffolding is built into the environment, which gives them a new level of autonomy.

People with higher cognitive flexibility, strong verbal communication, and a desire for novelty or self‑directed exploration would find village life constraining. The features that make a village liberating for some (the predictability, enclosure, curated social life) feel infantilizing and creepy for those who want the full complexity of ordinary community life.

This is what the women at the wine bar were discussing and why I was excited to chat with them. They knew their kids and wanted them in a place that provided the right kind of support. In my experience, the people who handle placement for each village know exactly who it is designed for and are honest about who will — and will not — find it liberating.

Care Villages

These villages operate on several shared principles. Daily life is normalized through architecture and routine. Residents live in small homes, with consistent staff who cook, share meals, and maintain predictable rhythms. The entire environment is enclosed or semi‑enclosed, allowing residents to wander safely, explore, and engage with the community without encountering hazards or disorientation. Signage is clear, sensory stimuli are controlled, and the layout is intentionally intuitive, reducing cognitive load and preventing agitation. Residents are not passive recipients of care; instead, they participate in gardening, cooking, music, crafts, festivals, and small daily tasks that reinforce identity and belonging.

The best‑known example of a dementia village is Hogeweyk in the Netherlands. Hogeweyk consists of small homes arranged around a town square with a grocery store, theater, café, and other amenities. In dementia villages like Hogeweyk, families visit constantly. They eat meals with residents, walk with them, attend events, and participate in daily life. In a dementia village, surveillance is absolute but entirely theatrical. The environment relies on “managed autonomy.” The grocery store clerk, the gardener, and the neighbor walking a dog are all trained psychiatric nurses and caregivers in plainclothes. Residents believe they are managing their finances at the market, but no real currency changes hands. Autonomy is a carefully constructed illusion designed to maximize dignity while minimizing actual risk.

In the United States, the Green House model adapts the same philosophy through decentralized micro‑homes. Each home has ten to twelve residents and universal workers who handle cooking, cleaning, and care, creating a stable, household‑like environment. The Lantern communities in Ohio attempt to replicate Hogeweyk more directly, building indoor streets with sky‑like ceilings, storefronts, and memory‑supportive cues that allow residents to navigate freely and comfortably. Smaller adaptations exist in the UK, such as the Fartown dementia village, which emphasizes walkable outdoor paths, community shops, and autonomy within a safe perimeter. Families often report that their relationships improve after a move to a village because they can shift from crisis‑management to companionship. They stop being exhausted caregivers and return to being spouses, children, siblings, and friends.

IDD villages share the same commitment to autonomy, predictability, and meaningful roles. Camphill communities, found across Europe and the US, are among the oldest and most philosophically developed models. They integrate disabled and non‑disabled people in shared households, with daily work in farming, crafts, baking, or weaving, all structured around rhythm and relational continuity. L’Arche communities follow a similar approach, creating small homes where assistants live alongside residents and daily life revolves around shared meals, celebrations, and deep interpersonal relationships. Group homes, intentional communities, and village‑style environments are meant to provide the level of support that families often cannot sustain indefinitely. Adults with IDD who live in these settings still go home for holidays, spend weekends with relatives, attend community events, and maintain outside friendships. Many villages have transportation systems, visitor programs, and community partnerships specifically to keep residents connected to the outside world.

In the US, autism‑friendly planned communities such as First Place Phoenix, Sweetwater Spectrum in California, and The Center for Discovery in New York offer sensory‑friendly architecture, predictable routines, vocational programs, and integrated support. Farm‑based IDD villages are common in Germany, Denmark, and Norway, where residents live in small homes on agricultural campuses and participate in daily farm work that provides structure and purpose. Intentional communities like Bittersweet Farms in Ohio or Brookwood Community in Texas combine small‑home living with on‑site work programs (greenhouses, bakeries, craft studios) that give residents stable roles and a sense of belonging.

Colonies vs villages

In a sense, the village model is not a break from history but a reconfiguration of a very old strategy: certain people can’t fit into ordinary environments, so they build settlements to manage them. Before the village model, we had the colony model. The whole historical lineage of planned settlements built for populations who could not easily be absorbed into ordinary social life tended to use the term “colony.” Today’s dementia and IDD villages inherit the form of the colony, but with a subtly different purpose.

In the late nineteenth and early twentieth centuries, many countries built psychiatric farm colonies as overflow systems for asylums. These were rural campuses where people with chronic mental illness lived in small houses, worked on farms, and followed regimented daily routines. The logic was partly therapeutic (fresh air and productive labor) and partly economic (colonies aimed to be self‑sustaining). Germany’s Heilanstalten, the Netherlands’ Veenhuizen, and Belgium’s Merksplas and Wortel are examples. In the United States, places like Pennhurst, Letchworth Village, and Sonoma State Home had farm components and colony-like layouts.

There were also industrial colonies, which were not medical at all but also used spatial design to shape behavior. Company towns like Pullman or Krupp created controlled environments where housing, work, leisure, and surveillance were integrated. Their purpose was to stabilize labor, enforce discipline, and cultivate a compliant workforce. And earlier still, religious colonies (like Moravian settlements, Hutterite Bruderhöfe, and Jesuit reductions) used isolation, communal living, and strict routines to produce idealized forms of Christian life.

Across all these variations, the common thread is that colonies were projects of improvement, discipline, and extraction. They were designed to change people. Residents were subjects of a project, not authors of their own lives.

Yes, reformers talked as if farm labor could “improve” people who were officially labeled incurable, although that rhetoric was doing political work rather than describing a realistic therapeutic goal. The people running these colonies knew the majority of residents would never “graduate.” The language of reform was a way to justify the existence of the colony and secure funding. When you have bills to pay, you learn to say the things funders want to hear.

Both colonies and villages are top-down projects. Historical colonies concentrated power in clergy, employers, reformers, or medical superintendents. Residents were subjects of a project designed by others, although they often had some role in daily administration. Modern villages are run by administrators, gerontologists, psychiatrists, social workers, therapists (physio, occupational, music, art, etc), and the nursing team.

The residents do not govern the village. Any environment where vulnerable people depend on others for safety, food, medication, and daily structure will always have asymmetrical authority. This inescapable power dynamic is exactly why the village model faces intense resistance from advocates who champion full, organic community integration over enclosed settlements.

Creating a village vs community integration

The idea of building purpose‑built villages rather than relying entirely on home care, family placement, or scattered group homes comes from a very simple observation: integration is a beautiful ideal, but it breaks down for people whose cognitive, sensory, or behavioral needs exceed what ordinary communities can provide. People with high support needs require environments that are not just friendly but engineered.

Supportive care at home works well when a person’s needs are light or moderate, when families are stable, when caregivers are available, and when the home environment can be adapted. But dementia, severe autism, profound intellectual disability, and complex neuropsychiatric conditions often require 24/7 supervision, structured routines, and relational continuity that is unavailable. Group homes solve some of these problems but introduce others. A group home may be physically “in the community,” yet socially cut off from it. Residents are subject to rigid rules. Spots are often virtually impossible to get, leading people to end up in homes far from their community of origin.

Residents of a village are given a world that fits them. Villages typically provide more social interaction than home‑care or group‑home models. A person with dementia might see dozens of familiar faces each day — those of neighbors, visitors, and shopkeepers — rather than just their immediate family and a home health aide. A person with IDD can have meaningful community roles, predictable routines, and a sense of belonging that is incredibly difficult to achieve in an ordinary community.

Inclusive communities work well for people whose impairments are compatible with the pace and unpredictability of ordinary life. Purpose‑built villages work well for people who need a world that is smaller, calmer, safer, and more predictable.

Village staffing

Home care relies heavily on low-wage workers. In the US specifically, the system depends on agencies utilizing part-time independent contractors who are given unpredictable schedules, new clients every shift, little support, and no potential for advancement or even raises. Aides juggle multiple jobs and can’t afford their own childcare or transportation. Even if you raise wages or offer bonuses, the underlying job remains fragmented, rushed, and exhausting. A worker who is responsible for fifteen residents in a long corridor with constant alarms will quit no matter how well you treat them. A worker who is assigned to three different clients in three different towns will quit no matter how much training you provide. The system itself produces churn.

Aides are responsible for too many residents, in environments that trigger behavioral crises, under supervisors who must enforce compliance with regulations that don’t match human needs. Workers float between units because the staffing model assumes flexibility rather than continuity. Agencies supply per‑diem workers because the reimbursement system doesn’t support stable full‑time employment. Turnover becomes rational: the job is physically punishing, emotionally draining, and structurally chaotic. Even facilities that try to treat workers well cannot escape the architecture and the reimbursement rules that force instability.

Workers are burnt out. People receiving care aren’t provided with reliable, consistent care. A rotating cast of aides doesn’t know their preferences, triggers, communication style, or their personality. There’s no opportunity to build a relationship and, since aides are penalized for every extra second taken on a task, they’re not allowed to. A home‑care model that treats each shift as a discrete transaction cannot provide relational care, even if many of them use the right buzzwords on their brochures.

Villages have consistent staff because their entire operating model removes the structural conditions that normally produce churn. In nursing homes, turnover is driven by low wages, chaotic assignments, floating between units, unpredictable schedules, and the physical and emotional strain of caring for too many people at once. A village eliminates these pressures through design, staffing structure, and funding. Staff work in small households (usually six to eight residents) and they are not constantly rotated or pulled to cover other units. Cooking, walking, conversation, and gentle supervision replace the frantic rush of traditional care. This makes the job physically and emotionally sustainable.

Villages hire staff directly rather than relying on agencies, which means workers have full‑time jobs, benefits, and consistent schedules instead of per‑diem or gig‑style shifts. In countries where villages are common, universal long‑term care funding provides stable reimbursement, allowing organizations to pay competitive wages and maintain higher staffing ratios. Even in the United States, where funding is more fragile, villages still prioritize full‑time staff because the model collapses without continuity. Leadership structures are flatter and more supportive, giving staff autonomy and reducing the punitive oversight that drives turnover in institutional settings.

The utopia to dystopia pipeline

We keep inventing new care models to fix the failures of the last, only to watch them produce the same quiet suffering. Almshouses saved people from monastery hospitals. Asylums were humane alternatives to almshouses. Farm colonies saved people from asylums. Then came community care.

Every model begins as a well-funded, idealistic project. The first asylums were philanthropic showpieces with gardens, libraries, and generous staffing. Early farm colonies were utopian communities offering fresh air and dignity. Even boarding homes were initially championed as radical vehicles for community integration.

But the arc is always the same. States take over, scale up, and try to deliver the care cheaply. Budgets tighten, admissions skyrocket, and the therapeutic environment collapses. The asylum becomes a crowded warehouse. The farm colony becomes a cheap labor camp. The boarding home becomes a neighborhood dumping ground. The exact same architecture — enclosure, routine, communal living — can support dignity or enforce discipline.

People fear institutions because they have become symbols of abandonment. But the danger is not inherent to institutional care. Abuse and neglect aren’t inherent flaws in these models; they are the predictable outcome of starving them of what makes them work. When staffing and funding dry up, any environment where vulnerable people depend on others for survival will produce cruelty. No amount of regulation layered on top in a pathetic attempt to square the circle can prevent that.

Abuse and neglect were never secret. Inspections have always existed — I’m going through inspection reports from hundreds of years ago. More recently, reports documented problems. Journalists wrote exposés. Families complained. Legislators held hearings.

Oversight only works when the system has slack. When funding is too low and every bed is full, a failed inspection doesn’t lead to closure because there’s nowhere else for people to go. Oversight without alternatives is theater. Real safety requires enough funding, staffing, and placements that regulators can actually shut down the places that fail.

Villages are not immune. If they remain boutique enclaves for the wealthy, they will fail to change anything. And if we scale them up while starving them of the money and staff required to sustain them, they will fail exactly like everything else before them.

Funding

If you’re thinking that dementia and IDD villages sound expensive, you’re right. They take the already high baseline cost of long‑term care and layer on specialized architecture, higher staffing ratios, and a whole social world built around residents’ needs.

Hogeweyk is not a boutique private project. It was built for about €19.3 million, with €17.8 million of that funded by the Dutch government and the rest by local organizations. Hogeweyk’s ongoing operating costs are covered through the Dutch long‑term care insurance system. Residents pay income‑linked contributions, so the state covers the bulk of the cost. European governments are more willing to treat village‑style care as a variant of ordinary residential care rather than a separate luxury product. In countries with robust social insurance for long‑term care, dementia villages and IDD communities are typically funded under the same umbrella as nursing homes or residential disability services.

Most current or planned US dementia villages rely heavily on private pay, long‑term care insurance, and sometimes philanthropic or state pilot funding, with minimal Medicaid involvement.

We know how to provide long‑term care ethically and well. We’ve always known how to do that. The problem is that the systems we have built make it nearly impossible to do so at scale. The Green House model shows that even within the regulatory category of “nursing home,” it is possible to create a place that feels like a home rather than an institution. The Green House model is widely admired, backed by strong evidence, and consistently rated as one of the best models of nursing home care in the country. Yet only a few hundred homes exist, serving a tiny fraction of the people who could benefit. The problem is reimbursement rates, regulatory rigidity, and workforce shortages.

Regulations

A few months ago, I was told I had to take the wreath off my apartment door. I thought it was odd, because all of our doors have hooks for a wreath. When I looked it up, I confirmed that it’s against the fire code to have anything on your door in an apartment building and violations come with huge fines for the building. Just imagine what the rules are like in residential care. Many of the things that make a place feel like home are technically illegal outside of single family homes.

Once you start looking at the regulatory landscape, you realize that a huge number of “common sense” improvements that would make life more pleasant, more personal, more normal are either illegal or involve multiple layers of regulations. Administrators have no choice but to enforce rules that make environments feel sterile, generic, and institutional.

• The fire code is the most obvious culprit. A hallway that looks inviting is, according to a regulator, a death trap. Fire‑safety rules limit the amount of upholstered furniture because it increases “fuel load,” so lounges often end up with vinyl‑covered chairs.

• Then there are infection‑control rules. Plants, throw pillows, quilts, and personal furniture are hard to sanitize. Books and knick‑knacks collect dust (an allergen). Obviously pets are impossible. During outbreaks, these rules tighten even further, and facilities often never relax them again.

• ADA and Life Safety Code requirements shape far more of the nursing‑home environment than most people realize. Anything that narrows a hallway, even slightly, can violate ADA clearance requirements. That means no benches, no decorative tables, no shelves, no cozy nooks. Resident rooms must have enough open floor space for staff to maneuver lifts, which means furniture is sparse and pushed to the edges. Bathrooms must be large, bare, and utilitarian to accommodate wheelchairs and grab bars, leaving no room for warmth or personalization. Doors must be wide, heavy, and often self‑closing, which makes them feel more like hospital doors than home doors.

• Liability rules add yet another layer. Facilities don’t want personal furniture because it may not meet stability standards. Resident‑installed shelves or hooks could fall. Personal appliances are a fire hazard. Facilities ban candles, string lights, space heaters, weighted blankets, rocking chairs, and anything that could be construed as a fall risk, burn risk, or entanglement risk.

• Residential care licensing imposes strict requirements. Facilities need clear sightlines for supervision. They must maintain “cleanable surfaces,” which discourages wallpaper, textured paint, and textiles. They must maintain “clinical lighting levels.” They must maintain “staff access,” which means no locked personal storage. They must maintain “uniformity,” which discourages individualized décor in shared spaces. To be home-like is to be non-compliant.

Taken together, they produce a built world that is stripped down, over‑wide, over‑bright, and over‑controlled. The result is an aesthetic that feels clinical even when the staff and residents want something warmer.

Villages are built to meet fire codes, accessibility rules, and licensing requirements without looking like institutions. They use sprinklers, fire‑rated materials, wide streets instead of hallways, household kitchens instead of central ones, and architectural tricks that allow personalization without violating safety rules.

Once a built environment is created to satisfy a particular regulatory category, it becomes extraordinarily difficult to retrofit it for a different purpose. Suburbs are shaped by zoning codes that forbid mixed‑use buildings, require large setbacks, mandate wide roads for fire access, and impose parking minimums that prevent density. Dead malls were built under occupancy classifications that assume large assembly spaces, specific egress patterns, particular ventilation systems, and structural loads designed for retail, not housing or healthcare. Changing the use of these spaces triggers a cascade of regulatory requirements (new fire codes, new accessibility standards, new plumbing and ventilation rules, new stormwater systems, new parking ratios) that make transformation prohibitively expensive.

Boarding homes

When you trace the history, you see how safety regulations, liability fears, and zoning laws converged to make certain forms of communal living nearly impossible. Tragic fires led to major reforms of fire codes in the US, reshaping entire categories of housing. Boarding homes were once a respectable option for middle‑class families, widows, students, and workers.

Boarding homes were ordinary houses run by ordinary people, usually widows, couples, or families, who took in a handful of boarders. They provided services like meals and light housekeeping by the week or month. Residents had more than just a clean room; they had someone who noticed if you didn’t come down for breakfast, freedom from the responsibility of housekeeping and laundry, and the quiet reassurance of other people under the same roof. Of course, boarding homes varied widely in quality. But they provided exactly what people look for in long-term care: independence, small scale, companionship, and the quiet assurance that someone nearby knows you well enough to notice when something is wrong.

Boarding homes were dramatically less expensive than any other form of care. They were run by families rather than professional staff, because boarding homes officially provided only meals and housekeeping. Board and care homes, which emerged in the 1960s, provided additional services for people who needed more support, but faced even more regulations.

The introduction of Social Security in 1935 onward led to a boarding home boom, as eligible people were freed from financial reliance on their families. Many opted to relocate to inexpensive boarding homes for more independence. Medicaid, introduced in 1965, covered nursing home care but not boarding homes. Consequently, runaway inflation in the 1970s pushed people into nursing homes. When they couldn’t afford the boarding home anymore, a nursing home was the only option.

Fire codes, licensing requirements, and rising housing costs caused boarding home expenses to skyrocket just as residents were being pushed into nursing homes by their own financial necessity. Cities began enforcing codes aggressively, often in combination with zoning changes. Boarding houses either shut down or reclassified themselves as “rooming houses” which offered no services at all, just rooms. Since this coincided with deinstitutionalization, the state soon stuffed these full of the formerly homeless, people with psychiatric disabilities, and other people who would have been institutionalized in an earlier era.

And then, as in my own hometown, people fought the influx of people with high, unmet care needs who had been abandoned in their neighborhoods. In Geel, boarders placed with families had layers of support to ensure they were integrated into community life, not disrupting it. In the Ocean Grove of my childhood and my Toronto neighborhood today, the police are reluctant to respond to calls about mentally ill residents smashing things, setting small fires, or behaving in other alarming ways that aren’t true emergencies because they know there’s no point.

Residents who had previously lived in structured environments were suddenly responsible for their own medication schedules, hygiene, food, and safety. Many couldn’t manage it. People wandered, became disoriented, forgot to eat, or experienced psychotic breaks with no one nearby trained to intervene. When hundreds of vulnerable people were clustered in a few blocks, the burden fell on the same handful of emergency rooms, police precincts, shelters, and outreach workers. The state that placed people in these rooming houses didn’t provide local funding for mental‑health clinics or crisis teams.

People often assume that the wave of regulations in the 1960s-1990s — the fire codes, licensing rules, staffing requirements, inspection regimes — must have reduced neglect and abuse. It feels intuitive: more rules, more oversight, more safety. But when you look at the historical record, the answer is far more complicated, and honestly, a bit bleak. Regulators rarely bothered to wonder about the impact of these regulations. They acted to reduce liability. They simply assumed that “institutional standards” would be safer, even though the data on nursing home abuse was already alarming by the 1970s.

Licensing rules were similar. They were designed to standardize care, but they also eliminated the informal, relational oversight that made boarding homes work. A landlady who knew every resident’s habits was replaced by shift workers who didn’t. Regulators never asked whether the loss of familiarity increased risk. They asked whether the facility met the checklist.

Regulation made small boarding homes too expensive to operate. Regulation still makes group homes, small nursing homes, and other community housing options expensive or impossible. The collapse of small homes funneled vulnerable people into larger institutions where neglect was more common, more hidden, and more systemic.

European zoning laws are no less strict or concerned about fire safety, but they’re very different from those in the US. Europe’s fire‑fatality rates are not higher than the US, and in many countries they’re lower. European countries have a different philosophy about what makes people safe. France’s zoning laws make group homes incredibly difficult and expensive to build, so they place people in group homes in Belgium instead. If they believe the regulations were so important, how can they justify it? If they know the regulations aren’t important, why do they keep them? Regulations persist because they are structurally embedded, politically inertial, and administratively difficult to reform.

Every nursing home as a village

People and the media love the idea of the dementia village because it offers a vivid, emotionally satisfying counter‑image to everything people fear about long‑term care. The village story is charming: small houses, cafés, gardens, familiar streets, residents wandering safely, staff blending in as neighbors rather than hovering as clinicians. It lets people imagine a future where needing care does not mean losing identity, autonomy, or beauty.

News about the Department of Justice permitting more Medicaid waiver home care cuts, by contrast, trigger a different fear: abandonment. Most people imagine two choices: home or a neglectful institution. When Medicaid waivers are threatened, people imagine themselves and their loved ones being forced into a nursing home. They know that Medicaid guarantees a nursing home bed but does not guarantee home care, and they know that most people with dementia or disability want to avoid institutions as long as possible. So the same person who shares a heartwarming story about Hogeweyk will panic at the idea of HCBS cuts, because the village feels like a dream while the nursing home feels like a default they might actually face. The village is aspirational; home care is survival.

In 2014 a rule was passed, the CMS HCBS Final Rule (often called the Settings Rule), prohibiting Medicaid waivers from funding environments that have “institutional qualities” or isolate individuals from the broader community. This makes it very difficult for villages and group homes to get HCBS funding, since licensing requirements require they have “institutional qualities.” States can still fund these settings if they prove to CMS that the facility does not isolate residents. It is an uphill battle, but not a strict legal impossibility. You have to choose between the high level of Medicaid scrutiny or accept that a more self‑contained enclave will have to live on private pay, institutional funding streams, or other government funding sources.

In the US means‑tested system, flourishing is treated as income, and income threatens survival. In universal systems, the state provides survival and families can provide flourishing. In countries like Canada and Japan, long‑term care is treated as a public service, a baseline of support that every resident is entitled to, regardless of income. Because the benefit is universal, families and charities can add whatever they want on top: outings, clothes, transportation, companionship, cultural activities, and small luxuries. None of this threatens eligibility. None of it is counted as income. The state guarantees survival, and families are free to provide flourishing. The system assumes that human beings need more than subsistence, and it does not punish people for receiving kindness.

The United States does the opposite. Medicaid, the primary funder of long‑term care, is a poverty program, not a care program. To qualify, you must be poor enough, stay poor enough, and behave poor enough. That means almost any outside help is treated as income. If a family member buys groceries, pays for transportation, covers a phone bill, provides clothing, or gives a gift card, the system can treat it as “in‑kind support and maintenance,” which reduces or eliminates SSI benefits and can jeopardize Medicaid eligibility. Even non‑cash support can be counted. The rules are written to prevent fraud, but they end up criminalizing normal life. A person who needs significant care must either refuse help or hide it.

This dynamic is clearest for people who rely on SSI alongside Medicaid. SSI has a $2,000 asset limit for individuals and it counts nearly everything as income. If someone contributes support in cash or kind, SSI may reduce the monthly benefit. If someone provides anything that resembles basic support, the system assumes the person is less poor and therefore less deserving of aid. Medicaid often follows SSI’s eligibility rules, so losing SSI can mean losing the care that keeps a person alive. The result is a system where people must be deprived in order to qualify for the services that keep them alive. Families who want to help must disguise support as loans, route assistance through special needs trusts, or avoid giving anything directly. The system forces people into secrecy simply to live a normal life.

Right now, the US has a system that treats huge institutions as safe and small homes as a radical, potentially dangerous experiment. Regulations treat support staff as interchangeable, as if it’s fine for a different person to give you a bath each time. Regulations focus on easily measurable metrics, rather than what really matters. Change requires federal and state regulators to rewrite the assumptions baked into current rules: that efficiency, centralization, and risk control are the primary goals. As long as regulations and funding reward large, efficient facilities, nursing homes will remain places people fear. The American system is self‑defeating. It tries to prevent neglect and abuse while using a design that guarantees both.

There’s no question that human beings cannot live on biological maintenance alone. We need meaning, connection, stimulation, autonomy, and dignity. Yet American law and government funding behave as if humans were entities that require only calories, shelter, and medical intervention. This is why dementia villages receive glowing media coverage but almost no public funding. They represent the kind of care people wish existed, but the political system refuses to pay for. Honestly, property taxes in much of the US are already incredibly high. If we simply increased taxes under our current funding system to eliminate means-testing for long-term care, well, that would not go well.

Creating ethical long-term care options isn’t about getting politicians to use the right jargon to show they’re on “our side.” It requires a major overhaul of zoning laws, fire codes, licensing regulations, and taxation. That’s a tall order in a country where bipartisan projects are just not a thing right now. Everyone says they care about caregiving, but no one can work together to get anything done. It’s one more form of abandonment.

But despair and rage are not a strategy. We cannot wait until Washington or state legislatures suddenly become functional. We have to figure out how to survive within the gridlock.

Actionable options

The problem is not that people don’t care or that long-term care is impossible. The challenge is regulatory and financial feasibility. Given the system we’ve got, what can we actually do—not in theory, but in the world we’re actually in right now?

Could we turn ordinary communities into inclusive communities?

Right now, too many people on waivers live what looks like “community life” on paper but is, in practice, solitary confinement with intermittent help. The Settings Rule doesn’t prevent people from being isolated in their houses.

HCBS and MLTSS are both subject to the Settings Rule. Managed Long‑Term Services and Supports (MLTSS) is the system where states pay private managed‑care plans to coordinate long‑term care for people who meet nursing‑home level of care. Instead of Medicaid paying nursing homes directly, the state pays a managed‑care organization a monthly rate, and that plan can fund home care, adult day programs, assisted living, and small group homes. Because MLTSS is part of the Medicaid state plan, it doesn’t depend on waiver caps. States like New Jersey already use MLTSS to shift people out of institutions and into community settings.

The most powerful way to use HCBS and MLTSS is to treat them as platforms for building community participation rather than as narrow funding streams for personal care. States can fund transportation supports, community habilitation, day programs that actually take place in the community. HCBS can also fund small shared‑staff models: two or three people living near each other with overlapping support, which makes outings and activities possible without requiring one‑to‑one staffing for every moment.

But the deeper work happens outside Medicaid. Communities can build the scaffolding that makes participation possible: volunteer visitor programs, transportation co‑ops, inclusive recreation leagues, library‑run social groups, faith‑based circles, maker‑spaces that welcome disabled adults, and neighborhood associations that include everyone as part of civic life. These supports don’t replace Medicaid; they wrap around it, filling the gaps that personal‑care hours can never fill.

Could we create Medicaid‑funded villages and group homes?

Medicaid‑funded villages and group homes are possible. State legislatures can push this further by creating licensing categories designed specifically for small‑house or village‑style models.

Medicaid has two pathways for paying for long‑term care that could be used for a village:

• PACE (Program of All‑Inclusive Care for the Elderly) is a federal program that wraps medical care, social care, transportation, therapies, and daily support into one package. People enrolled in PACE (55+) get all their care through a local PACE center, but they live at home or in small community settings. PACE is permanent federal law and it allows states to fund village‑like environments without relying on institutional nursing homes.

• State‑funded assisted living refers to the fact that some states choose to pay for assisted‑living services through their Medicaid state plan rather than through waivers. When a state does this, assisted living becomes a stable, guaranteed benefit rather than an optional, capped program. States can then license and fund small‑house models, clustered housing, and dementia households as part of their assisted‑living system.

For people with dementia or IDD who currently receive many hours of one‑to‑one care at home through waivers, a well‑designed group home or village‑style setting would likely be less expensive per person because staff and infrastructure are shared. Instead of paying for 168 hours of individual care per week for each person, the state pays for a team supporting several residents together. Housing, food, utilities, and activities are bundled. For people who need supervision, cueing, and structured days — but not constant skilled nursing — this model can deliver a better life at lower cost.

The exception is individuals with very complex medical or behavioral needs. For them, the cost comparison is more ambiguous, and the question becomes which model can reliably deliver the level of care required.

Could community groups support nursing homes by adding in flourishing?

For nursing homes that remain owned by nonprofits and local families, it can be run in a way that feels different from the typical institutional model, even though the regulatory and financial structure stays the same.

• You can reorganize staffing so residents see the same aides every day, creating small household teams within the existing building and offering more predictable schedules. You don’t need new construction to cluster rooms and routines. Prioritizing full‑time roles over per‑diem work stabilizes relationships and reduces turnover. Build time for non‑task interactions into the day. When wages can’t be raised sufficiently, other arrangements can be made to provide staff housing, reliable transportation, and reliable childcare.

• You can create a small nonprofit arm or “Friends of the Home” group. Once that entity exists, the home can cultivate long‑term relationships with local churches, service clubs, schools, and neighborhood associations, inviting them into the building regularly so they see residents as neighbors rather than strangers. People give to what they feel connected to.

  • The organization can raise money for things like outings, concerts, gardens, hobby supplies, visiting performers, holiday celebrations, and improvements to shared spaces.

  • You can build a volunteer corps drawn from local schools, churches, libraries, service clubs, and neighborhood groups, and give them roles that enrich the social world of the home. Having the same volunteers come in each week is more rewarding for both residents and volunteers.

  • Local institutions become natural partners: libraries can run book clubs, schools can send choirs or art students, animal shelters can bring visiting pets, and community theaters can offer performances.

Gifts to a Friends of the Home don’t trigger Medicaid clawbacks or risk losing coverage like gifts to individual residents would. Gifts, outings, donated goods, and volunteer‑funded amenities are understood as third‑party contributions to the facility’s social environment, not as income to the resident. A volunteer group can take residents to a baseball game, knit sweaters, bring special groceries for a shared meal, or buy a new TV for the lounge, and none of it counts as income to the residents. Medicaid does not treat these contributions as resources because they are not under the resident’s control and do not increase the resident’s personal assets. They are simply part of the communal life of the facility. When someone lives at home on Medicaid HCBS, the rules are stricter because the program is designed around the idea of personal income and household resources.

Federal and state nursing‑home regulations lock the building into a particular aesthetic. But bland architecture doesn’t doom a home to feeling lifeless. What transforms a nursing home is the presence of people, the rhythm of activities, and the sense that the building is woven into the community rather than sealed off from it. The real challenge is sustaining that involvement over years and decades, because flourishing depends on continuity. The more deeply the home is embedded in its neighborhood, the easier it becomes to build a donor base that reliably funds the extras Medicaid will never cover.

How can we protect local nursing homes?

Part of why nursing homes today are the way they are is that private equity is scooping up struggling homes. Private equity firms do not typically buy nursing homes to operate them long-term. The standard playbook is: a PE firm buys the facility, splits the real estate (Property Company) from the care operations (Operating Company), places the real estate into a Real Estate Investment Trust (REIT), and forces the OpCo to pay exorbitant rent. The operator is bled dry, staffing is slashed to cover the lease, and the REIT extracts the value. Communities can step in to intervene.

• A unionized workforce is the single biggest deterrent to private equity. Collective bargaining agreements lock in staffing ratios, wages, and severance packages, making it difficult for a new PE owner to immediately slash staff to extract cash. Communities can vocally and financially support the workers if they attempt to unionize prior to a sale. PE firms can still utilize bankruptcy restructuring to void collective bargaining agreements, shed pension liabilities, and force renegotiations.

• While staffing is usually regulated at the state or federal level, local municipalities can pass ordinances requiring specific nurse-to-resident ratios for facilities operating within city limits. If a facility legally requires high staffing, a PE firm cannot extract their desired margin.

• If the underlying land is highly valuable for redevelopment (say it’s in a gentrifying neighborhood), PE will buy the facility just to close it, demolish it, and build luxury housing. Local zoning boards can rezone the parcel strictly for healthcare/residential care use, or historic preservation boards can designate the building structure. If a PE firm knows they cannot easily demolish or flip the real estate for a more lucrative commercial use, the speculative value of the land drops, driving away predatory buyers.

• Local non-profit hospital systems are often the best-positioned buyers. Because hospitals face massive financial losses when they cannot discharge patients due to a lack of nursing home beds, they have a vested financial interest in keeping local nursing homes open. Community leaders can lobby a regional hospital network to absorb the nursing home to protect their own discharge pipeline.

• A CLT can purchase the real estate (acting as a non-profit PropCo) and lease it back to a non-profit care operator. This permanently removes the real estate from the speculative market. Typically CLTs are used to protect small multi-family housing, so you’d really need to hustle to come up with a mix of municipal grants, philanthropic capital, and community bonds to fund an unusually large CLT.

• Though rare in the US due to capital requirements, a multi-stakeholder cooperative (owned jointly by the workers and the residents’ families) can secure financing through specialized cooperative funds (like the Local Enterprise Assistance Fund) to purchase the operating company, while partnering with a local municipality or CLT to buy the building.

• In states with Certificate of Need (CON) laws, the transfer of ownership of a healthcare facility requires state approval. Communities can organize aggressively during the public comment period, demanding the state review the buyer’s track record in other states. If the PE firm has a history of health violations or bankruptcies (which is common), public pressure can force regulators to deny the ownership transfer.

• Many PE firms hide behind layers of LLCs. Communities can demand that state health departments enforce federal CMS (Centers for Medicare & Medicaid Services) transparency rules, forcing the buyer to disclose all individuals and REITs with a 5% or greater ownership stake before a sale is approved.

• Don’t invest your savings in REITs and encourage your pension fund, municipality, etc to avoid them.

There is no single solution

Even if the Department of Justice escalates its enforcement of the Olmstead mandate, a legal right to community integration remains a hollow promise without the physical and financial infrastructure to back it up.

As much as the silver tsunami framing irks me, the basic statistics are real. We cannot provide one-on-one care at home to every person who needs it in the US, no matter how it’s funded.

Insisting that all individuals must fit into the unpredictable pace of “ordinary” neighborhoods, regardless of their cognitive, sensory, or behavioral complexities, is its own form of ideological rigidity. People’s needs and desires are far too varied for one type of solution to work.

Residential care is not a failure we can wish away or legislate out of existence. Care homes exist. Care homes have existed for hundreds of years. We have to stop fighting to shut them down and instead focus on ensuring that all places where care is provided are places that are actually worth living in.

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I knew there were farm colonies for the poor, thanks to my time doing urban exploring in Staten Island. When I visited Geel’s museum, it stood out to me that it was the Colony of Geel. Then I learned about the Colonies of Benevolence and the vision of Salvation Army Colonies. Then I learned about agricultural colonies in the Banat of Temesvar, and “freed” serfs in Bologna being coerced into settling new towns along the contested frontier.

I kept coming across these colonies because colonial formation produces distinct patterns of kinship, labor, obligation, and infrastructure. These things determine who cares for whom, under what constraints, and with what resources. Plus, people write about colonies because, as planned communities, they’re fascinating and incredibly well documented. Things with great records are just easier to write about.

Every few weeks there’s a new media piece about a dementia village, a planned community for people with IDD, or co-housing for solo seniors. Each time I came across these, it became harder to see how they were different from certain types of historic colonies.

It was becoming obvious that what I’d learned in my history classes and social justice heavy reading was very much focused on the North American experience and that there was far more to colonization than I’d realized. When someone mentioned their ancestors were Anabaptist colonies in the Russian Empire over dinner, I finally caved and did a little research.

What’s a colony?

The reason I only learned about a few very specific types of colonies is because the majority of historians and political theorists use a different definition of ‘colony.’ Lots of things I’d heard about – penal colonies, leper colonies – are no longer colonies as far as they’re concerned.

There are four recognized kinds of colonies today:

• Settler colonies: An imperial power imports a foreign population to replace an existing population and build an autonomous society based on private property.

• Administrative colonies: An imperial power uses a small administrative, military, and commercial elite to rule over an indigenous population and extract resources and value.

• Plantation colonies: An imperial power uses merchant cartels, landholders, and overseers to build cash-crop estates, forcibly transporting and exploiting laborers to generate export wealth.

• Mercantile colonies: An imperial power establishes a minimal level of domestic settlement in order to establish the network infrastructure necessary to control trade routes, secure strategic military locations, or maintain commercial monopolies.

The term colony is now exclusively used to describe when an external territory is dominated, occupied, and governed by a foreign imperial state. Domestic colonies, colonies with forced settlement, and utopian colonies have different dynamics and are thus no longer technically colonies.

In the old days, a colony was a planned settlement that often included claiming or reclaiming land (frontiers, wetlands, deserts, etc). It described a spatial mechanism, but today it needs to also have a specific political outcome. So something that was a colony 100 or 1,000 years ago is often now a total institution, concentration camp, penal facility, a carceral geography, an internal spatial enclosure, a social welfare experiment, an agricultural commune, or an intentional community. Unless it’s overseas, in which case it’s still a colony.

The shift happened because in 1960, the UN General Assembly needed to determine what territories qualified for decolonization and self-determination. They determined that a colony was a geographically separate territory that was ethnically and culturally distinct from the administering state.

I’m going to ignore the present definition and rely on the older, broader use of colony, because while scholars, legal theorists, and politicians might have started to make the shift during the 19th century, the sources I’ve been reading have not. It was legally the Colony of Geel until 1984. The Belgian Colonies of Benevolence legally remained colonies until they were closed in 1993.

Frontiers & statecraft

The term colony comes from colonia, which referred to a Roman agricultural settlement, military outpost, or land grant established by citizens outside Rome. The root, colere, means to cultivate, to till, to inhabit, or to honor.

In the Roman Republic and Empire, a colonia was a planned settlement established on conquered territory. In Ancient Rome, senior officers, generals, patrician elites, and even standard soldiers were given land carved out of newly conquered territory. Settling military commanders and veterans along frontiers created a military buffer which helped keep territory under Roman control. It also created a social hierarchy led by Roman elites in conquered regions.

Following the 1066 conquest, William the Conqueror distributed Saxon estates to Anglo-Norman barons with the requirement that they build castles, controlled local populations, and provided military service. Russian tsars in the 15th and 16th century granted landed estates to the nobility in exchange for lifelong military and civil service. In New France, seigneurs were obligated to settle the land and establish infrastructure in order to keep it, allowing the French Crown to outsource the capital expense of clearing wilderness and recruiting settlers. In British North America, when colonial governments or the Crown granted huge tracts of land to military officers, aristocrats, or political favorites, it usually came with explicit requirements that it be settled, although these were rarely carried out, leading to widespread speculation and disputes over squatting. In the colonial era and early days of the US, authorities granted land to military officers and veterans. This rewarded people for their loyalty, claimed the frontier, and built the empire.

By the middle ages, a colony might be any planned agrarian migration or newly cultivated settlement. From the 11th to the 13th century, the Counts of Flanders and Dukes of Brabant had growing populations, food shortages, and vast, uncultivated peat bogs and coastal tide-lands. Lords issued land charters to settlers who agreed to dig drainage canals and convert wasteland into agricultural use. Around the same time, bishops in the Rhine-Meuse Delta sold land rights to peasant cooperatives. They cleared woods, drained wetlands, and established self-governing polder settlements. Across France, Germany, the Low Countries, and Britain, Cistercian monks were acquiring wastelands and borderlands. They converted the land to agricultural use and established self-contained agricultural outposts worked primarily by lay brothers. Lay brothers were typically illiterate peasants or laborers who took monastic vows (poverty, chastity, and obedience) but whose primary duty was manual labor rather than things like scholarly study or copying manuscripts.

Bologna famously freed the serfs in 1256. This didn’t happen because the serfs wanted to be freed. In fact, they’d been wandering off to the city when they wanted and the nobility couldn’t do anything to stop it. Which is part of why Bologna bought them, because it wanted the authority to require them to remain in the countryside. It also, more importantly, made it virtually impossible for the rural nobility to raise an army in the future. The ex-serfs now had to serve Bologna’s military, pay taxes to Bologna, and had to remain outside the city but in the region of Bologna. Bologna used tax incentives and other perks to lure these ex-serfs to new towns it created along the frontiers. Other North-Italian city-states, like Florence and Siena, similarly founded ‘new towns’ and ‘free castles.’ They settled peasants there specifically to clear timber, drain floodplains, and build irrigation canals to feed urban populations.

From the 12th to the 14th centuries, German princes, bishops, and military orders (like the Teutonic Knights) invited Western European farmers to settle Slavic territories east of the Elbe River. They hired recruiters to lure families from overcrowded regions like Flanders and Westphalia. They surveyed the land, laid out the village, and distributed long, uniform strip-farms. Settlers were exempt from taxes and tithes for several years, to give them time to clear forests and drain swamps. As part of the deal, they got to bring their own legal codes with them. Western European farmers brought agricultural expertise and infrastructure experience that increased crop yields eventually boosted revenues.

In 1375, King Dom Fernando I of Portugal mandated that landowners cultivate all arable land or it would be redistributed. He appointed inspectors to identify fallow plots and reallocate them to tenants. The state controlled prices for draft animals, tools, and seeds. The law also banned peasants from migrating to cities or even working in non-agricultural jobs. Those without acceptable employment or deemed able to work in any capacity were forced to labor on rural estates for fixed wages. This all happened because the Black Death had shaken up traditional society by killing up to half the population. Peasants were migrating to the city for higher wages and better working conditions and food production plummeted as a consequence.

In 13th and 14th century France, the nobility and abbeys used joint legal agreements to build hundreds of planned towns in sparsely populated regions of Aquitaine and Languedoc. Settlers were given free building plots and tax exemptions in exchange for clearing the forests and brushland to establish wheat fields and vineyards.

From the 16th to the 19th centuries, the Habsburgs had a permanent militarized buffer zone along its border with the Ottoman Empire (parts of today’s Croatia, Serbia, and Romania). They enticed Orthodox Serb refugees, Croatian peasants, and Protestant German settlers to come with free land, freedom from feudal dues, and promises of religious tolerance. In exchange, every adult male was a soldier responsible for patrolling borders, and repelling raids. This provided the Habsburgs with a standing peasant army along the frontier that they didn’t have to pay for directly.

This conversion of wasteland intensified in the 18th century, because European empires viewed uncultivated land as lost revenue. In the 1740s, King Frederick the Great wanted to repopulate territories that were devastated by the War of the Austrian Succession and the Seven Years’ War and bring marshlands into active cultivation. He deployed the Prussian military for hydraulic engineering, laid out dozens of planned agricultural colonies, and constructed houses at state expense. Prussian peasants were bound to the land or subject to military conscription, so he needed to recruit foreigners. He lured families from Swabia, the Palatinate, Pomerania, Poland, Switzerland, and the Netherlands with exemption from military service, 10-15 year exemptions from taxes and tithes, free land, free timber, seed stock, breeding livestock, those pre-built homes, and religious freedom.

Starting in the 1720s and accelerating under Empress Maria Theresa in the mid-18th century, the Habsburg Monarchy recruited Catholic German farmers (the Danube Swabians) to settle the Banat of Temeswar, a depopulated frontier region recently reconquered from the Ottoman Empire. In 1763, Catherine the Great launched a parallel Russian initiative. Her Imperial Manifesto offered Western European farmers free arable land, interest-free building loans, tax exemptions for up to 30 years, freedom of religion and language, and perpetual exemption from military service. Over 100 German colonies were established along the Volga River and later in the Black Sea region, shifting agrarian land use and gradually displacing semi-nomadic pastoralists.

In the mid-18th century, the Sierra Morena pass connecting Madrid and Andalusia was overrun by bandits, so King Charles III wanted to populate the area. Starting in 1767, he recruited Catholics from Germany, Switzerland, and Flanders with small plots of land, livestock, seeds, tools, and exemptions from taxes. They established towns with grid layouts for public order, sanitation, and easy surveillance. Nobles were banned, since there was the utopian goal of creating a model society of equal, independent family farmers. Land plots could not be divided among heirs or merged with neighboring plots. The mastermind behind the plan, Pablo de Olavide, was targeted by the inquisition in 1775 and had to flee to France.

New South Wales was originally a penal colony, but it soon pivoted. In the 1810s, the British Crown began offering free land (in line with the amount of capital each settler had available) along with convict labor. By 1831 the rules were modified.

In 1781, Habsburg Emperor Joseph II invited Protestants from the Palatinate and Southwest Germany to settle the newly annexed province of Galicia (modern-day western Ukraine and southern Poland). He offered free land, pre-built houses, farm animals, tax relief, and religious tolerance. Agricultural colonies were intermixed with existing villages.

In 1862, the US federal government began offering 160 acres of practically free land, cheap credit, inexpensive seed, and subsidized rail and steamship tickets to farmers in the Eastern US and Europe. The government needed settlers to physically occupy Indigenous lands and put state-backed infrastructure to use.

During the late Ottoman Period, zionist organizations bought large amounts of land from a few aristocratic families in major urban centers of the Ottoman Empire and the Ottoman government. This was possible because from 1858, the Ottoman state required peasant farmers to formally register their land plots. Many peasant farmers allowed urban elite to register land in their names, for fear of higher taxes and military conscription. This transformed them into tenants on their own land, which they’d cultivated communally. Decades later, many of these elites sold the land to foreigners with a clean title.

The earliest private agricultural settlements founded during the First Aliyah (1882-1903), were directly referred to as colonies. When collective models emerged later, the international press and British Mandate officials often referred to them as agricultural colonies or Jewish colonies. Starting in 1910, the kibbutz movement established agricultural colonies with direct communal ownership of all production tools, equal division of labor, shared meals, collective childcare, and a prohibition on hiring outside wage labor. Zionist organizations purchased property collectively and leased it to collective settlements.

In the late 1920s, Benito Mussolini launched the “Battle for Land” as part of his broader program of ruralization. The state drained the Pontine Marshes, built five new planned cities, and forcibly or semi-voluntarily relocated landless peasant families from the northern regions of Veneto, Friuli, and Emilia-Romagna.

In the early 1900s and under the 1934 Indian Reorganization Act, the US government purchased land to establish Indian Colonies, created specifically to secure land for displaced, landless Native American communities. Because Colonies were formed around regional labor centers rather than traditional ancestral boundaries, many developed as multi-tribal communities.

While most places called colonies are planned communities, these simply involved the distribution of plots by the Bureau of Indian Affairs, without assistance with home building and infrastructure until later, when the New Deal brought in the Civilian Conservation Corps Indian Division. While many 19th-century reservations were designed to force Native people into farming, the colonies were created for those who refused to work in agriculture. Nevada is home to the Reno-Sparks Indian Colony, Elko Indian Colony, and Carson Indian Colony. Today colonies possess tribal sovereignty, operate tribal courts, manage public safety, and exercise regulatory authority within their trust boundaries.

In 1940, Germany began carrying out Generalplan Ost. Polish territories directly annexed into the Reich saw their existing populations forcibly removed and replaced by ethnic Germans from the Baltic states. In 1942, occupied Ukraine saw locals evicted from collective farms along major military supply routes and replaced by ethnic Germans. Settlers were granted fully furnished, operational farms, houses, shops, and workshops. The Nazi state offered tax exemptions, low-interest state loans, debt forgiveness, and direct transport subsidies. Germany had signed treaties with the USSR to transfer ethnic Germans out of the Soviet sphere of influence.

When people migrated, they rarely moved as isolated individuals. They moved as extended families, congregations, and entire villages. Where the state was absent, collective care filled the void. Survival depended on the informal safety net: barn-raisings, shared harvests, mutual aid societies, and, above all, the unpaid labor of women.

Where isolation forced mutual reliance, colonies hardened into tightly woven, interdependent ecosystems with fierce norms of reciprocity. Where settlement was coerced, fragmented, or starved of resources, those social webs fractured or never came together.

In watching these frontier outposts construct functioning societies out of raw land and social obligation, imperial planners came to view settlement as a technology for engineering human behavior. Building an empire required more than controlling borders and extraction; it required building the people themselves.

Social engineering

When states, churches, or utopian reformers founded new settlements, their ultimate objective was to reshape the population itself.

Driven by Enlightenment anxieties that urban life bred disease, criminality, and decay, reformers looked to the countryside as a moral engine. They believed hard agricultural labor on open land could restore health and discipline. To ensure this transformation occurred, administrators often enforced rigid daily schedules, prohibited vices, monitored private behaviors, and tracked everything.

Regardless of the form, all of these colonies involved elites imposed their visions onto captive or vulnerable populations. Colonization reorganized family life, restructured property rights, rewrote the law, and used health and education as tools.

The results spanned a dramatic spectrum. Some colonies degenerated into places of unfathomable cruelty, while others offered security, dignity, and a better life than the world they had left. The success or terror of a colony never lay in its grand design, but in how those who held authority chose to exercise it.

Leper colonies

The existence of leper colonies suggests that colonies for social engineering and poverty management have existed for a very long time. It was a weirdly long amount of time before I understood that leper colonies were not just for people who were believed to have leprosy. Rather, this was a disability identity and a social status.

Between the 11th and 13th centuries, at the peak of leprosy (as in Hansen’s disease) in medieval Europe, leprosaria functioned as semi-monastic communities. Just like people entering a monastery for other roles, they typically took vows of poverty, chastity, and obedience. They wore distinctive habits, observed daily prayer cycles, and were given food, clothing, and shelter. When entering a monastic-style leprosarium, the individual surrendered remaining personal wealth or paid an entrance fee.

When a person was diagnosed with leprosy in the high Middle Ages (12th-14th centuries), they became civilly dead. There was a funeral, their marriage was dissolved, their will was executed, and their property passed directly to their heirs or to the church. They lost the right to inherit land, sign contracts, sue in court, or hold public office. The legal status of civil death began fading by the 15th century.

By the 13th century, there were an estimated 19,000 leprosaria across Europe. During the Black Death, many went bankrupt or lost all their monastic staff, leading municipalities to step in. States began using quarantine laws, city bans, and forced institutionalization. Leper grew into a social category, including the destitute, vagrants, heretics, prostitutes, and people with mental illnesses.

In the late 19th century, the scientific confirmation that leprosy was infectious triggered panic. Colonial medical authorities framed leprosy not just as a bacterial infection, but as a marker of racial degeneration. Victorian-era tropical medicine operated on the assumption that non-Western populations were “reservoirs of disease” threatening white settlers and global commerce. Native populations, poor laborers, and political agitators were routinely targeted for forced inspection and exile. Colonial governments selected naturally inescapable geographical features (isolated peninsulas and islands) to build containment sites.

The US military established a model leper colony on Culion Island in the Philippines. Culion had its own police force, had colony-only currency, and strict gender segregation. Patients lost the right to vote, hold property, control personal finances, or seek legal recourse. Marriages could be legally annulled, and parental rights were permanently severed upon intake. Patients were required to farm, construct buildings, or perform maintenance to make the settlements self-sustaining, as part of occupational therapy.

Many remained in the colonies after they were technically free to go, since they had lived in isolation for decades, had their property confiscated, and faced severe societal stigma. Consequently, some leper colonies transitioned into long-term residential sanctuaries or specialized care communities.

Penal colonies, reform colonies, and labor colonies

In Spanish controlled colonies in the Americas, the Crown granted the nobility rights to indigenous labor and tribute. This was difficult to exercise when the indigenous populations were rural and semi-nomadic. During the 17th century, native communities were forcibly moved into grid-patterned towns modeled on European urban planning and converted by the Jesuits. This produced massive surpluses to trade and prevented Portuguese incursions. Then the Jesuits were expelled from all Spanish territories in 1767.

Jeremy Bentham (1798) and William Booth (1890) both published grand plans to establish networks of colonies to reform the poor. While their plans never came to fruition, plenty of colonies were built to reform and reeducate. Robert Owen’s 1820 vision led to New Lanark in Scotland and New Harmony in Indiana. Charles Fourier’s publications around the same time inspired dozens of “Fourierist” colonies across the US.

The first Colony of Benevolence was founded in 1818 as a private charitable investment project with the promise to reform wasteland and wastepeople in the Low Countries. Paupers, beggars, and orphans were provided with housing, seed, livestock, and training. By the time the United Kingdom of the Netherlands had been split into Belgium and the Netherlands, the colonies were bankrupt and were turned into penal colonies and work colonies for the poor.

They were modelled on the colonies of the Dutch East Indies, where the founder had served in the military. Settlers wore enforced uniforms, adhered to strict daily sirens, and were monitored through panoptic watchtowers and physical checkpoints. Failing to meet target outputs resulted in fines, reduced rations, or transfer from the free to the “unfree” colonies. By the time the United Kingdom of the Netherlands had become two separate countries, they were bankrupt. The Netherlands and Belgium scooped them up, taking them over as agricultural colonies for the poor and penal colonies.

After launching the Colonies of Benevolence, the founder was appointed Governor-General of the Dutch East Indies in 1830. Javanese farmers were compelled to dedicate a portion of their village land and labor to growing export cash crops for the Dutch crown, leading to widespread famine and social disruption. From 1905 to 1942, the Dutch government addressed overpopulation, poverty, and land scarcity by financing the relocation of Javanese farming families to southern Sumatra to clear rainforests and establish rice paddies. Following Indonesian independence it was expanded as a nation-building project. During the 1970s and 80s it was funded by the World Bank and Asian Development Bank.

The Colonies of Benevolence inspired the Mettray Agricultural Colony, established in 1839 to use agricultural labor to reform boys through hard labor. The French Penal Code allowed children under 16 who acted “without discernment” to be detained for re-education until age 20. It also housed homeless orphans, child vagrants, and boys whose wealthy parents requested placement. Mettray became a prototype for modern reformatories, industrial schools, and boot camps across Europe, the UK, and North America.

While Louis-Napoléon Bonaparte was in prison for a failed coup, he wrote The Extinction of Pauperism, published in 1844. By creating agricultural colonies and transferring surplus urban labor to uncultivated rural land, the state would absorb unemployed workers, reduce urban wage competition, increase agricultural yield, and eliminate the threat of working-class revolution. Charity could be replaced with a productive national investment.

Napoleon III expanded state-chartered agricultural colonies for orphaned, destitute, and delinquent youth, personally buying land to create new colonies. Adult prisoners sentenced to hard labor were shipped to agricultural and penal colonies across the globe to clear jungle, build infrastructure, and secure French territorial claims. A prisoner sentenced to less than 8 years of hard labor was legally required to stay in the colony as a “free” settler for an additional period equal to their original sentence after release. A prisoner sentenced to 8 years or more was exiled to the colony for the rest of their natural life. After 1885, people with multiple convictions for even minor crimes were labelled “socially incurable” and shipped to overseas colonies.

The German Protestant Home Mission, a private charity, created a network of agricultural labor colonies across Germany, starting in 1882. The unemployed and homeless were coerced or forced into the colonies, where they converted peat bogs into farms in exchange for room, board, and low wages. Unemployed men on the search for work were required to carry a Wanderer Book. Anyone who turned down offers to work were arrested for vagrancy.

During the Great Depression, Franklin D. Roosevelt’s New Deal adapted the farm colony framework. The state purchased marginal land to construct planned subsistence homestead colonies and resettlement colonies like Arthurdale in West Virginia and Jersey Homesteads (now Roosevelt) in New Jersey. Because subsistence farming was no longer viable, the vision was that homesteaders would grow food and work part-time in state-built garment factories, furniture shops, or cooperative processing plants for cash income. Impoverished coal miners and urban factory workers were relocated. By 1937, the program faced such criticism that it pivoted away from building new towns to focus on migrant labor camps and tenant farmer loans.

In 1954, British colonial authorities in Kenya forcibly relocated Kikuyu people to guarded, stockaged villages. The British “villagization” program in Kenya was a counterinsurgency tactic responding to the Mau Mau Uprising designed as temporary emergency containment, but it operated using the explicit infrastructure and legal mechanisms of a penal-agricultural labor colony. Men deemed capable of work were placed in labor and reeducation colonies. Women, children, and those unable to work were placed in internment camp “villages.” Land was transferred from the “disloyal” to the “loyal.”

By concentrating the civilian population into tightly monitored strategic hamlets, the British severed the supply lines, intelligence networks, and recruitment pipelines supporting anti-colonial guerrillas operating in the forests. The program evolved into a permanent transformation of rural Kikuyu society. Many forced villages became permanent modern towns and trading centers across Kenya’s Central Province.

Health colonies

The practice of placing adults who needed care (because of IDD, physical disability, age-related frailty, or mental illness) with families paid by the parish or municipality was ancient and widespread, but came under scrutiny as modern medicine developed and promised a cure for all. Custodial care was condemned as immoral and unscientific, with religious personnel who placed people with foster families and oversaw their care being taken to court for practicing medicine without a license.

In Belgium, Geel’s economy relied on these boarding out patients. When the French had abolished the joint religious-civic organization managing boarding, they’d replaced it with a municipal organization involving local doctors, the charity board, and the mayor. When this was no longer sufficient to address concerns, they used the language of the domestic agricultural colony to gain legitimacy. It became an agricultural colony for the insane in 1850. Oversight shifted from the municipality to the state.

What was unique about Geel was that the colony label was applied after its creation. In France, other psychiatric colonies were created in Fitz-James, Sainte-Anne, and Lierneux. The US established psychiatric colonies like Kalamazoo State Hospital’s Colony Farms in Michigan and Gouverneur Hospital Farm in New York, as well as colonies for the feebleminded like Rome State Custodial Asylum in New York.

People with epilepsy were commonly confined to workhouses and asylums, like they were in Geel. In 1867, when Germany opened the Bethel Institution. It followed the cottage system, functioning as a rural village with residential houses, workshops, farms, a church, and schools. Reformers believed fresh air, manual labor, and a regulated diet reduced seizure frequency. It was widely copied, leading to the Chalfont Colony in England, the Craig Colony for Epileptics in New York, and the infamous Virginia State Colony for Epileptics and Feebleminded. Changes in medical philosophy shifted epileptics to the category of “hereditary defectives,” leading to increased concern for their confinement and supervision.

When I think about TB, I think about sanitariums. When tuberculosis patients recovered enough to leave a sanitarium but weren’t yet ready to return to a life of factory work, governments placed them in tuberculosis farm colonies like the UK’s Papworth Village Settlement, established in 1916, and New York’s Potts Memorial Colony. Medical staff determined how many hours patients could work. Workers were paid standard wages and could bring their families to live with them in a place designed to minimize the risk of infection.

Farm colonies were also used as venereal disease detention centers, such as the State Industrial Farm Colony for Women in North Carolina and the Kansas State Industrial Farm for Women. The US and Britain also established inebriate farm colonies and narcotic farm colonies.

There were a few colonies for deaf and blind adults, although it seems like most projects were less isolated than a typical colony.

Religious colonies

Religious colonies often functioned as laboratories for moral discipline, communal order, and cultural transformation. Moravian settlements, Hutterite Bruderhöfe, Jesuit reductions, Puritan “godly communities,” and Russian Old Believer villages all used spatial isolation, collective labor, and regimented daily routines to cultivate idealized forms of Christian life. These colonies imposed strict behavioral codes, reorganized kinship structures, and centralized authority in elders or clergy. Missionary colonies in the Americas and Africa went further, using settlement design—gridded streets, communal workshops, regimented worship—to reshape Indigenous societies into Christian agrarian communities aligned with imperial goals. In these contexts, religion was not merely belief but a governance technology: a way to reorder families, regulate sexuality, suppress dissent, and produce compliant subjects through enclosure, surveillance, and ritualized labor.

Industrial colonies

Industrial colonies emerged in the 18th and 19th centuries as paternalistic responses to the social dislocation of early industrialization. Company towns like Pullman, Krupp, and Hershey, mining colonies in Appalachia and Wales, and railroad colonies across the American West combined employer-owned housing, stores, schools, and churches into tightly controlled settlements. Employers used spatial design and economic dependency to regulate workers’ behavior, suppress labor organizing, and stabilize production. These colonies promised modern housing, sanitation, and social amenities, but they also enforced moral codes, monitored private life, and tied every aspect of daily existence to the workplace. Reformist industrial colonies—New Lanark, Saltaire, and the Garden City experiments—added utopian ambitions, using planned environments to cultivate industrious, sober, “improved” workers. Whether exploitative or idealistic, industrial colonies treated settlement as a tool for shaping labor, loyalty, and social order.

Dystopia and utopia

Across a thousand years of history, colonies share a common logic: a planned container designed to reorder human life through the built environment.

The reality of these diverse settlements resists simple moral binaries. Imperial boards and state bureaucracies could never govern every detail of daily life within them. Out of logistical necessity, authority was routinely handed to the residents. Inside the boundaries of the colony, disenfranchised, destitute, and exiled people carved out surprising degrees of civic leadership, economic enterprise, and self-determination.

Seclusion can create a sanctuary from external hostility, fostering tight networks of mutual aid, shared infrastructure, and deep social cohesion. Standards of worth, beauty, and contribution are rewritten internally. The simple act of working together to maintain the physical colony reinforces trust and legibility among members.

Most importantly, each colony demanded its residents serve a broader goal. When a group goal aligns with a person’s internal drive, it brings self-actualization. Some people thrive in systems with clear feedback, defined constraints, and tangible outcomes.

The top-down demand to serve a collective goal provided something modern life rarely offers: relief from the burden of hyper-individualism, a legible role in a shared universe, and the quiet satisfaction of seeing effort translate into tangible progress. Colonies could foster a collective identity, a sense of belonging, and strong loyalty.

This paradox explains why we remain haunted by the colony.We look back on company towns and planned communities with suspicion, even as we fantasize about creating a commune with our friends, a senior co-housing cluster, or finding a stigma-free community in Geel. We wish we could place someone in a dementia village, an autism-friendly planned community, an IDD campus, or on a therapeutic farmstead, even as we condemn institutions for their use of enclosure, routine, surveillance, and enforced norms.

Modern care infrastructure inevitably echoes the historic colony: its enclosure, its routines, its surveillance, and its totalizing administrative gaze. We demand oversight, accountability, legibility, protection from fraud and abuse, yet recoil at the demand we submit to surveillance, follow layers of regulations, and play a role in a hierarchy.

Sift through the history of social welfare, and you find a recurring cycle of salvation. Every century builds a colony to liberate the vulnerable, and every half-century tears it down to liberate them from the sanctuary. One generation’s emancipatory experiment becomes the next generation’s institutional horror.

We present these modern care models as novel, compassionate innovations, burying the reality that they are the latest iterations of a very old strategy. When we pretend these modern projects have no history, we forfeit our ability to critique them in a meaningful way. Spatial design will always reshape the human beings who live inside it. If we ignore the past, it becomes all too easy to repeat historical mistakes—or reproduce historical horrors—under the banner of care.

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The history of taxation is not just a story about money. It is the story of how care—medical treatment, elder support, disability assistance, poverty relief, public health, education, and community stability—moved from parishes, landlords, and kin networks into the administrative machinery of the modern state. As political authority centralized, elites and experts in distant capitals came to control the infrastructure of survival: land, law, information, and revenue. Whoever controls these systems controls the conditions under which care can happen. Understanding this shift is essential for making sense of the modern welfare state and the legal frameworks that shape care work today.

The Myth of the Untaxed Past

Modern American commentators often claim that income tax did not exist before World War I. It’s true that before then, the federal government funded its operations almost entirely through taxes on imported foreign goods (customs tariffs), taxes on specific domestic goods (excise taxes, primarily on alcohol and tobacco), and public land sales (selling western territories). Ordinary Americans had no direct tax relationship with the federal government.

Early modern European states lacked the administrative capacity to collect broad, standardized annual taxes. Monarchs financed government operations through their own property and feudal rights, known collectively as the Royal Domain. This included income from farming, forestry, and rents on lands owned directly by the dynasty, as well as sovereign monopolies over valuable industries such as silver mines, salt production, river tolls, and court fines. Because war costs far exceeded what domain income could provide, rulers frequently sold or mortgaged these lands to wealthy merchants to obtain cash.

When that proved insufficient, the crown turned to forced loans, compelling nobles, merchant guilds, church institutions, and foreign traders to lend money (often at below‑market or zero interest) under threat of imprisonment, loss of titles, or confiscation. Repayment rarely came in cash; instead, creditors received tax‑collection rights, land titles, or long‑term IOUs. Without central banks, rulers also extracted revenue through minting practices, charging fees for turning bullion into coins and debasing currency by mixing precious metals with cheaper ones while keeping the surplus for themselves, a hidden tax that fueled inflation.

Later, North American governments used analogous mechanisms, though under constitutional constraints. Where European monarchs relied on personal land holdings and feudal rights, the US and Canada continue to generate revenue from Crown Lands through timber leases, mineral extraction, and oil royalties.

Forced loans have reappeared in other forms during crises. Governors in New France occasionally compelled merchants to lend money to keep the colony functioning. The Continental Army requisitioned supplies during the Revolution, and both the US and Canada used intense patriotic pressure to sell war bonds during the world wars.

Currency manipulation also continued. The US issued unbacked paper money during the Revolution and Civil War, causing severe inflation, while New France famously created “card money” by stamping playing cards with official values and forcing their acceptance as currency. The fundamental difference lies in political authority. Historic monarchies could directly coerce subjects or dilute money, whereas modern governments, constrained by constitutional limits, eventually built central banks and national debt markets that allowed them to borrow from investors rather than extracting wealth through force.

Early states heavily financed themselves by chartering banks. They charged a direct tax on a bank’s capital stock or took a portion of bank dividends. States levied annual franchise taxes on corporations for doing business within state borders. This was usually calculated as a percentage of total corporate capital stock or gross receipts.

Returning to the federal income tax, Congress famously changed the 1913 income tax from something impacting the elites into the primary funding mechanism for the federal government. We’ve been filling out our tax forms ever since.

But this considers only the federal government and reflects a narrow idea of a “tax” as a cash payment (often a deduction from a paycheck) sent to a centralized state. If we define taxation functionally as the forced extraction of labor, goods, or money to fund governance and social infrastructure then people were heavily taxed long before WWI.

Collective Financing

Ordinary people lived under dense webs of obligation. They paid land taxes, poll taxes, customs duties, excises, fees, fines, and quitrents; they owed tithes to churches; they performed corvée labor on roads and fortifications; they served in militias; they provided carts, horses, and supplies when authorities demanded them. A person could be heavily burdened by public obligations without ever encountering anything resembling a modern tax return.

These older taxation systems were highly differentiated by age, biological sex, occupation, property, household status, religion, legal status, ability to work, and personal circumstances. A landholder might owe property taxes regardless of physical condition, while a laborer might owe corvée only if able‑bodied. A household head might be responsible for the taxes of everyone living under his roof. Poor relief systems could shift a person from contributor to recipient if sickness, disability, or age made work impossible. The logic behind each region’s laws was that every person owes what their role, status, and productive capacity requires.

Governments gradually moved from demanding labor and in‑kind contributions toward demanding money. As cities grew in the nineteenth century, governments needed cash budgets and permanent employees. You cannot run a modern police force, fire brigade, water system, or sewer network on occasional compulsory labor.

For example, colonial roads were created and maintained through a mix of compulsory labor, property taxes, head taxes, county or town levies, tolls, and the requisition of things like carts and horses. Now they’re funded through fuel taxes, sales taxes, property taxes, income taxes, general funds, tolls, and bonds. Both then and now, everyone contributes to collective infrastructure.

Tithes

The tithe was a mandatory tax collected by Western European societies to support the Church, local clergy, and parish administration. It began as a voluntary religious custom based on Old Testament models and was codified into secular civil law under Charlemagne in 779 CE, making it the primary source of public finance from the Middle Ages and early modern period. It was typically 10% of annual agricultural produce, livestock, or personal earnings. A quarter of the proceeds went to support widows and orphans, paupers, and travelers.

In Colonial America, 9 of the 13 colonies had a mandatory tithe. Baptists, Quakers, Anglicans, and other dissenters in colonies with the tithe were still required to pay. Refusal was treated as a civil offense enforced by the town constable. When the British Crown increased oversight in the 1760s, many colonists feared Britain would appoint an Anglican bishop for America. That would mean centralized religious authority, mandatory tithes, and the erosion of local control over community institutions.

The Quebec Act of 1774 intensified these fears, interpreting it as a model for how imperial authority might override their own religious and civic autonomy. The tithe was established as law in Quebec in 1663 and required parishioners to contribute a portion of their grain harvest (eventually standardized at 1/26th) to the local parish.

Thomas Jefferson banned tithes in Virginia in 1786. The ban was subsequently included in the First Amendment. However, initially it was interpreted as only preventing a national church with a federal tithing requirement, allowing Massachusetts law to permit mandatory tithing until 1833. In exchange for forfeiting state tax funding, American courts and legislatures gradually formalized tax exemption for churches. If the state could no longer tax citizens on behalf of the church, it should not tax the church itself.

Head Tax

A head tax (or poll tax) was a fixed per-person fee regardless of their wealth or income. Being included in this tax was sometimes referred to as being “tithable.” The legal head of household was required to register a complete list of every tithable person living or working on their property. A tithable list could include family, free servants, indentured servants, enslaved people, tradesmen, and others associated with a family’s plantation. The laws for different regions signal who was assumed to be economically productive – such as all people from 16 to 60, Black women but not white women, etc.

Quitrents

A quitrent was a small, recurring cash or crop payment made by a landowner to a feudal lord or colonial proprietor (like Lord Baltimore in Maryland or William Penn in Pennsylvania) in place of historical feudal labor services. By paying this nominal annual fee, landholders were “quit” of all other manorial obligations and secured clear, transferable title to their property.

Seigneurial Fees

Under French feudalism and colonial New France, seigneurial fees were mandatory dues and monopoly charges paid by tenant farmers to a local noble or landlord (the seigneur). Unlike a quitrent—which was a single fee to extinguish feudal ties—seigneurial fees enforced ongoing feudal hierarchy.

The fees funded the seigneur’s administrative role: maintaining the mill, overseeing disputes, and managing local infrastructure. There were three kinds of fees:

• Cens et rentes: Annual dues paid in cash or crops for living on the seigneur’s grant.

• Banalités: Mandatory fees for using the seigneur’s exclusive mill to grind grain or oven to bake bread, typically 1/14th of the flour.

• Lods et ventes: A tax of 8.3% paid to the seigneur whenever the tenant sold their land to someone else.

When Quebec abolished the seigneurial system in 1854, the province had to replace the administrative functions seigneurs had performed. The Municipal Authorities Act allowed towns to form secular councils, which funded the same services through municipal property taxes.

Parish Rates

A parish rate was a local property tax assessed at the parish level to fund local public services, poor relief, and church upkeep. Land, livestock, buildings, commercial goods, boats, mills and other assets could be assessed. There were three parts:

• Poor Rate: Used to fund local relief, workhouses, and care for the impoverished. It was originally established in England with the Poor Relief Act of 1601.

• Church Rate: Used for the physical maintenance of the parish church, the parish graveyard, and basic liturgical supplies.

• Highway & District Rates: Used to build and repair roads, bridges, and drainage infrastructure within the parish boundaries.

English colonies typically adopted the parish rate model. Each colony had its own system. New England developed what was essentially a multi-level “rate” system with different rates for the colony, county, and town.

After the British Conquest, Quebec’s parishes instituted the parish rate. They were assessed by parish wardens and used to fund the secular responsibilities of parish life. Quebec developed a dual system: religious tithes funding care institutions, and parish rates funding civic infrastructure.

Quebec introduced municipal property taxation in 1845. Municipal property taxes did not replace or eliminate the tithe or parish rates. Catholic landowners faced a dual obligation: civil property taxes paid to the newly created municipality, alongside traditional ecclesiastical obligations paid to the parish.

School Taxes

Local property taxes for public education were first introduced in North America by Dedham, Massachusetts in 1644. Between the 1830s and 1870s, Northern and Western states systematically abolished rate bills (tuition) and mandated local property tax levies to fund compulsory public school districts. Southern states followed suit after the Civil War.

Following the 1841 unification of Upper and Lower Canada into the Province of Canada, the colonial legislature passed the School Acts of 1841 and 1846 to establish mandatory local school taxes.

Although British authorities designed a unified, non-denominational public system to assimilate French Catholics, the legislation included a “dissentient clause” that empowered religious minorities to opt out. This mechanism inadvertently created a dual, confessional system: Ontario’s Catholic minority withdrew to form separate schools, while Quebec’s Protestant minority split off to tax themselves, granting the French-Catholic majority complete control over its own autonomous school network.

Corvée

Before widespread cash circulation, governments taxed the only resource most households had: their labor and their tools. People might be required to work a certain number of days per year on public infrastructure or to provide the use of their cart, mule, or other tools. You could perform the work yourself or you could pay to hire someone in your place.

In Quebec, corvée was used to maintain the basic infrastructure of the colony — clearing manorial land, repairing the seigneur’s mill, and building and maintaining the Chemin du Roy, the royal highway connecting Quebec City and Montreal. If a farm bordered the road, the family was responsible for the upkeep of that specific stretch. Compliance was enforced through parish and seigneurial authorities, and failure to appear for mandated work days could result in fines.

Quebec gradually allowed residents to “commute” their corvée, paying a small cash fee instead of performing the labor. Eventually, corvée was replaced with municipal property taxes.

There was also mandatory militia service, a civic obligation that extracted time, labor, and resources even in periods of peace. Every able‑bodied male was legally required to enroll in the militia, attend regular training days, maintain weapons and equipment at personal expense, and respond to musters when called. Although they didn’t describe militia service as a tax, it functioned like one: a compulsory transfer of labor and resources from households to the state.

Use Fees

Just like today, there were fees for using the court, registering things, obtaining a license, using a port, and conducting regulated activities. Early modern officials (such as public officers, judges, sheriffs, and clerks) relied on user fees for their personal income. This allowed governments to provide services without having to formally budget for them, but of course it also incentivized extortion and corruption.

Other fees went directly to financing related services. In New Amsterdam there was a targeted municipal service fee, the chimney tax, which funded fire buckets, ladders, fire hooks, and pay for the night watchmen. Cities built and operated large public market halls (like Boston’s Faneuil Hall and Baltimore’s Lexington Market) to control food sanitation and supply. The bench fees and licensing rates paid for market inspectors, street sweeping, and waste disposal. Port cities funded harbor maintenance, dredging, and waterfront policing by charging ship captains and merchants fees based on vessel tonnage and the number of days docked. Private wells were replaced by public waterworks before it was feasible to charge based on actual usage. Instead, water fees were based on the size of each building, the number of plumbing fixtures, and the type of business.

States charged licensing fees for many trades, occupations, and regulated activities. The cost of business licenses were tied to related services, with saloon licenses often being very high in order to fund municipal policing, courts, and public health facilities.

Fines and Forfeiture

Fines continue to operate as both a penalty for crimes and funding for local budgets. In the early modern era, fines were commonly levied for crimes such as Sabbath-breaking. My dad’s first ticket was for running on a Sunday, so I can confirm this continued into the modern era.

Forfeiture is the forced surrender of land, personal property, or financial assets to the Crown or colonial state as a consequence of illegal acts or treason. Often triggered by customs violations, smuggling, felony convictions, or political rebellion, it legally stripped offenders of their holdings and transferred ownership to the sovereign.

Excise Taxes

Excise taxes are charges imposed on the manufacture, sale, or consumption of specific domestic products, services, or activities. These are famously placed on “sin” goods like alcohol and tobacco. Excise agents visited distilleries, breweries, salt works, and cider mills to measure production volumes and assess taxes before goods were sold.

Custom Duties

Custom duties (aka tariffs) are taxes on imported goods assessed at the port of entry. Ships were required to dock at designated ports of entry before unloading cargo. Merchants submitted ship manifests and customs officers inspected them.

Customs and excise duties shifted from local or imperial officers to national governments as political authority consolidated. The US Constitution prohibited states from levying tariffs in 1789, and Canadian Confederation centralized customs collection under the federal government in 1867.

Inheritance Taxes

Beginning with Pennsylvania in 1826, states imposed inheritance taxes on property passing to non-direct heirs (and eventually direct heirs).

Collecting Taxes

Throughout history, the figure of the tax collector has stood at the volatile intersection of sovereign power, local economy, and social resentment. Long before modern electronic payroll withholdings and standardized civil service agencies, rulers relied on private agents, local elites, and feared enforcement officers to extract revenue. These intermediaries were paid by keeping whatever surplus they could squeeze from taxpayers above their quota. Consequently, across millennia and cultures, the tax collector was simultaneously indispensable to state survival and one of the most universally vilified figures in human society.

Tax Farming

In the 1700s, France used tax farming: the Crown auctioned off the right to collect specific taxes to private financial syndicates known as the farmers‑general. These syndicates paid the state a fixed amount upfront and kept any revenue they collected beyond that amount. The Revolution abolished it, replacing tax farming with a system of professionalized, salaried employees.

Local Tax Collection Liabilities

When I was reading the diary of Martha Ballard, a midwife in what was then Massachusetts (but is now Maine), I discovered how towns in Massachusetts collected taxes. Citizens appointed by the town were given a tax list and a quota. If neighbors defaulted, fell on hard times, or refused to pay, the collector was legally on the hook. When he failed to meet his quota in 1804, Ballard’s husband not only did not earn anything for his work, the 79 year old was thrown in jail for the debt. This pushed her to return to her work as a midwife, which she continued until just before her death.

Field‑Based Audits

The tithe was a tax on agricultural output, assessed directly at harvest. Parish priests counted wheat bundles in the field and claimed a fixed portion for church support. Seigneurial milling monopolies reinforced the audit. Farmers were legally required to grind grain at the landlord’s mill, where weights were recorded. Mill ledgers and parish counts could be compared, making concealment difficult.

Regulations

Regulation similarly predates the modern era. Authorities controlled weights and measures, bread quality, markets, taverns, sanitation, forests, hunting, and public morality centuries before the rise of modern administrative agencies. Much of the historic record consists of court records, account books, government memos, and other bureaucratic documents, which drive home just how regulated life in the past was. Medieval guilds regulated product quality, pricing, and labor entry. Town councils set market rules. Maritime codes governed trade routes locally long before central regulatory agencies existed.

Parish authorities possessed legal jurisdiction over poor, orphaned, or disabled children. Under English Poor Law regulations and American colonial statutes, churchwardens could legally remove children from impoverished households and bind them out into compulsory apprenticeships until adulthood. Master-apprentice contracts were legally binding documents that required masters to provide food, clothing, lodging, and instruction in exchange for labor.

Regulation surrounding hospitals, poorhouses, and vulnerable populations predates modern state bureaucracy by centuries. Far from being an unregulated free-for-all, pre-modern care was governed by dense networks of ecclesiastical canon law, royal statutes, municipal ordinances, and judicial precedents. Medieval and early modern legal systems drew sharp distinctions between different forms of cognitive and mental impairment, imposing strict regulatory frameworks around guardianship. Regulations mandated that the parish provide the elderly, blind, physically disabled, or sick who could not work with support either at-home or in an institution. Bishops and municipal wardens conducted formal inspections to audit hospital account books, inspect food quality, enforce hygiene standards, and verify that endowments were spent on patients rather than pocketed by administrators.

Transitioning to Modern Taxation

The modern state’s core transformation was replacing overlapping regional and feudal jurisdictions with national law and replacing private tax farming, feudal duties, and local alms with salaried civil servants, standardized bureaucracies, and systematic record-keeping.

Industrialization and enclosure accelerated the transformation. Poverty was no longer primarily about inability to work; it was about loss of wages. Governments developed social insurance: workers’ compensation, old‑age pensions, mothers’ allowances, disability programs, unemployment insurance. These programs required predictable, large‑scale revenue that could not be provided by municipalities.

I want to say that these programs went from local to regional to federal, but the truth, even at the level of a broad overview, is far more complex. There had already been national and regional laws for hundreds of years. But the making of rules, collecting of funds, and administering of benefits increasingly involved a tangle of local, regional, and federal agencies. Today, in many cases, the federal government raises funds through taxation, the province or state administers a program by making rules and carrying out inspections, and a municipal or social agency actually distributes benefits.

Along the way, the goals and meaning of programs shifted. Old age assistance was originally local poor relief for old people. Today, Canadian Old Age Security is a national entitlement based primarily on age and residence. In the US, old age assistance is support for the indigent administered by states using federal grants.

The modern state centralized and professionalized systems that had existed in fragmented form for centuries. However, for the average taxpayer, business owner, or recipient of social welfare, things do not necessarily feel more centralized, predictable, or fair.

Modern tax codes, welfare qualification criteria, and regulatory requirements are notoriously complex. Navigating multiple overlapping municipal, state, and federal layers can feel impossible. Bureaucratic inconsistency, shifting legislative rules, and unequal enforcement can erode the feeling of predictability or procedural fairness.

Quebec carried an older world further into the modern era than most places in North America. The system evolved with changing circumstances, but it maintained local control far longer. Most oversight remained municipal, with the province involved at a minimal level when it was absolutely necessary. The province actively wanted to avoid taking responsibility away from municipalities.

Quebec also retained older fiscal tools longer than many regions. Corvée and statute labor survived into the nineteenth century, especially in the Eastern Townships, where rural residents could satisfy road obligations by supplying their own labor, horses, and tools.

Anthropologist David Graeber argued – very controversially – that early states often used taxation to create demand for their own currency. When governments mandated payment in cash, households had to produce goods for sale or engage in wage labor. This shift moved subsistence communities into cash economies and reorganized household labor. Women’s unpaid caregiving and domestic work became economically invisible, while wage labor—typically performed by men—became the basis of taxation, political participation, and state funding.

Conclusion

As the state centralized and monetized taxation, it severed the direct relationship between the taxpayer and the care provided. We surrender a portion of our wages to a distant treasury, which funds regional agencies, which subsequently hire credentialed professionals to administer care according to standardized criteria.

Calls to return to an earlier era of localized, voluntary care overlook a basic historical reality: pre-modern community care was neither voluntary nor informal. People dreaming of care work comprised entirely of neighborly goodwill without state intervention typically seem unfamiliar with the systems they’re nostalgic for.

The evolution of funding for local infrastructure and social welfare did not follow moral progress (or deterioration), shifting community preferences, or even industrialization. It followed the rise of the modern nation‑state. As national governments consolidated authority, they absorbed or abolished the overlapping feudal, ecclesiastical, and municipal jurisdictions that once governed care. Tithes, parish rates, corvée labor, and manorial dues were not replaced because people became more ethical; they were replaced because the political architecture of the state made them obsolete at best and a threat to the new ruling order at worst.

Modern taxation and regulation cannot be unwound without unwinding the nation‑state itself — which is why fantasies of “returning” to earlier systems amount, in practical terms, to dissolving sovereign authority. Understanding this is essential to making sense of the present so we can find a pathway into the future.

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Back in 1965, the law establishing Medicaid (Title XIX) required participating states to offer placement in a nursing home to those who qualify. There is no option to put someone on a waiting list if they qualify. In contrast, Home- and Community-Based Services (HCBS)—such as personal care aides, home modifications, and adult day programs—are almost all classified as optional benefits. To offer community care, states request “waivers” from the federal government. Federal law explicitly allows states to cap enrollment and maintain waitlists for optional benefits.

Post-war social policy operated under the doctrine that the nuclear family—and secondarily, local charity—bore the moral and economic duty to care for dependents. Policy architects worried that if the government took on responsibility for long-term care, families would abandon their caregiving duties and demand state-funded labor for routine domestic care. Including nursing homes in Medicaid was seen as providing a professional medical service, whereas paying for someone to live in their own home was viewed as expanding general welfare. In 1965, unpaid family care at home was the overwhelming norm for long-term care in the United States and the government did not want that to change.

Under Olmstead, the federal government stepped in to protect your funding if a state did things that put your loved one at “serious risk” of institutionalization. If a state proposed Medicaid or home care cuts that made institutionalization likely, the Department of Justice (DOJ) could intervene, launch investigations, and compel states to maintain “optional” HCBS.

Over the last 25 years, the DOJ negotiated consent decrees with dozens of states, forcing them to close state-run institutions and redirect funds toward community housing and Assertive Community Treatment (ACT) teams. If the Executive Branch ceases to enforce or monitor these existing agreements, states lose their legal mandate to maintain those community-funding pipelines.

The memo does not override the Supreme Court’s ruling on Olmstead, nor did it eliminate the right to community‑based care. Instead, it signaled a major shift in federal enforcement. The Office of Legal Counsel (OLC) argued that the “integration mandate” originates from federal regulatory rules rather than the ADA itself.

In the memo, the OLC argues that executive agencies have no statutory authority to force a state to build, fund, or expand HCBS systems. The OLC argues Congress never explicitly gave federal agencies authority under Title II of the ADA or Section 504 to dictate how states structure or fund their social service budgets. If there is no statutory right for the DOJ to enforce access to optional HCBS programs, institutionalization caused by a lack of personal funds or family caregiving capacity would be viewed as a social welfare/budget deficit, not illegal state discrimination.

Abandoning all Olmstead enforcement would expose the DOJ to lawsuits for failing to execute federal civil rights statutes or risk having courts directly order federal enforcement. Instead, the DOJ will not pursue negative cases (where the state fails to act) but will pursue positive cases (where the state acts to institutionalize someone against their will). An OLC memo sets binding internal policy for Executive Branch agencies (like DOJ and HHS).

In the past, the DOJ typically demanded structural injunctions forcing states to expand Medicaid waivers, raise worker pay, or expand statewide HCBS capacity. The OLC argues this exceeds agency authority under the ADA.

The text of Title II and Section 504 does prohibit state discrimination and unjustified physical isolation. Thus, if a state takes a legal action to place a specific person in an institution (like executing an involuntary commitment, terminating a care plan to force a facility transfer, or denying access to a public program unless the person moves into a state facility) the DOJ will potentially continue to enforce the ADA. In the future, the DOJ will likely ask judges for a narrow negative injunction—ordering the state not to transfer a specific individual or not to execute a specific placement.

Olmstead v. LC remains Supreme Court precedent, and private litigants can still file ADA lawsuits arguing that unnecessary institutionalization is discriminatory. However, the federal government has significantly more enforcement power, investigative authority, and settlement leverage than individual people and advocacy organizations.

The memo was not just a policy update, it was a constitutional argument about federal power, issued in the middle of active litigation. This reinterpretation of Olmstead was issued during Texas v. Kennedy. Texas and a coalition of states sued the federal government, arguing that federal agencies overreached by turning community integration requirements into mandatory funding obligations for community psychiatric care.

Instead of using the DOJ to defend its own longstanding administrative policy, the Executive Branch issued the memo to align federal legal policy directly with the arguments of the suing states. The OLC argues that interpreting the ADA as a requirement to fund community infrastructure exceeds Congress’s structural authority over state budgets.

Because of Texas v. Kennedy, the immediate effects will fall on community‑based obligations for people with severe mental illness, but the consequences expand to all optional Medicaid services. States already ration HCBS through caps on personal care hours, waiver waitlists, long waits for evaluation, and narrow definitions of “medical necessity.” The memo provides legal justification to intensify these practices.

The memo creates tension with Medicaid’s Maintenance of Effort (MOE) rules. MOE provisions restrict states from arbitrarily lowering financial eligibility thresholds or cutting baseline coverage criteria without risking their federal matching funds (FMAP). Although states can’t eliminate HCBS waiver programs without falling afoul of MOE, they can dramatically expand administrative rationing. This allows them to further reduce services while technically keeping the program intact for MOE compliance.

When state-funded personal care hours are cut, the physical and administrative labor of care shifts onto family members, friends, or community networks. For disabled individuals without safe, reliable, or unestranged family networks, relying on informal care is often impossible or unsafe.

Under established US law, adults possess a strong right to refuse medical treatment and social services. Concerned friends and family often struggle to stop people experiencing mental illness or dementia from making financially ruinous or dangerous decisions. State adult protective services cannot forcibly intervene simply because an individual lives in squalor, experiences severe self-neglect, or refuses medication—the legal bar requires an imminent threat of harm or severe lack of decisional capacity.

Now, people retain their incredibly strong ability to refuse services, particularly institutional placement. And they have no explicit right to services designed to allow them to stay in the community, so long as the state is rationing care bureaucratically, rather than eliminating services outright or discriminating against an individual. The inevitable result is systematic neglect.

In cities like San Francisco, Portland, Los Angeles, and New York, we have a preview: people cycle through short psychiatric holds, rapid discharges, and repeated 911 contacts as they wait months for community services, deteriorating in public view. Emergency responders are asked to manage chronic social‑care failures with tools designed for acute crises.

Someone on an HCBS waitlist has no way to force the state to provide support. If they refuse the state’s only offer—an institutional bed—the system steps back. The burden falls entirely onto informal family and social networks. If those networks do not exist or refuse to step in, the individual remains at home without support. State Adult Protective Services (APS) agencies investigate self-neglect. However, APS cannot involuntarily remove or institutionalize an adult unless a court formally finds that the person completely lacks decisional capacity and appoints an emergency guardian. If the individual understands the risks of their decision—even if that decision leads to severe deterioration or death—the state lacks the legal authority to override their refusal.

Canada: Theoretical rights, bureaucratic rationing

The US creates a legal void between crisis and intervention, while in Canada rights exist on paper but there is no requirement that programs be funded to fulfill those rights. Provinces closed institutions from the 1960s through the 1990s to modernize budgets, not because they were legally required to build community‑based alternatives. Provincial human‑rights codes prohibit discrimination based on disability and the Canadian Charter of Rights and Freedoms guarantees equal protection under the law, but Canadian courts treat long waitlists, rationed home care, and institutional placement as budgetary decisions rather than civil‑rights violations. Canada has provincial Human Rights Tribunals that enforce individual accommodation duties up to the point of “undue hardship,” but these mechanisms don’t have the authority to force provinces to fund systemic community‑care infrastructure.

In the name of efficiency, Quebec consolidated local health hubs (CLSCs) into large regional corporate structures (CISSS and CIUSSS), replacing flexible, relationship-driven care with centralized management, rigid algorithms, and timed clinical throughput. Provincial courts reinforced this shift by insulating the government from liability. Ruling that anti-discrimination frameworks do not guarantee entitlements to specific public resources, courts hold that the province has no legal obligation to provide timely, local, or safe levels of home care. Consequently, the state can legally decline home care funding and offer an institutional bed miles away.

This is why the June 2026 OLC memo is so significant: it marks an American pivot toward a structural model long established across Canadian provinces, most closely following the system in Quebec. Human-rights frameworks remain intact on paper, but the legal duty to fund, build, or maintain community care is decoupled from those rights. Rights collapse not through explicit statutory repeal, but through bureaucratic reinterpretation—expanding managerial discretion, narrowing enforcement thresholds, and shifting the physical and financial burden of long-term care back onto families when state systems fall short.

The Olmstead memo targets people in the community who want access to subsidized care. In Ontario, the concern is aimed at medically stable people who refuse to be discharged from the hospital (alternate level of care patients) because they can’t access subsidized home care and don’t want to go to a nursing home. While Ontario Health atHome coordinates care alongside Ontario Health Teams, actual service delivery is contracted out to a patchwork of private, non-profit, and for-profit agencies operating under strict service caps.

In Ontario, once a patient is cleared for discharge, they are billed $400/day for failing to arrange their own home care or placement. Hospital placement coordinators are then legally authorized to access the patient’s medical records, apply to long-term care homes on their behalf, and authorize admission without the consent of the patient or their family. The rules explicitly prohibit physically forcing someone into a nursing home against their will. They assume the financial penalty will be sufficient. The Ontario Superior Court upheld the law, ruling that provincial hospital capacity management outweighs an individual’s right to geographic choice.

New Brunswick governs long-term and home care through the Department of Social Development rather than the healthcare system, treating care as income-tested social assistance rather than a universal entitlement. While initiatives like Nursing Homes Without Walls extend some services home, it’s heavily rationed. For people attempting to find a nursing home placement, provincial social workers manage access via functional assessments, placing eligible applicants on a unified waitlist governed by a strict 100-kilometer rule: applicants must accept any available nursing home bed within 100 km of their municipality. A second refusal removes the applicant from the waitlist for twelve weeks, with official language preference (English or French) serving as the sole legal constraint on placement. If someone has been cleared for discharge and then refuses a nursing home placement, provincial healthcare stops covering the hospital bill. Quebec’s hospitals similarly bill the patient.

In the US, when a patient is medically cleared for discharge and they refuse a long-term care facility, the hospital can—and routinely does—discharge the patient back to their home. If the patient cannot organize home care or placement on their own, the discharge coordinator will find them a temporary bed in a rehab facility to give them more time to make their own arrangements. If a competent adult wants to go home, they can sign themselves out against medical advice. If someone is medically stable, the hospital can simply release them. If they’re not stable and refuse whatever plan the coordinator creates, they will be billed for any additional time in the hospital and it will not be covered by insurance. If a patient lacks the cognitive capacity to make safe medical decisions and has no designated proxy and their family refuses safe placement, the hospital’s legal team petitions a state court to appoint an emergency temporary guardian. Once appointed, this court-ordered guardian can sign nursing home admission paperwork on the patient’s behalf, bypassing personal or family consent.

England: The Myth of the Free NHS Safety Net

For many Americans, mention of the English healthcare system conjures images of the National Health Service (NHS)—a single-payer icon where medical care is free at the point of delivery. Americans often assume this cradle-to-grave universal coverage extends seamlessly to all forms of care, including long-term eldercare and disability support.

The NHS covers acute medical treatment, but long-term care coverage is not universal, not federal, and not free. Governed by the Care Act 2014, social care is administered by over 150 local councils that act as brokers, commissioning support from a fragmented marketplace of private, for-profit agencies. Access relies on local municipal budgets.

If an individual’s primary need can be legally classified as a complex medical condition, the NHS must fund 100% of their care. Because desperate local councils want to shift costs to the central health ledger and families want to avoid asset liquidation, Continuing Healthcare (CHC) assessments have devolved into al battleground where eligibility is fiercely rationed through shifting clinical definitions of medical care and social care.

For those who don’t meet the CHC medical criteria, rationing operates through two local gatekeepers: functional needs tests and financial means tests. Individuals with assets above £23,250 (approx. $31,000 USD) must pay for 100% of their care at market rates until their wealth is depleted down to this threshold. Those with assets under £14,250 receive full council funding, while “middle-income” families face a sliding scale. This mechanism is the direct philosophical mirror of the US Medicaid spend-down.

Councils use their bulk-purchasing power to force private care homes to accept unsustainably low, state-dictated room rates. This results in high turnover and a shortage of available workers. To stay solvent, private providers aggressively overcharge self-funders for identical services, just as US nursing homes charge private-pay residents 40% to 100% more than Medicaid rates.

Americans who dream of programs to pay family caregivers often point to the Carer’s Allowance. Alas, the Carer’s Allowance pays £86.45 per week for a minimum of 35 hours of physical care, an effective rate of just £2.47 ($3.37 USD) an hour. Earning more than £204 in net earnings—even £1 over the limit—per week terminates the allowance and triggers retrospective scrutiny to claw back overpayments.

While small-scale alternatives like Shared Lives (a foster-care-style model where adults with disabilities live with families) demonstrate that England can provide care in different ways, it remains a niche program supporting only 13,000 of the 683,000 people in adult social care. Councils default to block-booking corporate beds because it is administratively simpler than managing family placements.

The June 2026 Department of Justice Olmstead memorandum brings the US long-term care dynamic closer to the English model. English courts have consistently ruled that local councils’ statutory duties are bounded by their available financial resources. When municipal budgets run out, councils narrow functional eligibility thresholds, raise the bar for what constitutes need, and default to unpaid family labor. In both the US and England, citizens hold a legal protection against forced institutionalization, but lack an enforceable entitlement to the public funding required to actually stay in their homes.

France: The Illusion of Centralized Solidarity

Americans who advocate for universal healthcare often view the French system as a premier model. Unlike single-payer models (like Canada) or fully state-run systems (like in England), the French system allows patients to choose their own primary care doctors, specialists, and hospitals without strict restrictions.

France’s long-term care framework spans home-based support and residential institutional care, administered under the Fifth Branch of Social Security created in 2020 and overseen by the National Solidarity Fund for Autonomy. The system is organized by age:

• The Elderly Track (60+): Managed directly by local departmental councils through the Personalized Autonomy Allowance (APA).

• The Disability Track (-60): Gated by independent single-window authorities called Maisons Départementales des Personnes Handicapées (MDPH), which administer the Disability Compensation Benefit (PCH). Multidisciplinary teams at the MDPH conduct assessments, determine eligibility, and approve care plans.

The central government sets legal rights, but local departments pay the bills. Because departmental tax bases vary wildly, so does the actual availability of care. The state’s definition of “independent” for clinical scoring includes care needs that pose a significant burden on families. While low-income applicants receive near-total coverage, middle-income families face progressive co-payments. These out-of-pocket fees can reach hundreds of euros per month, forcing some families to turn down hours they are legally entitled to receive.

Under the French PCH framework (and to a more restricted degree under the APA) beneficiaries can opt to receive their state allocations as direct payments. Care recipients choosing this option assume the legal role of an employer and directly recruit their own support staff. People can hire their adult children, parents, or siblings as personal assistants.The low rate of pay often makes it impossible to hire anyone other than family. Spouses, civil partners, and cohabiting partners are only permitted in special exceptions requiring extreme, round-the-clock assistance. Those who become full-time unpaid family caregivers can register with Assurance Vieillesse du Parent au Foyer (AVPF) to continue accruing contribution time to government retirement benefits.

While the US permits the direct hiring of relatives through certain state-level Medicaid Home and Community-Based Services (HCBS) waiver programs (such as Structured Family Caregiving) these self-direction policies vary by state, and many continue to ban spouses or legal guardians. Paid family caregivers in France are employees with paid leave and pension accruals. US care workers under Medicaid self-direction programs are typically independent contractors or low-wage hourly attendants with minimal access to pensions or health benefits.

France’s Allocation Journalière du Proche Aidant (AJPA) is a temporary wage-replacement stipend for family caregivers. It pays 66.64€ ($77.86 USD) per day with a lifetime maximum of 66 days per caregiver, making it irrelevant for long-term care.

France’s elderly residential sector (EHPADs) has been plagued with recent scandals of systemic neglect, rationed food, severe understaffing, and falsified care records inside Orpea, a massive multinational commercial care provider. The state provided per-bed funding to commercial operators, who then used aggressive cost-cutting to maximize shareholder returns. Orpea’s has rebranded and the state has increased inspections. While public and non-profit EHPADs do not operate under shareholder profit demands, the fallout impacted the reputation of the entire institutional ecosystem. The scandal has increased the demand for home-based care.

French residential institutions have the right to refuse admission to anyone deemed a safety risk to staff. France utilizes an extraordinary escape valve for people with complex behavioral profiles (severe intellectual disabilities, profound autism, or auto-aggressive behaviors): between 7,000 and 8,200 French citizens—including 1,200 children—live in specialized facilities or foster placements in Belgium.

This is exacerbated by a 1989 law allowing people over the age of 20 to remain in pediatric facilities indefinitely if no adult bed is available. As a result, adults spend years occupying pediatric beds, creating an acute shortage of pediatric care beds.

French and Walloon authorities have capped these cross-border placements and rolled out the Zéro sans solution (Zero without a solution) initiative. It requires regional health agencies and local authorities to create high-intensity care arrangements for complex individuals who would otherwise be exported. In practice, Zéro sans solution is held back by the same structural limits: severe labor shortages, high regulatory requirements for specialized facilities, and fragmented coordination between the MDPH, departmental councils, and local care providers.

If something similar were happening in the US, under pre-2026 DOJ ADA Title II principles, a public entity cannot escape its obligation to serve individuals in integrated settings simply because individual private providers reject complex cases. The state would have been obligated to modify its system to ensure high-intensity community support exists locally. Now, reliance on specialized residential facilities and cross-border institutionalization would not violate the memo’s interpretation of Olmstead. France’s practice of sending individuals with complex behavioral profiles to Belgian facilities—driven by facility rejections, safety assessments, and resource limits—would be viewed as an administrative resource allocation decision rather than an illegal act of segregation.

Continental Europe: The Diverse Machinery of Care Rationing

The European Union frames long-term care as a right, but member states execute that right through distinct bureaucratic mechanisms to limit access. Where Canada relies on global budget caps and England uses municipal wealth-depletion mandates, continental Europe restricts care through algorithmic clinical scoring, administrative delay, cash-for-care devaluations, and reliance on unmonitored labor markets.

Established in 1995, Germany’s mandatory Long-Term Care Insurance (Pflegeversicherung) calculates eligibility through Pflegegrade, a five-tier scoring system introduced in 2017 that uses standardized algorithms to evaluate functional capacity. This framework is similar to the matrices used in Ontario and US state Medicaid programs: clinical algorithms evaluate human need to set strict spending ceilings, shielding the state from discretionary appeals. Once approved for a certain level of support, people choose between professional home services, a lower cash benefit paid to family caregivers, or a combination of both. When family caregivers are paid, they get roughly half the amount allocated for professional agencies. Because this cash stipend cannot replace a primary income, the financial architecture structurally incentivizes the lower-earning partner—typically women—to drop out of the workforce. Because the system is financed through payroll contributions rather than general taxation, the aging population makes even this level of support unsustainable. Germany is phasing in higher contribution rates and restricting benefits.

In Spain, the 2006 Ley de Dependencia created a universal right to publicly funded care, administered by 17 autonomous communities. Rationing mirrors US Medicaid HCBS waiver lists, where citizens qualify on paper but wait years for an available slot.

Spanish regions rely heavily on the Prestación Económica para Cuidados en el Entorno Familiar (PECEF). Under PECEF, regions issue a small monthly cash stipend (often under €200–€300) to family members who cohabit with the beneficiary and lack full-time employment. By formalizing this low-cost, sub-minimum wage caregiver classification, the state checks the box of serving the citizen while locking women into unpaid domestic roles at a fraction of the cost of public home care.

Italy’s community care is administered through regional health units (ASL), backed by the Indennità di Accompagnamento—a flat, unconditional cash transfer for individuals certified as 100% disabled. Established in 1980, the benefit is indexed to inflation, but the stipend covers less than half the market rate of a full-time professional care worker. This encourages an unmonitored gray market of badanti—predominantly female, migrant live-in caregivers. Italy’s 2024 disability reform—undergoing multi-province pilots—attempts to replace this cash-only program with detailed assessments and mandatory baseline social-assistance levels (LEPS), attempting to force fragmented regions toward a standardized care model.

Portugal established a universal National Health Service (SNS) in 1979, but lacked the capital to construct state-owned long-term care infrastructure. Consequently, community care was outsourced to non-profit entities: the Catholic Misericórdias (tracing back to 1498) and private IPSS (Instituições Particulares de Solidariedade Social), formalized in 1983 to subsidize parish-based charities. The state-integrated care network (RNCCI), created in 2006, remains constrained by waiting lists, means-testing, and regional disparities. The low payment amount makes it difficult to find workers. The state offers small stipends and social security credits to informal caregivers, utilizing the same logic as Spain’s PECEF.

The Olmstead memo aligns the US with the administrative mechanisms used across Continental Europe. Germany, Spain, Italy, and Portugal all guarantee community care on paper, yet each has built a distinct mechanism for limiting access—mechanisms shaped by religion, political transitions, regional governance, and the economic constraints of aging populations. These systems determine how difficult it is to obtain care, how long one must wait, and how much unpaid labor the state’s bureaucratic architecture quietly but deliberately forces private households to provide.

Paper rights and practical scarcity

Long‑term care systems reveal a sharp divide between what governments promise, what rights exist legally, and what families actually experience. Every nation claims to support community living, but each relies on its own administrative machinery to strictly ration access. For caregivers, the difference between a statutory right and a practical reality often comes down to clinical scoring tools, means‑testing thresholds, regional budgets, and workforce shortages rather than the moral commitments written into law. Satisfaction is low among the disabled and family caregivers in all of these countries.

By redefining community integration as a regulatory preference rather than an enforceable civil right, the June 2026 Olmstead memo shifts the American system toward the same bureaucratic machinery other nations use to ration care. The memo does not repeal Olmstead, but it hollows out its practical force, replacing structural obligations with case‑by‑case protections that prevent only the most explicit acts of segregation. In doing so, it marks the end of a uniquely American enforcement model and ushers in a familiar international one—where rights remain intact on paper, but the infrastructure required to make those rights real is reliant on family capacity, local budgets, and administrative classification.

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The Church was responsible for many failures, but those failures were also products of a wider institutional model created by governments, professionals, and social norms. The Quiet Revolution was not simply secular liberation from Catholic oppression; it was a technocratic state-building project that absorbed, reorganized, and expanded existing Catholic and civic welfare structures while inheriting many of the problems attributed to the Church.

When a new group of elites overthrow the old, they discredit the old ways. That doesn’t mean their accusations are valid, yet they become the story everyone remembers.

The Institutional Shift: Medicalization and the Rise of Mega-Asylums

Quebec dismantled an industrialized version of Catholic custodial care that the province itself had created. Catholic care was traditionally provided in small, local religious complexes. Institutionalization was an expensive last resort, with home visits, supplies, and cash assistance provided more commonly. The monastery was the institution, so residents were incorporated into a disciplined, spartan world of the order. These institutions were embedded into the community.

Recall that in Quebec the cities were populated through the Hôtel-Dieu, so of course in Quebec City it was both the geographic and spiritual center of civic and religious life. After multiple expansions, it had 100 beds in the 1890s. The Hôtel-Dieu de Montréal was in the commercial heart of Old Montreal until 1861, when overcrowding forced a move to Mount Royal. It re-opened with space for 150 indigent patients and 60 orphans.

The phenomenon of Catholic mega-asylums in Quebec was directly driven by its unique legal, financial, and structural framework. Large institutions emerged when the province restructured funding, under-funded institution beds, and provided no funding at all for home care.

In the 1870s, Quebec shifted from lump-sum charity grants to a fixed daily rate per patient. Small convent infirmaries were no longer financially viable. Instead, the Church became co-architects of the institutional model in order to balance the demand for medicalized care, maintain their control over healthcare, and create financially viable institutions.

Quebec’s first permanent psychiatric facility and the blueprint for the province’s custodial care model was Beauport Asylum, just outside Quebec City. It was founded in 1845 by three doctors, who negotiated a per-diem contract with the province to house “indigent lunatics” previously held in local jails or poorhouses. Care emphasized moral treatment—fresh air, farm work, and structured routine. As Quebec’s population grew and local authorities increasingly sent “pauper lunatics,” unwed mothers, and the disabled to Beauport, the facility was flooded with residents requiring lifelong custodial support.

The private asylum turned a profit through overcrowding and neglect, since the province would not provide sufficient funding. By 1890, it could not secure financing to maintain the buildings. The province could have taken over, issued public bonds, raised taxes, and established a civil service payroll. Instead, it negotiated a sale to the Sisters of Charity in 1893. The Sisters were legally obligated to construct new, modern wings and vastly increase bed capacity to meet the state’s projected needs.

The asylum became one of the largest and most technologically advanced agricultural operations in the Quebec City region. The sisters leveraged their large-scale laundry and baking infrastructure to take on external service contracts for other Catholic religious institutions, schools, and convents in the area.1 At its peak, it housed 6,000 residents.

Just as in the Great Confinement in 17th century Europe, it was the provincial authorities and licensed doctors who had the power to detain and confine. Before 1892, confinement could only be authorized by justices of the peace and mayors. These men were influenced by parish clergy and family patriarchs, but did not take orders from them.

Lobbying for updated legislation in Quebec was driven primarily by early medical superintendents and alienists. Municipal governments and county councils lobbied for legislation to transfer the financial and social burden of “pauper lunatics,” the unhoused, and the disabled from local jails into state-subsidized institutions. Police associations across Canada lobbied for sweeping criminal codes to control urban public spaces.

In 1892, Quebec law changed to establish licensed doctors as the sole people authorized to classify individuals as mentally ill and certify them for involuntary confinement. New federal law granted magistrates and law enforcement broad legal power to arrest, detain, and institutionalize unhoused, impoverished, and socially disruptive individuals under federal criminal jurisdiction.

In the 1920s, national advocacy groups like the Canadian National Committee for Mental Hygiene lobbied federal and provincial lawmakers to broaden legal commitment criteria beyond severe psychiatric conditions. This expanded state committal power to include the “feeble-minded,” unwed mothers, and those deemed morally or intellectually “unfit” under the banner of public order and social hygiene.

In the 1940s, the federal government offered matching grants to provinces for psychiatric hospital beds, but provided virtually no federal matching funds for general welfare or disability care. This led to the widespread classification of the poor as insane in order to provide funded beds.

The massive expansion of forced institutionalization was driven by secular legislation, state funding mechanisms, and the medicalization of social control.

There’s also the fact that large-scale custodial institutions—whether run by Protestant boards, municipal governments, state departments, or religious orders—all experienced an explosion in patient admissions while exhibiting striking similarities in institutional violence, neglect, and systemic harm.

From Moral Duty to Gatekept Access

People eagerly tell me that Quebec’s community based healthcare system was inspired by radical leftists and grassroots activism. Alas, it seems that this is ahistorical rebranding to justify a technocratic, centralized administrative model. Planning was led by Claude Castonguay, an actuary and the father of the Quebec Pension Plan. Castonguay’s plan employed a top-down architecture managed by civil servants, doctors, and regional health boards.

Since hospital care was free for patients, virtually all care was routed through the hospital. By the late 1960s, the cost of hospital care was unsustainable, even with matching funds. In 1973, Quebec launched the “front door” of its new public health and social services system, the CLSC (Centre local de services communautaires or Local Community Health Centre) network — publicly funded clinics staffed by nurses, social workers, psychologists, home‑care teams, crisis intervention staff, and rotating doctors.

Many discussions of the CLSC begin with how it was created in contrast to the Catholic system but of course it’s never compared to the pre-1850s Hôtel-Dieu, which operated as an integrated community care center. Instead of medical and spiritual care being inherently intertwined, it was now health and social welfare that were inseparable.

It was in trying to make sense of the odd framing of the CLSC system that I discovered that between secularization and the launch of CLSCs when access was heavily gatekept. Home nursing, medical equipment, and financial support all required a doctor to diagnose you, refer you, and label you incapacitated or indigent. Since these situations were the lowest priority for hospital triage, it essentially required you pay for a private doctor.

Every article notes how there’s no need for a referral or a diagnosis to go to the CLSC. Under the Catholic system, refusing to treat an injured person would have violated their vows and institutional mandate, even if that person was obviously a sinner.

When I press for how the CLSC is different, it always comes down to this: before it was charity and now it’s a right. Nevermind that the Church’s doctrine of caritas imposed a moral obligation to provide corporal mercy to the suffering.

Can you exercise this right any more than you could demand charity? If a religious institution ran out of beds or money, it turned people away, viewing suffering as an inevitable part of a fallen world. The state can’t legally turn you away, but it can place you on a 36-month waiting list, tighten eligibility requirements, or ask for documentation that’s impossible to get. This is equality in action, proof of a system prioritizing care based strictly on medical urgency rather than wealth or privilege. The system assumes that those with the most critical needs will push through the administrative hurdles, while less urgent cases will self-select out or seek alternative solutions.

CLSC services are funded entirely through Quebec’s centralized tax base. Catholic hospitals used a sliding-scale fee system. Because before the Quiet Revolution, the province viewed state-funded social welfare as dangerous, “socialistic,” and financially ruinous. Direct state spending on healthcare and poverty relief was kept minimal to keep taxes low. The Church was everyone’s favorite contractor because religious orders built and maintained their own infrastructure, they had the lowest labor costs, and communities were more willing to donate to charity than to pay taxes.

Religious Vows vs. Secular Realities

The Church is discredited for using nuns and lay volunteers who were trained through apprenticeships. In contrast, secular institutions rely on licensed medical professionals, expert social workers, and volunteers operating out of settlement houses.

By the 1950s, nearly every major Catholic hospital ran its own accredited school of nursing. Orders sent selected sisters to universities for more advanced training in nursing, social work, hospital administration, anesthesia, psychiatry, etc. Parish priests frequently acted as neighborhood advocates, advising working-class families on local housing options, labor unionization, and municipal relief. To keep pace with community needs, religious institutions also hired lay professionals, including credentialed social workers and nurses.

In secular hospitals where female staff could marry and have children, they were fired or forced to resign. Although the legal justification for marriage bars was eliminated in 1964 when married Quebec women were granted legal autonomy, forced resignations for pregnant employees persisted until federal and provincial reforms in 1971 and 1975 established protected maternity leave and explicitly banned pregnancy-based discrimination. In Catholic institutions, women held top roles and dedicated their careers to care work. In secular institutions, women who never married and widows held top positions within nursing, while individual nurses, social workers, and settlement staff typically left the field after 3-7 years. Hospitals relied on unpaid interns and entry-level staff to keep costs low.

For all the debate over qualifications, the truth is that there simply weren’t enough nuns to continue the Catholic system. For over three centuries, Quebec’s social safety net functioned because religious orders provided labor at negligible cost. When the asylums were closed, professionals did not take on the burden of care.

Hiring women to provide care in institutions or the community is simply more money than the government is willing to spend. When publicly funded home care hours through CLSCs were introduced, they were capped and heavily rationed. The practical burden of daily assistance falls primarily to untrained, unpaid family members—predominantly daughters, wives, and mothers.

Follow the money

Following the Conquest of 1760, the new Anglo-Protestant ruling class and the imperial state had little interest in taxing themselves or spending public funds to build social institutions for a French-Catholic majority. It stayed like that for 200 years.

The province relied on private capital to build railways, develop natural resources, and fund industrial expansion. Because Anglo-Protestant merchants and financiers controlled the major financial institutions, the province catered to their economic demands. The Church was the only wealthy, highly organized, French-language institution that operated independently of the Anglo-Protestant state. It created a self-contained linguistic and social system that protected the Québécois from absorption into the Anglo-American mainstream.

When modern Québécois nationalism emerged in the 1960s, they redefined the provincial government as an instrument for progress and modern nation-building. The provincial government replaced the Church as the protector of the language and culture.

The province finally developed the political willingness to use tax revenue to fund a welfare system, in part because the landscape had changed. In 1957, the federal Hospital Insurance and Diagnostic Services Act offered matching funds for hospital care to any province establishing a universal, portable, publicly administered, non-profit system covering all medically necessary services.

Quebec initially rejected this federal intrusion into provincial jurisdiction—a stance shared by Ontario, Alberta, and Newfoundland. Resistance soon proved financially unsustainable, however, as people paid higher federal taxes without receiving coverage. By 1961, Quebec’s new Liberal government enrolled in the program, utilizing these federal funds to buy out the Catholic health network by assuming the massive debt religious orders incurred constructing mega-asylums. Because the Act only funded acute hospital care, soon nearly all medical care was being routed through hospitals. Hospital care became fully covered, while community-based, primary, and preventive care remained out-of-pocket. By 1970, Castonguay had devised his plan for the CLSC network, a front-line gatekeeper to keep people out of hospitals.

The popular imagination misattributes the creation of CLSCs to radical anarchists because it remembers the grassroots clinics that predated them, the activist culture of the early staff while forgetting the fiscal crisis that actually drove the Quebec government to build them.

Deinstitutionalization and the CLSC

Most people assume the CLSCs were created to receive the wave of discharged patients. In reality, the majority of patients had already been discharged before the first CLSC opened.

Quebec began releasing people from institutions as soon as the new government came into power. In 1962 the Bédard Commission identified how institutionalization causes patients to lose basic social and daily living skills and lose community ties through geographic isolation, creating permanent dependency. Paradoxically, high-functioning residents were valuable workers and thus institutions were disincentivized to discharge them. Large numbers of patients were institutionalized under social hygiene frameworks rather than medical criteria. They recommended that custodial institutions be shut down and replaced with short-term treatment and community care to avoid long-term financial responsibility for custodial welfare.

The Bédard Commission itself was led by reform-minded psychiatrists whose recommendations were in alignment with European social psychiatry and human rights principles. The goal of the state during the 1960s was to empty expensive acute hospital beds. Between roughly 1960 and 1965, the state re-evaluated and abruptly discharged thousands of patients not deemed to meet medical definitions of insanity. Mid-century neuroleptics like Thorazine were heavily utilized to manage outward behaviors and justify discharging or transferring patients to lower-cost settings.

The data is highly fragmented, so it’s difficult to determine how many people were even in institutions, nevermind what happened to them. There were fewer than 25,000 patients. It seems that a small portion of patients were transferred to acute care wards for treatment. A similarly small portion was simply released. Around 30% were released to their families. The remainder were transferred into unlicensed private boarding homes, religious rest homes, nursing homes, or rooming houses. These offered room and board, along with medication distribution. Community care was grassroots community clinics, religious charities, philanthropic organizations, and private doctors.

Between when the legislation was passed to create the CLSC network (1971) and when they actually launched (1973-1976), the Mental Illness Protection Act was passed (1972), severely restricting who could be held in custodial care. By this time, patient capacity had already dropped 40% since the liberal government took over. Another 6,000 patients were released in the next four years. The number of patients continued to decline steadily through the late 1980s as commitment criteria became stricter. Newly released patients flooded the ERs. They were stabilized using medication, discharged back to a rooming house or boarding home, and often readmitted a few months later.

How could they build a network of physical community clinics so quickly? The explanation people are eager to tell is that during the late 1960s, leftist activists, medical students, unions, and neighborhood ran neighborhood clinics. It’s true that when Castonguay introduced the bill to create the CLSC network, he envisioned absorbing popular clinics into a standardized public health apparatus. He wanted them to be subordinate to regional health councils, civil service union mandates, and top-down ministry directives.

The government offered these clinics block grants in exchange for bringing their staff, leases, and client rosters under state administration. Clinics fought for the right to receive funding without surrendering their autonomous citizen-led governance structures. They feared the province would replace collective social action with a sanitized version of organizing to enforce social hygiene. Only Montreal’s Clinique communautaire de Pointe-Saint-Charles succeeded in getting state funding without surrendering to top-down control. Just as they feared, the province forced CLSCs to abandon neighborhood organizing and narrow their mandate strictly to clinical triage and primary care delivery by the late 1970s.

The more common origin story for a CLSC is that it was part of a public health network established in 1926 and funded by municipalities, the provincial government, and international philanthropy (such as Rockefeller Foundation grants). The law creating the CLSCs stripped municipalities of their jurisdiction over public health offices and abolished their administrative boards. The new boards took over their offices, equipment, budgets, and staff. The sign on the door changed and they went from providing preventive care and administrative services to being responsible for integrated medical care, social work, and walk-in triage. Local clinics were now controlled by top-down provincial priorities. The mandatory integration forced doctors, public health nurses, social workers, grassroots activists, and newly secularized former religious personnel into shared workplaces, leading to significant friction over authority, medical referral models, and intake priorities.

When a CLSC opened, its initial focus was often basic medical triage, maternal care, and general social work. Because the province had already discharged thousands of long-term asylum residents into rooming houses and private boarding homes without outpatient support, they were flooded with people facing severe housing instability, cognitive decline, and chronic psychiatric needs that the initial CLSC triage framework was ill-equipped to handle. Because doctors were fighting the province to remain fee-for-service, CLSCs were chronically short on doctors, leaving them only able to provide basic nursing and social work.

Once CLSCs were open, former institution residents did have a certain level of support. They could go to the CLSC and wait until someone was available to help them find housing, financial support, and activities. They could go to the CLSC when they were in a crisis. CLSCs responded by creating crisis-response teams and expanded home-support programs.

The triage-first user experience leaves people feeling like they’re being processed through a system rather than supported. The centralization, standardization, and territorial responsibility make it intensely bureaucratic. There were rigid service limits because of insufficient funding. There were long waitlists, rigid eligibility criteria, and the sense that one must perform a specific script to receive help. Quebecers technically possess a guaranteed civic right to local community support. While it works incredibly well on paper, the people who use it don’t necessarily feel supported. Which is why they’re constantly reminded of how lucky they are to be in Quebec and not the US.

In the US, community mental health centers are chronically underfunded, heavily reliant on Medicaid or private insurance, and often tied to strict income or diagnostic eligibility thresholds, leaving vast gaps where uninsured or underinsured individuals receive no outpatient care at all.

Ontario relies on a fragmented patchwork of independent non-profit agencies, municipal public health units, and Family Health Teams that vary widely by region and require complex navigation.

Despite Quebec’s structural advantage in frontline accessibility, the revolving door model persists across all three jurisdictions for a fundamental reason: acute crisis stabilization has been prioritized over deep, long-term residential and social infrastructure. Decades after deinstitutionalization emptied chronic asylums, none of these systems built enough supportive housing, long-term case management, or low-barrier community living arrangements to match the volume of need.

Because community-based outpatient services in all three regions suffer from severe staffing shortages, rigid intake criteria, and long waitlists, the emergency room remains the only 24/7, legally mandated safety net when a crisis recurs. Thus, while Quebec’s CLSC network provides a stronger, publicly integrated entry point than the market-driven US model or the fragmented Ontario system, it operates within a policy framework that continues to treat acute symptoms while ignoring the daily burden of care.

Administrative Logic: Fiscal Correction Without Institutional Accountability

When the Lesage government and the new secular technocrats took over, they approached the healthcare crisis with the mindset of system engineers. The core problems to solve were lack of centralization, structural inefficiency, and unsustainable debt. They corrected these flaws in the system and moved on.

Admitting that the secular state spent its first decade running and expanding custodial mega-institutions undermines the tidy liberation narrative of the Quiet Revolution. Yet, between 1961 and the early 1970s, the state negotiated formal contracts with various orders in order to retain religious staff. A significant number of younger nuns left their orders and stayed on in the healthcare system as unionized employees. Daily life inside facilities changed only gradually as nuns and former nuns retired. There was no state investigation into neglect or abuse, and internal reassignments remained the default response to misconduct. The skyrocketing cost of paying unionized salaries, combined with the fact that federal matching funds explicitly excluded psychiatric institutions, made operating mega-asylums fiscally unsustainable—at which point the state suddenly found human rights arguments against forced confinement very compelling.

Deinstitutionalization was executed primarily as a discharge of state liability and cost. Thousands of individuals who had been wrongfully confined, misdiagnosed, or subjected to institutional abuse were released into communities without welfare support, housing placement, or psychiatric follow-up.

This new elite redesigned Quebec as if they were playing Sim City. In this managerial view, population management was about optimizing human capital and public expenditure. The long-term victims of the old system simply did not fit into their forward-looking narrative.

When the old system failed someone, the harm was experienced directly at the hands of religious personnel—making them the obvious, visible face of institutional violence, while the state’s complicity remained invisibly in the background.

The practices we now condemn were open secrets involving tens of thousands of people across the province. This system required massive supply chains, public budgets, local employment, and agricultural labor. Local populations knew these facilities existed, knew who was sent there, and understood their function as repositories for the socially unwanted. Doctors and nurses saw the overcrowding and the untreated illnesses. Local politicians approved budgets and toured facilities. Suppliers delivered food and equipment and walked past rows of children or adults performing unpaid labor. Volunteers, parishioners, and charity workers entered these buildings regularly. Blaming the Church allows us to erase the complicity — passive, active, or resigned — of the wider society that allowed these conditions to persist for decades.

Part of understanding that complicity requires stepping back into the world people inhabited between 1900 and 1960. Across the Western world, child labor was only beginning to be phased out. Patient labor was considered normal and therapeutic. Subsistence living was harsh enough that institutional conditions did not usually appear shocking. Asylums were part of a broader international pattern of underfunded welfare systems, overcrowded institutions, and a cultural belief that the marginalized should be managed cheaply and out of sight. To understand the past, we have to place those facts back into their original context — not to excuse the harm, but to recognize how ordinary people, not just leaders, participated in and normalized a system that we now rightly view as horrific.

Everyone today acknowledges that nursing homes are understaffed, neglectful, and sometimes outright abusive, yet we work in these facilities, contract with them, deliver food and medical supplies to them, and place our own relatives in them when we feel we have no other choice. Lots of people strive to improve things, yet it feels impossible to make and sustain progress. That’s why blaming the Church and Duplessis for Quebec’s institutional abuses is so misleading. It lets us imagine that the bad old days were the product of villains and the victims have been rescued. The underlying dynamics have changed shape but ultimately remain the same. The forces that produced those institutions are still with us.

State-Led Capitalism

It was embarrassingly late into this research when I realized that it wasn’t just the Catholic system that was secularized. When Quebec overhauled its healthcare system in the early 1970s the Catholic, Protestant, Jewish, union, mutual aide, and public health programs were brought under the same legal, administrative, and financial umbrella. All funding was controlled by the state, their boards were forcibly restructured, and staff were united under standardized contracts—athough doctors successfully fought to remain independent fee-for-service contractors. Municipal health offices and rural county health units were dissolved. The real issue wasn’t that the Catholic Church was corrupt or not upholding its obligations. Care provided through union membership or funded by donors was just as inefficient and politically unmanageable. A modern health system required centralized control.

Health, education, and public service reforms created a massive, state-salaried French-speaking middle class virtually overnight. Centralization allowed the province to generate thousands of administrative, managerial, and professional positions. As the largest buyer of construction, equipment, and professional services, the state directed contracts toward emerging Francophone firms. Ambitious French Canadians no longer needed to assimilate into Anglo-dominated corporate Montreal to achieve success.

When Quebec opted out of the federal Canada Pension Plan framework in 1965 to create the Régie des rentes du Québec (RRQ), it retained control over a massive pool of worker payroll contributions. To manage these assets, the province created the Caisse de dépôt et placement du Québec (CDPQ)—a state-owned investment manager. Unlike the federal CPP, which operated as a pay-as-you-go system until 1997, Quebec used its pension reserves as a strategic capital pool.

The CDPQ deployed this capital to finance major public infrastructure and buy equity in promising Quebec companies (such as Bombardier and Cascades), protecting them from foreign takeovers and fostering global corporate players. This Québec Inc. model transformed pension savings into a powerful engine for state-led industrial growth and financial autonomy.

While Anglo-Canadian financial elites resisted the CDPQ model out of fear of state-directed capitalism, radical groups like the Front de libération du Québec (FLQ) rejected the Quiet Revolution entirely, viewing its state-building project as mere bourgeois reformism.

How a country structures retirement savings isn’t just about financial security in old age, it shapes who holds the levers of the domestic economy. When the US adopted 401(k)s and IRAs, it shifted the responsibility of retirement planning onto individual workers. This model leaves individuals to navigate financial markets on their own, often paying high retail management fees to private investment firms. Since Quebec pools millions of payroll contributions into centralized, professionally managed funds, these systems operate with significantly lower administrative overhead while keeping risk shared across the population.

The real-world impact extends far beyond low-cost retirement benefits. The US explicitly chose a market-neutral approach, barring its public Social Security trust fund from investing in corporate equity or local infrastructure and leaving private 401(k) capital fragmented across Wall Street. The US chose not to use its pooled retirement capital to build public transit networks, finance renewable energy infrastructure, provide expansion capital to local businesses, and protect key domestic companies from foreign takeovers. While the American model treats retirement strictly as an individual wealth-building exercise, the Quebec approach uses public retirement savings as a tool for long-term regional development and economic autonomy.

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If you examined the books, it was obvious that Quebec was a province run by systemic complicity, institutional silence, and a paternalistic medical-religious consensus. Following the death of Premier Maurice Duplessis—remembered as an authoritarian strongman—strategically exposed scandals were weaponized to discredit the old guard and dismantle Church authority. The Quiet Revolution toppled Quebec’s traditional elite, replaced ecclesiastical charity with a powerful secular state, and birthed a modern Québécois nationalism that would ultimately reconfigure the economic and political balance of Canada.

Anglo‑Canada’s Secular Welfare State: The Contrast

By the early 20th century, the broader Western world was undergoing a decisive shift away from punitive poorhouses and ecclesiastical charity toward state-administered social security. In Continental Europe, Bismarckian social insurance—famously pioneered in Germany in the 1880s with statutory health, accident, and old-age coverage—established a template across the continent for entitlement based on citizenship and labor rather than moral worthiness. In the UK, the Liberal welfare reforms of 1906-1914 dismantled the Victorian Poor Law framework by creating non-contributory state old-age pensions in 1908 and national health and unemployment insurance in 1911. In the US, Progressive Era reforms led to the rapid spread of statewide Workers’ Compensation laws and municipal Mothers’ Pensions throughout the 1910s and 1920s, establishing public cash relief as a legal right long before the federal Social Security Act of 1935.

A mother’s pension (often called a mother’s allowance in Canada or widow’s pension) was an early 20th-century welfare policy that provided state-funded cash grants directly to impoverished mothers so they could raise their children at home rather than sending them to orphanages, foster homes, or child labor. The 1909 White House Conference on Dependent Children declared that children should not be deprived of home life except for urgent moral reasons, never for poverty alone, allowing reformers to argue that motherhood itself was a form of service to the state. Therefore, the state should pay “pensions” to needy mothers to act as full-time caregivers in their own homes. However, these frequently explicitly excluded “immoral” women and were not actually sufficient to cover basic expenses. They cut off once a child reached the age of 14, since it was assumed the child would then enter the workforce.

Despite these limits, they proved to “secular” economists and social reformers that giving cash support to poor families was cheaper and far more humane than funding residential institutions. This was not a new idea, as Catholic poor tables had been doing this for centuries. What was new was that these were administered by local “secular” governments and carried out by a new cohort of experts – social workers, economists, statisticians, sociologists, urban planners, and public health doctors.

Anglo-Canadian provinces directly mirrored these international developments. By the 1920s, they were shifting from the poorhouse model in favor of direct cash entitlements administered by civil servants under secular legislation, although the poorhouses remained operational into the 1950s. Ontario and New Brunswick pioneered Mothers’ Allowances and workmen’s compensation boards—programs that created legal rights to income adjudicated by public officials rather than clergy or private charity boards.

The Old Age Pensions Act of 1927 extended this logic nationally across Canada. For the first time, elderly residents held a statutory right to public money, allowing them to remain at home or purchase independent care. Poorhouse populations plummeted. Across Western Europe and North America, the institutionalization of secular, bureaucratic welfare established an international baseline against which Quebec’s parish-based, ecclesiastical model would appear increasingly anomalous.

The Agrarian Crisis and the Collapse of Church Financing

Unlike Anglo‑Canada, Quebec did not build a provincial cash‑transfer welfare system of its own. It participated in federal schemes like the 1927 Old Age Pensions and Family Allowances after 1945, but the primary safety net for most families remained the Catholic Church.

Quebec’s welfare administration relied on a parish‑centered model built around local priests and relational oversight. Its financial foundation rested on agricultural tithes, traditionally one‑twenty‑sixth of a farm’s grain harvest, and parish rates, civilly enforceable property assessments used to build churches, rectories, and cemeteries. Anything beyond this required private donations and volunteer labor. This model functioned adequately in a rural society where institutional care was rare. It began to fail once Quebec industrialized.

Over‑farming, soil exhaustion, and a catastrophic wheat midge plague devastated Quebec’s agricultural output. Quebec agriculture pivoted away from wheat toward dairy and mixed farming due to the wheat midge and Western competition. Thousands of young French‑Canadians left farms for urban textile mills, shoe factories, and railyards. Montreal doubled in size between 1871 and 1891. The Church could not tithe one‑twenty‑sixth of a factory worker’s hourly wage. Its compulsory funding base evaporated just as urban demand for social services surged.

During the 19th century, the lower courts, municipal incorporated acts, and shifts in civil law post-1850 increasingly treated tithes as voluntary rather than legally enforceable. By the mid‑20th century, the Supreme Court of Canada confirmed that tithes were not civil taxes and could not be enforced by the state. This stripped the Church of its primary compulsory funding tool without requiring the province to build a secular replacement, even though social welfare was a provincial responsibility under the British North America Act.

The Church’s Financial Adaptations: Education vs. Healthcare

To survive, Church leaders engineered a new financial strategy. They leaned on pew rents, a standard medieval and early-modern financial practice across Roman Catholic and Anglican churches globally. They expanded fees for services like baptisms, weddings, and funerals. They also aggressively sought state subsidies and donations from Anglo‑Protestant industrialists. The Church interpreted subsidiarity, the belief that the state should only step in when families and local communities are unable to provide for themselves, in a way that permitted them to accept state funding so long as they retained operational autonomy.

Beginning in the 1840s, Quebec created elected school boards authorized to levy local property taxes. The dissentient clause of the Constitution Act of 1867 guaranteed minority religious education rights (Protestants in Quebec, Catholics in Ontario). This allowed wealthy Anglo‑Protestants to form their own boards, so rejecting school taxes would have left Francophone children in underfunded institutions. Further, the Church could easily control the local school boards. Education taxes were embraced as a defensive weapon to preserve French‑Catholic identity.

Church leadership fiercely opposed a dedicated healthcare tax because they knew centralized funding would bring secular oversight, standardized regulation, and the displacement of nuns from hospital management. When rising medical costs made pure charity unsustainable, Quebec enacted the Public Charities Act of 1921, creating a three-way funding split between municipalities, the province, and religious orders. Under this compromise, the state provided partial funding while religious orders managed all staff, governance, discipline, and record‑keeping. The Act failed because the split bankrupted municipalities during the Great Depression, then bankrupted religious institutions in the post-war baby boom.

Federal Funding with Strings Attached

Programs like Family Allowances and Old Age Pensions sent cheques directly to individuals from public treasuries. They required no local administrative state and posed little threat to parish governance. Any federal funding tied to federal encroachment, civil service administration, and public regulatory inspection was rejected by the provincial government and the Church.

As the Public Charities Act collapsed under these pressures, Maurice Duplessis refused to replace it with a state-run safety net. Instead, throughout the 1930s and 1940s, he kept the bankrupt Church-run system on life support through ad-hoc, discretionary government handouts, preserving clerical authority without establishing civil regulation.

During World War II, the federal government in Ottawa temporarily took over all income tax collection to fund the war effort. After the war, Ottawa didn’t want to give that central power back. Instead, Ottawa introduced massive “conditional grants” to fund healthcare, universities, and infrastructure across the country. Duplessis flatly rejected these funds, viewing federal strings-attached money as an Anglo-Protestant Trojan horse designed to strip Quebec of its constitutional control over social policy.

By refusing federal dollars to prove a point—and offering no state alternative—Duplessis intentionally starved Quebec’s medical and welfare system. To break the resulting funding shortfall, Duplessis established Quebec’s own provincial personal income tax in 1954, successfully forcing Ottawa to concede provincial tax autonomy. The establishment of federal equalization payments in 1957 provided an injection of unconditional capital that allowed Quebec to fund public infrastructure while maintaining its constitutional distance from Ottawa. While he won his battle for fiscal federalism, maintaining his financial vision had huge consequences.

Why Quebec Never Built a Secular Alternative

In Continental Europe, socialist movements, labor unions, and fraternal organizations systematically attempted to build non‑religious care institutions. German social democrats founded the Arbeiterwohlfahrt in 1919, creating nurseries, healthcare centers, and relief services; Dutch workers built secular mutual‑aid healthcare funds, clinics, and cooperatives.

In Canada, this socialist infrastructure failed to take root, leaving Quebec insulated from these trends. The Church argued that French-Canadians were a small Catholic island surrounded by a sea of Anglo-Protestant North Americans. They framed secularism, socialism, and non-religious unions as “foreign Anglo-Protestant plots” designed to erase French language and culture. By framing secularism as treason, the Church kept the Francophone working class loyal to religious institutions.

To prevent French-Canadian workers from joining international unions (like those in the US or rest of Canada), the Church created its own union in 1921: the Confédération des travailleurs catholiques du Canada (CTCC). Non-Catholics were barred from voting or holding executive positions within the union, and Catholic priests served as union chaplains to oversee policy. Because these unions were controlled by Church doctrine, they were forbidden from building independent clinics, mutual-aid funds, or cooperative hospitals.

When non-regligious organizers, left-wing activists, or independent labor unions tried to build alternative movements anyway, Maurice Duplessis used the full power of the law to crush them. Under the Padlock Act of 1937, police could padlock any hall, office, or printing press suspected of promoting “communism” (which Duplessis defined as virtually any non-religious or left-leaning group). By criminalizing the political infrastructure required to build a secular alternative, the state maintained the Church’s monopoly over healthcare, education, and welfare.

The Duplessis Reclassification Scandal

Between 1900 and 1950, rapid industrialization and urban growth severely strained Quebec’s social safety net. Modern medicine, psychiatric care, and expanded schooling demanded substantial capital investments, yet the province’s revenue model relied on localized property taxes and parish assessments designed for a rural agrarian society. Compounding these structural pressures, the Catholic Church’s low-cost operating model faced a severe labor shortage by the late 1950s as religious vocations declined. Institutions were forced to hire lay nurses, teachers, and technicians at prevailing market wages, while advancing medical standards required they buy expensive diagnostic equipment and increase physician-to-patient ratios, causing institutional budgets to explode.

The Great Darkness hinges on a scandal that came to light in the 1990s: the Duplessis orphan scandal. Because of the way funding was structured, children and adults were fraudulently diagnosed with mental illnesses.

There were 3,000 to 5,000 children in orphanages that were reclassified as psychiatric facilities. Because there was a severe shortage of charitable support, people were diagnosed as mentally ill and institutionalized in order to fund long-term care. This included the elderly, as well as people with addiction, epilepsy, or mild developmental differences. Others were diagnosed and institutionalized for social nonconformity, poverty, or moral offenses.

Orphanages in the 20th Century

The majority of orphans in 1950s Quebec were not literally children without a living parent. They were illegitimate children and the children of families who couldn’t support them for financial or practical reasons. It’s estimated that during this era, there were 20,000 orphans in orphanages in Quebec, in addition to children in orphanages that had been falsely reclassified as psychiatric facilities.

In 1943, Quebec was the last province to implement compulsory schooling. At the time, working class and rural children frequently stopped attending at grade 3 to work. Schooling was made free and mandatory from ages 6-14. The parents of children who failed to attend were fined. For children living with their families, this dramatically reduced dropout rates. This law was enforced by the schools themselves. Children who were disabled or lived too far from a school were expected. For working-class children living with their families, primary education followed by vocational training matched the available labor market.

Prior to this, orphans were expected to work in the orphanage from the age of 8. Children cooked, laundered, cleaned, maintained the grounds, and worked in institutionally owned bakeries, binderies, or farms. Around age 10, children were routinely placed out into local households or farms under service contracts. Boys were sent to perform agricultural labor; girls were placed in domestic service as maids or nursemaids. The wages from these placements were paid directly back to the institution to cover the “cost of their upbringing.”

This shifted slightly after the introduction of compulsory schooling. Practical vocational training could be used to satisfy educational requirements, allowing children to continue to work within the institutions. Beyond this, orphans were taught basic literacy and numeracy and catechism. Then, at the end of the school year in which they turned 14, they were placed out. While children attending primary schools and trade schools were granted diplomas at the completion of their studies, orphanages typically did not issue official diplomas. This meant that when their placement ended at the age of 18, they had to immediately find a job without any proof of their qualifications. Since they were not paid for their work, they typically left with a change of clothes and bus fare.

Misclassified orphans did not need to be educated at all. Their work within the institution was classified as occupational therapy. They could be boarded out for domestic and agricultural work at any age. Misclassified orphans did not need to be released. They could remain boarded out, be released, or be transferred to the adult asylum.

This model was not unique to Quebec. It was the prevailing global approach to managing “pauper” children throughout the 19th and early 20th centuries. Over 100,000 children from British orphanages and workhouses were sent to Canada, Australia, and New Zealand. Upon arrival in Canada, boys as young as 10 were contracted out as farm hands, while girls became domestic servants, specifically to provide cheap rural labor and relieve British institutions of financial burdens. Across the US and Canada, Industrial Schools were explicitly built around the idea that institutional care should be funded by child labor. Children spent half the day in rudimentary classes and the other half working in shoe shops, laundries, or farms operated by the school.

During the same era, disabled and elderly adults without private wealth or family care were subjected to the same logic. Those in institutions faced forced labor and neglect. If an adult resident was physically capable of moving, they were expected to work 10-12 hours a day to offset the cost of their food and bed. If a person refused to work or complained, it was often treated as a behavioral or moral failing, leading to revoked privileges, reduced rations, or confinement. From the 1920s through the 1950s, disabled adults in institutions across Canada, the United States, and Northern Europe were subject to compulsory sterilization laws under the justification of preventing “hereditary defectiveness.” Without independent financial means or a family member willing to sign for their release, adults remained institutionalized for life.

Children in both orphanages and asylums were subjected to rigid routines and enforced silence for large portions of the day.

Under the Canadian Criminal Code, teachers, parents, and guardians can use “reasonable force” to manage a child’s behavior. This has been limited by the courts since the 1970s. Corporal punishment was banned in Quebec schools in 1988, although most schools individually banned it before then.

The National Health Grant Program

A solution to Quebec’s funding crisis emerged through the convergence of federal health initiatives, provincial executive decrees, and institutional financial restructuring. In 1948, the federal government introduced the National Health Grant Program (NHGP), offering matching conditional grants covering 30% to 50% of capital construction, equipment, and specialized training costs for licensed medical facilities. While standard orphanages and social welfare homes were strictly excluded from these grants, psychiatric institutions were eligible for both federal capital matching funds and significantly higher provincial operating subsidies paid from Quebec’s provincial health budget, not the failed Public Charities Act stream.

Rather than reforming the Public Charities Act or creating a welfare ministry, Duplessis issued executive orders that officially reclassified welfare institutions as psychiatric hospitals. This administrative conversion unlocked a lucrative financial chain.

Reclassification allowed the institutions to secure federal NHGP matching grants for modern facility expansion. Religious orders then leveraged these guaranteed federal capital grants alongside the higher provincial health per-diems to secure private bank loans for their remaining construction costs. Because the actual cost of custodial care remained near the low orphanage baseline (sustained by the remaining religious labor force and unpaid patient work) the higher provincial operating per-diems generated an operational surplus. Religious orders used this margin to service their construction debt and maintain financial solvency, while the Duplessis government successfully sustained its institutional network through the health budget without openly establishing a public welfare program.

Major institutions across the province (including Mont-Providence, Saint-Jean-de-Dieu, and Saint-Julien) were either converted into mental hospitals or soon housed massive populations that met historical categories of “insanity” but not contemporary medical definitions.

From Pauper to Patient

If the doctors, nuns, and bureaucrats had viewed these orphans as completely normal, healthy human beings, falsifying their records might have sparked massive resistance. It did not. Under the prevailing eugenic and psychiatric theories of the 1930s through the 1950s, social class, illegitimacy, criminal ancestry, and poverty were viewed as “hereditary mental defectiveness.” Because they anticipated that children born of “defective” parents would be “feebleminded,” their behavior was interpreted as proof of this inferiority. Caregivers convinced themselves that classifying these children as mentally ill was necessary to protect society from moral decay.

In the 1940s and 1950s, institutionalization was the global standard of care for psychiatry across North America and Europe. Terms like “mental defective” or “feeble-minded” were standard medical terminology used by physicians nationwide, not slurs invented by Duplessis. Psychiatrists and medical directors in Quebec used the influx of misclassified patients to justify larger facility budgets, secure state capital grants, and elevate its clinical authority within the broader medical hierarchy. It was licensed doctors, not politicians or nuns, who had ultimate control over diagnoses and treatment plans.

Once a child was medically certified, the institution had to behave like a hospital. Nuns were explicitly instructed to stop educating them and treat them as patients. In order to maintain order, the children were subjected to mid‑century interventions including heavy sedation, cold‑water baths, straitjackets, electroshock therapy, and lobotomies.

Misclassified children could be kept until age 21, then released as “in remission” or “docile incurable.” Young men were typically sent to farms or factories as cheap labor; young women were placed in domestic service or returned to Church institutions. Their permanent psychiatric diagnoses gave employers immense leverage, since complaints about abuse or wage theft could be met with threats of re‑institutionalization. Many developed lasting psychological trauma and institutional dependency, leading to them eventually being transferred to adult wards rather than ever being able to integrate into community life.

Doctors and medical directors similarly reclassified senior wards into psychiatric annexes or transferred elderly patients directly to major provincial asylums. Dementia, senility, or mere physical frailty were routinely certified as psychosis or “cerebral degeneration” to trigger federal healthcare subsidies. Adults with Down syndrome, epilepsy, cerebral palsy, or severe physical disabilities had historically been grouped under broad legal classifications, so they were governed by the Quebec Lunatic Asylum Act. Because specialized rehabilitative or physical care received no federal support, facilities housing disabled adults were reclassified as psychiatric asylums to maintain financial solvency.

On paper, the process appeared legally valid: licensed physicians signed diagnostic certificates, and provincial authorities processed them without scrutiny. Ottawa had no constitutional authority to inspect Quebec hospitals, audit medical charts, or reassess patients. Attempting to do so would have triggered a jurisdictional crisis. As long as the paperwork met basic accounting requirements, federal funds flowed without challenge.

In fact, while what happened was unquestionably immoral and deeply traumatic for its victims, it’s not a slam dunk case that it was actually legally fraudulent. Quebec’s Lunatic Asylum Act of 1909 allowed commitment for three reasons: treatment, care, or maintaining social order in public and private life. No definition was given for what disrupting social order meant.

The Role of the Nuns

While the Catholic Church presented a unified front to the public, its internal structure was deeply gendered, hierarchical, and rife with institutional tension. The female religious orders—the nuns who actually ran the orphanages, hospitals, and schools—occupied a paradoxical position: they held tremendous operational responsibility, yet possessed zero authority over the financial policies set by male politicians and bishops.

The male clergy (bishops, archbishops, and cardinal) controlled Church governance, doctrine, and high-level negotiations with Premier Maurice Duplessis’s government. Nuns were legally and canonically subordinate to the male hierarchy. When the province negotiated funding rates for orphanages, the nuns were rarely at the bargaining table. They were simply handed the resulting budgets and told to make them work.

While Quebec famously uses its own French-derived Civil Code for private matters like property and family, all of Canada shares a single federal Criminal Code. Under these national criminal laws, inherited from British tradition, poverty itself was effectively criminalized through strict vagrancy statutes. Being unemployed without a visible income, loitering, begging, or having no fixed address made a person subject to police arrest. In Quebec, police enforced these national criminal laws alongside the province’s distinct Civil Code, which stripped unwed mothers of basic legal rights and parental status. Laws outlawing public poverty and the social coercion of unwed mothers created a massive, continuous pipeline of vulnerable people being funnelled into convents, creches, and orphanages.

Local parish priests acted as moral enforcers, working to keep vulnerable parishioners out of the secular legal system. To prevent public court scandals, police records, and state intrusion into local parish affairs, priests routinely coerced parishioners to “voluntarily” enter Church-run institutions.

Nuns had zero legal authority to deny entry to these intake cases, zero voice at the budgetary table, and zero power to change the laws. By the late 1950s, the female orders were reaching a breaking point. The physical workload was unsustainable, recruitment for religious vocations was beginning to drop, and many nuns were suffering from severe burnout.

For many women in mid-century Quebec, entering a religious order was one of the few respectable life paths available—and leaving one was a social and financial death sentence. The decision to stay was often driven less by ongoing religious devotion and more by social coercion, economic dependency, and systemic entrapment. Thousands of women left their religious orders during the Quiet Revolution, transitioning directly into the newly created secular civil service as professional nurses, social workers, and teachers. The nuns were both enforcers of a harsh system and victims of its institutional design.

The Church Takes the Fall

Whistleblowers were silenced. Duplessis’s authoritarian government suppressed dissent – journalists faced threats, loss of access, or libel suits, and medical professionals risked losing hospital privileges or their licenses, since hospital boards were controlled by religious orders and political appointees.

Part of why it was so easy to silence whistleblowers was because this was widespread practice. Mid-century psychiatric misclassification was the primary administrative tool used across Western bureaucracies to navigate rigid, shifting funding architecture and the pressure to maintain social control, keeping poverty and non-conformity out of sight. From Ontario’s hospital schools and Britain’s NHS deficiency wards to post-Medicaid American nursing transfers, post-war governments routinely used elastic diagnostic labels like “feeble-mindedness” to shift financial burdens and manage marginalized populations.

When Duplessis died in 1959 and the Liberal technocrats came to power, they strategically exposed the misclassifications and funding distortions of the previous decades. The scandal was revealed in a government report and corrected through administrative means. Reclassifying institutions was viewed by administrators as an aggressive accounting maneuver to pull Quebecers’ federal tax dollars back into Quebec to keep religious institutions from bankruptcy. They used their findings as leverage to get the Church to agree to hand over power and submit to oversight. Exposing the full extent of the systemic fraud would have undermined the very facilities, medical authorities, and religious staff the new government needed to build its secular healthcare infrastructure. This cleared the pathway to establish centralized ministries for education, health, and social welfare, led by people who shared their technocratic vision.

The newly elected Liberal technocrats and Quiet Revolution intellectuals popularized the phrase “La Grande Noirceur,” the Great Darkness. This referred to political patronage and corruption, economic stagnation and low levels of education for French Canadians, clerical domination over daily life and the suppression of modern science/socialism, and police repression against labor unions and strikes. The 1960s technocrats painted the 1950s as a “dark age” of backwardness and authoritarianism to justify creating a modern, secular state. The new elite continued the tradition of making decisions behind the scenes. Major structural maneuvers were executed via executive orders and internal policy directives rather than public mandates.

In 1977, the Youth Protection Act phased out orphanages and replaced them with group homes and foster care.

The closing of asylum wards was celebrated by intellectuals and media as progress and liberation from medieval Church control. They used it as justification to hand over control to secular medical boards, even though it was doctors who made the fraudulent diagnoses. The administrative details of what happened to individual discharged wards were swallowed by the overarching narrative of societal modernization.

Not a single doctor, administrator, politician, or religious official was ever criminally charged, stripped of their medical license, or formally punished for participating in the Duplessis misclassification scheme.

The Fate of Orphans and the Misclassified

I struggle to make sense of how thousands of young adults could be released, illiterate, without any documents, and without any life skills, without attracting attention about something being amiss. Supposedly, the released orphans were conditioned to hide their pasts, avoid authority, and remain silent to protect themselves from public hostility because being born out of wedlock and being mentally ill bore such social stigma. There’s also the fact that functional illiteracy was widespread in working-class urban neighborhoods and rural regions. In the 1960s it was a lot more common to lack documentation, because it wasn’t a requirement like it is today. And this was happening alongside deinstitutionalization.

Public moral reckoning for the Duplessis reclassification scandal didn’t take place until thirty years later. Even then, it fixated almost exclusively on the narrative of victimized children, which overshadowed the sheer magnitude of the systemic fraud. By framing it as an “orphan scandal,” society overlooked the fact that the same administrative machinery was simultaneously applied to tens of thousands of elderly residents, physically disabled adults, and impoverished workers across the entire provincial asylum system.

Media coverage leaned heavily into sensational trauma, physical horror, and moral outrage. Coverage focused on graphic accounts and emotional suffering, largely ignoring the structural hurdles that prevented orphans from integrating into society. Media outlets rarely explained why released orphans couldn’t get jobs, leases, or bank accounts, leaving the public to assume they were suffering only from PTSD and “institutional dependency” rather than legal hurdles. By viewing the crisis through a narrow lens, the public missed the broader reality of a widespread system that treated vulnerable populations as line items for budget optimization to maintain social control.

When the Lesage administration reclassified the facilities back into standard orphanages or secular hospitals, they changed the funding models, updated hospital regulations, and transferred governance from religious orders to state boards. The moment a facility switched back from a psychiatric institution to an orphanage or a ward reached the age of majority, the per-diem funding for that individual ceased instantly.

Government-employed social workers did exist in the 1960s, but they were not assigned to help the misclassified orphans. The state hospital boards did not correct the medical records of misclassified orphans. They just released the orphans as quickly as possible, still with just a change of clothes and bus fare. The state treated released orphans not as victims of a state-sponsored fraud and abusive forced treatment, but as former charity cases who had aged out of the system.

When all orphans were released, they were not released with identity documents. When children were surrendered, their original intake records were sealed. Baptism records (which functioned as birth certificates) often used temporary names or listed no name at all. They often did not know their exact date of birth, place of birth, or legal name. The combination of missing or incorrect baptismal records, no educational records, no address history, no family or community ties, and a lack of education made entering society incredibly difficult. The misclassified orphans faced these complex paperwork problems without basic literacy or numeracy and after having been subjected to psychiatric treatments like electroshock therapy, antipsychotics, tranquilizers, and lobotomies.

Between 1930 and 1960, almost every US state and Canadian province passed laws sealing original birth certificates permanently upon adoption. Vital statistics offices issued a new birth certificate that listed the adoptive parents as if they had physically given birth to the child. If an adoption was informal, handled by a private organization, or the child was never adopted, an amended certificate was frequently never generated. Thousands of children aged out of orphanages with an original birth certificate that was legally sealed and no secondary document to replace it.

Many of the British Home Children and other child migrants were similarly without legal identity documents as adults. Thousands of Indigenous children were taken from reserves and placed in non-Indigenous homes. State agencies frequently failed to file birth registrations or intentionally obscured birth names, leaving an entire generation without legal paperwork to claim identity or status.

When the Canadian federal government introduced Social Insurance Numbers for tax and pension purposes in 1964, provincial registrars began issuing delayed registration of birth certificates. This required sworn affidavits from a parish priest, a midwife, an older relative, or a physician attesting to the time and place of birth. Or they had to produce secondary documents created near the time of birth, such as early baptismal certificates, lying-in hospital entries, or institutional admission ledgers. There were special processes by which orphans could obtain extracts from their files. Around half of the Duplessis orphans were able to obtain birth certificates this way.

Social aid was highly decentralized, localized, and discretionary. When welfare was introduced in 1969, applicants technically needed identification. However, local welfare officers could use administrative discretion. They could issue benefits directly to an approved administrator for the benefit of the orphan. The state verified the administrator’s identity and credentials, not the resident’s. The administrator cashed the check, deducted housing, food, and management fees, and handed the resident a small cash allowance. Rooming-house operators commonly controlled the finances of dozens of undocumented, ex-psychiatric residents with minimal oversight until new regulations were introduced in 1972.

Around 30% of the Duplessis orphans were able to get support in this way. However, they were still blocked from getting driver’s licenses, formal leases, most jobs, or legally married. The remaining 20% of the Duplessis orphans remained totally locked out of society. They relied on soup kitchens and shelters which didn’t require ID and lived entirely in the cash economy.

By the 1980s, life without proper documentation or a tax ID was becoming increasingly difficult. Provincial health coverage, banks, government agencies, and employers began linking databases using SINs and standardized civil records. Background checks, formal lease agreements, and strict banking regulations became standard practice. Welfare administration was centralized, computerized, and strictly audited. The more time passed, the more marginalized the survivors became.

In the 1990s, new provincial privacy laws finally allowed files to be unsealed. They could discover and prove their birth names, date of birth, place of birth, and their mothers’ identities.

In 1997, Quebec’s public Ombudsman issued a report confirming that the state had systematically misclassified thousands of healthy children as mentally ill for financial gain. Some people were able to use this to legally overturn their psychiatric diagnoses.

In 2001, a compensation fund was established. Survivors who signed away their right to sue were given $10,000 plus $1,000 per year of asylum confinement and had their pediatric medical records corrected. Survivors had already spent decades having their lawsuits thrown out. There were around 3,500 people who met the strict evidence criteria to collect an average of $25k in compensation.

The timing was fortuitous. Post-2001 security standards stripped away local administrative discretion. The workarounds that allowed undocumented citizens to navigate society for decades have been almost entirely phased out, leaving anyone with a missing core document suddenly locked out of basic economic life.

Today, children raised by anti-government or “sovereign citizen” parents experience a modern form of administrative invisibility when their parents deliberately refuse to register their home births, request Social Security numbers, or enroll them in formal schooling. When these children reach adulthood, they face the impossible hurdle of proving their legal identity. Similarly, thousands of adults adopted internationally in the 1960s-1980s discovered that their adoptive parents never completed the separate naturalization paperwork required at the time. As governments began requiring standardized state-issued birth certificates for government healthcare and pensions (like Social Security), millions of adults suddenly discovered they did not have the documents necessary to prove their legal identity or nationality.

The vast majority of those trapped, misclassified, and exploited inside Quebec’s asylum network were, in fact, adults. Misclassified adult victims never received a compensation fund or a public narrative of their own. They were simply released during deinstitutionalization, discharged into rooming houses, foster homes, and street-level poverty like any other psychiatric patient. Their medical diagnoses were never corrected.

Children could be assumed to be innocent victims, while adults would need to be scrutinized to determine who was institutionalized for their politics, nonconformity, neurodivergence, or “immoral” behavior rather than mental health issues in alignment with the DSM. Most importantly, by the time the public was paying attention in the 1990s, adult victims from the Duplessis era were either elderly, deceased, or severely broken by decades of institutionalization.

During this time the broader Western world was also undergoing a shift away from large-scale mental hospitals. Public psychiatric bed counts dropped by over 50% across the US, UK, and Western Europe between 1955 and 1975. Misclassification, abuse, and failure to support discharged patients was a widespread policy failure, not exclusive to Quebec technocrats.

However, Quebec is famous for how well it supported its discharged patients. In the popular imagination, in the version of the story that I was told countless times, the architects of the quiet revolution established a network of community care networks – modelled on radical grassroots health centers – and then freed people from the asylums. The Quiet Revolution is Quebec’s modern origin story: In 1960, Quebec flipped from being oppressed by the Church to being a shining beacon of human rights. Quebec eventually did build progressive social welfare systems, and these get projected back in time. When I read the actual history books and reports, it was pretty shocking.

The Quiet Revolution: Administrative Modernization

Economically, French‑Catholics—roughly 80% of the population—were locked out of power. Montreal’s finance, industry, and executive positions were controlled by American corporations and a small Anglophone Protestant elite concentrated in enclaves like Westmount. Francophones were relegated to lower‑paid labor and systematically blocked from advancement. English was not simply useful; it was mandatory for economic mobility.

French-Catholic Quebec’s educational and fiscal stagnation was the result of deliberate political choice. In 1897, Premier Félix‑Gabriel Marchand introduced a bill to create a Ministry of Education—a mechanism that would have given the province legal authority to oversee Church schools and enforce standardized curricula. Catholic bishops mobilized, using their leverage in Quebec’s unelected Legislative Council to kill the legislation. This defeat inaugurated a sixty‑year era defined by a tacit pact between the ruling political class—most famously perfected by Duplessis and the Union Nationale—and the clergy. As long as the state capitulated to Church autonomy, the bishops would secure the party’s electoral survival.

Guided by traditional Catholic social ideology, the Church fostered community-based institutions like the Caisses populaires credit unions and Catholic labor unions. While the Duplessis government encouraged rapid industrialization by inviting foreign American and Anglo-Canadian capital to extract the province’s resources, the Church enforced traditional values and family structures.

By the late 1950s, a rising generation of Francophone intellectuals, professionals, and technocrats—educated within the Catholic collèges classiques but increasingly trained in economics, sociology, and law—saw this arrangement as keeping the Quebecois backward. They argued that the Church’s control of education and health care, combined with Anglo-Canadian control of big business, kept French Quebecers economically subordinate and undereducated. By 1960, a mere 4% made it to university, and 42% of men in Quebec had not studied past the 8th grade.

During the Quiet Revolution, Jean Lesage’s Liberal government and secular reformers modernized the province. Overwhelmed by post-war growth, the Church largely yielded its control over education, medicine, and welfare. The state secularized education, created a modern university system, and aggressively intervened in the economy. Through key state-driven initiatives—such as the nationalization of hydroelectricity and the creation of the public pension fund manager—Quebec rapidly created a Francophone managerial class and multinational corporations.

Yet, in dismantling the old order, the new secular elite maintained a familiar practice: managing the population from above. Rather than creating a decentralized grassroots democracy, the new bureaucratic elite viewed the population as an ignorant, backward citizenry that needed to be engineered into a modern industrial society.

While the Quiet Revolution is celebrated as a moment of liberation, it essentially replaced the moral paternalism of the Church with the managerial paternalism of a newly empowered technocratic state. Rather than decentralizing power, the new elite reorganized Quebec society through top-down models of economic optimization and bureaucratic efficiency. They frequently treated ordinary citizens less as democratic partners and more as social variables to be engineered into a modern industrial populace.

This top-down ethos shaped nearly every major reform of the era. In education, they transformed a fragmented network of parish-run schools into a centralized public system, stripping local communities of control and deploying state-certified counselors and standardized tracking to align students with the needs of the industrial economy. In regional planning, they applied cold socio-economic formulas to declare dozens of rural Gaspé fishing villages “economically unviable,” attempting to forcibly relocate thousands of residents to designated urban hubs until local resistance forced a retreat. While state corporatism sought to integrate labor unions into government planning bodies to maintain economic predictability, the state reacted with iron-fisted back-to-work legislation when workers struck outside those sanctioned bounds. In the mega-energy projects like the James Bay Hydroelectric Complex, northern rivers and Indigenous lands were unilaterally targeted for exploitation to fuel southern industrial growth. Ultimately, the new technocrats modernized Quebec not by dismantling top-down governance, but by mastering it under a new banner of administrative authority.

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From a North American vantage point, Quebec’s mid‑century welfare system can appear anomalous: a modern, industrial society whose social safety net remained anchored in a paternalistic, parish‑based matrix. But in a broader context, Quebec’s experience doesn’t seem unique. Across the 20th century, Catholic corporatist regimes attempted to carefully channel the disruptive forces of industrial capitalism, preserving established hierarchies and religious authority. These systems eventually broke under demographic change, economic modernization, and external pressures.

It seems odd that an urban, industrial province had political and clerical elites who deliberately kept a welfare system designed for rural life. Quebec encouraged industrialization and urban growth, yet maintained a welfare, education, and healthcare structure originally built for a world of agricultural villages.

To understand why, and to understand how this system ultimately was dismantled, we need to place Quebec in a global context — and Portugal under António de Oliveira Salazar offers a parallel. Both were modern societies whose welfare and social structures are now cast as “backward” and “feudal.” Both systems were held together by a single dominant leader whose sudden removal triggered rapid institutional transformation. Both “bloodless” revolutions led to significant structural turmoil, deep ideological polarization, and armed political violence. Quebec’s armed violence peaked during a 7-year period which transitioned into parliamentary sovereignty politics, whereas Portugal’s political violence and paramilitary operations dragged on into the late 1980s.

To compare Quebec and Portugal is to compare entities operating at different scales. Portugal was a sovereign nation-state with a colonial empire, independent monetary policy, an army, and international diplomatic agency. Quebec was a province operating within the legal, financial, and constitutional guardrails of a federal democracy. This difference in geopolitical scale demonstrates that the Catholic-corporatist model was not solely a state-level political strategy, it was a widespread institutional architecture capable of shaping society at any level.

The Catholic‑Corporatist Paradigm

In 19th‑ and early 20th‑century Europe, many states modernized their welfare systems. Quebec’s mother country, France, had violently severed state ties with the Church during the French Revolution. Belgium modernized its Catholic institutions into a technocratic welfare state.

Quebec did not follow this path. Quebec instead found its mid‑century structural peers in the authoritarian Catholic regimes of Italy and Portugal. These systems all retained subsidiarity, the belief that families, parishes, and religious orders should handle social care, and the state should intervene only when those informal systems failed completely.

Across Europe, when subsidiarity faded, it wasn’t replaced by a belief that the state should take over care entirely, it was replaced by systems that still assumed families would carry the primary burden, just without entrusting Catholic institutions to run everything.

• In Northern Europe and the Anglo‑Protestant world, subsidiarity gave way to bureaucratic universalism, where national ministries and civil servants ran health, education, and welfare directly as standardized public services.

• In France and Belgium (and eventually Quebec and Portugal after their revolutions), it was replaced by secular technocratic universalism, where the state absorbed Church infrastructure and used centralized ministries, planning tools, and administrative law to deliver universal programs as instruments of nation‑building.

• In Germany, Austria, and parts of the Netherlands, subsidiarity was folded into a Bismarckian social‑insurance model, where mandatory employment‑based insurance funds delivered care under state regulation while Church charities continued operating as major providers funded by public money.

These three systems mark the shift from parish‑based care to the modern nation‑state’s administrative monopoly over welfare.

In the early-to-mid 20th century, Catholic corporatism emerged as an ambitious “third way” social model designed to counter both the individualist exploitation of industrial capitalism and the totalizing state control of Marxist socialism. At the heart of this framework was a specific interpretation of subsidiarity, which held that human social life is naturally organized in a hierarchy of organic communities—families, parishes, local guilds, and occupational associations—and that higher administrative authorities (such as the state) should never usurp functions that smaller, local bodies can perform effectively.

Under this vision, Catholic corporatism sought to reorganize society into occupational “corporations” uniting workers and employers within shared industries to resolve class conflict through moral solidarity rather than strike action or wage warfare. Within this architecture, the state was assigned a strictly auxiliary role: its purpose was not to directly administer health, education, or welfare, but to provide the legal guardrails and financial backing that enabled family networks, religious orders, and parish institutions to manage social care independently.

Salazar’s Catholic corporatism was a centralized, state-enforced political and economic system designed to freeze social change and halt industrial capitalism. Guided by the principle of subsidiarity and papal encyclicals, Salazar viewed the traditional, self-reliant rural village as the moral anchor of Portuguese society. Catholic lay brotherhoods and religious orders were chosen as the sole providers of health, elder, and social care. By marrying Catholic subsidiarity to an authoritarian police state, Portugal used corporatism as a structural brake on the transition into an urban, industrial, mass-consumer, secular democracy.

In mid-century Quebec, Catholic corporatism manifested not as an authoritarian state regime, but as an institutional social architecture operating within a liberal parliamentary democracy and a capitalist economy. Under Premier Maurice Duplessis’s Union Nationale, political elites embraced Catholic social theory and anti-statism to keep the provincial state apparatus small.

Francophone civic life was structured through Catholic corporatist bodies. Because major industries, mines, banks, and utility companies were owned by Anglo-Canadian and American firms, Francophones faced immense pressure to assimilate or work in English to gain economic mobility. To combat this, Catholic social theory was used to build a parallel, Francophone-controlled financial and agricultural ecosystem. The Church supported the creation of credit unions in local parishes. They pooled the savings of Francophone farmers and workers to lend to local families who were routinely denied loans by Anglo-dominated commercial banks. Catholic Trade Unions rejected both American-style secular trade unionism and Marxist class warfare.

French-Canadian elites explicitly prioritized cultural, linguistic, and institutional autonomy over maximum capitalist growth and individual wealth accumulation. They viewed unbridled industrial capitalism as an assimilation trap. Quebec used Catholic corporatism to preserve French-Canadian identity and institutional autonomy. By shielding core pillars of human life from government hands, Quebec ensured that even if Anglo-Canadian capital dominated the economy and Ottawa controlled federal politics, the internal mechanics of French-Canadian daily life remained completely autonomous.

Portugal Under Salazar: A Parallel Built on Opposite Economic Choices

I’m going to set aside the things Salazar is famous for — secret police, political imprisonment, torture, censorship, forced labor, and state-enforced poverty— since they are widely discussed elsewhere and aren’t directly relevant to my topic. While Cold War propaganda often contrasted the practices of liberal democracies with those of totalitarian states, Western nations regularly deployed these exact mechanisms, both internally against marginalized or dissident populations and externally across their colonial or imperial territories. Through wartime emergency acts, colonial policies like the Indian Act, and covert intelligence operations, the Canadian state has historically deployed political imprisonment, forced labor, censorship, and systemic displacement against Indigenous populations, political dissidents, and minority groups.

Salazar’s Estado Novo was explicitly designed as a brake on industrial capitalism. As an economist and devout Catholic, he looked at the brutal industrialization of Europe — with its crowded tenements, hyper‑capitalism, communist unions, and the erosion of rural family structures — and saw spiritual and social catastrophe. To prevent the “freeing” of peasants into the factory system, Salazar built a corporatist, anti‑capitalist state engineered to preserve a specific vision of Portugal.

António de Oliveira Salazar’s idealization of the rural, subsistence lifestyle was an anti-industrial agrarianism vision. The self-reliant peasant was the moral and economic anchor of society. His vision tapped into a deeply felt critique of modern capitalism. The British Enclosure Acts and Europe’s rapid Industrial Revolution forcibly separated millions of peasants from communal lands, driving them into overcrowded, disease-ridden industrial cities, leading to major social crises. For working-class families, the transition from field to factory was not necessarily experienced as “progress,” but often as a traumatic loss of autonomy, health, and dignity. In Portugal, industrialization was restricted through state licenses to prevent the growth of an organized urban working class.

By intentionally slowing down industrialization and urban migration, Salazar shielded Portugal’s peasantry from the cold realities of proletarianization, such as boom-and-bust cycles that continually destabilized economies. In a factory, a worker is dependent entirely on a wage and a boss. A cash economy means your ability to feed your family depends on global commodity prices, inflation, and market crashes. A subsistence farmer, by contrast, retains direct ownership over the means of their own survival (food, shelter, community). Salazar prioritized national self-sufficiency and local economic resilience, aiming to build an economy immune to Wall Street panics, international trade embargoes, or currency devaluations.

If these values seem familiar, it may be because the early US built its national identity around the ideal of the independent, land-owning yeoman farmer from the 1780s through the 1840s, a vision spearheaded by Thomas Jefferson and expanded through Jacksonian democracy. Jefferson argued that self-reliant agrarian families who owned their land were immune to economic coercion and moral corruption, making them the only reliable guardians of a free republic compared to vulnerable, wage-dependent factory workers. This philosophy directly shaped massive federal policies, driving westward territorial expansion (most notably the Louisiana Purchase and later the Homestead Act of 1862) to ensure cheap land for smallholders. While early leaders envisioned a nation of self-sufficient homesteaders, American farmers quickly turned to commercial cash crops and global markets, transforming into industrial producers and ending the agrarian era by the time urban populations surpassed rural ones in 1920. The 1920s in Portugal were defined by extreme political instability, economic collapse, and a violent democratic crisis, which ultimately paved the way for the military dictatorship and Salazar’s regime.

In 1926, agrarian subsistence living was still common across rural areas worldwide. Roughly 40% of Americans and Canadians still lived on farms, most without electricity or indoor plumbing. An estimated 40-60% of the US population lived below what was considered the national poverty line, particularly tenant farmers, sharecroppers, and rural families. Europe was recovering from the devastation and hyperinflation of World War I. Large swaths of rural France, Italy, and Eastern Europe still relied on peasant agriculture and subsistence farming. In the late 1940s, rumblings of discontent grew, since Western Europe was rapidly modernizing while Portugal remained deliberately stagnant. By the 1960s, the political repression was palpable and people were not content to remain subsistence farmers while workers in the rest of Europe obtained modern conveniences.

Much like the Back-to-the-Land movements of the 1960s and 70s, Salazar’s agrarian ideal emphasized the non-material value of life. Rural life operated on natural, seasonal cycles rather than the rigid, arbitrary clock-time of the assembly line. It preserved the tight-knit village structure, intergenerational family support, and local customs—protecting people from the profound isolation and social fragmentation often found in rapidly expanding urban slums.

Like religious communities that evaluate technology through a moral filter (such as the Amish, Old Order Mennonites, or Orthodox Jewish communities), Salazar’s Estado Novo did not reject industrialization or modern technology entirely, it strictly curated it. He restricted technologies that encouraged social mobility, individual consumerism, or political organizing. He framed modern consumerism as a decadent Western vice. When a Mennonite community or a digital minimalist sets boundaries on technology, it is an act of collective or individual self-determination. In Salazar’s Portugal, it was a state policy.

However, true subsistence requires enough fertile land to thrive. Many Portuguese peasants faced high land rents, landlord exploitation, and malnutrition rather than idyllic self-reliance. Portuguese peasants were born into this system and could not simply opt-out. Portugal viewed its colonies (later re-branded overseas provinces) as a key part of their ability to become self-sufficient. The resulting wars gave many Portuguese – especially young men – the motivation to leave. It’s said that 1.5 million people left during Salazar’s era and another 1 million left during EEC modernization.

When Salazar consolidated power in the late 1920s and early 1930s, medical, elder, and long-term care were anchored by the Santas Casas da Misericórdia, a network of Catholic lay brotherhoods established in the 15th century. During the First Republic (1910-1926) politicians tried to nationalize church property and secularize care, but lacked the administrative capacity and funds to build a replacement state system. The Misericórdias survived largely intact.

Salazar’s Estado Novo formally institutionalized Catholic subsidiarity. In 1944 the Misericórdias and religious orders were designated as the official instruments of public welfare. The state began supplying subsidies, land grants, and technical guidelines, while the Church retained day-to-day operational control, management, and religious framing. In urban industrial sectors, the state built formal social security funds for unionized workers, but these funds contracted medical services directly from Catholic-run facilities. By the late 1960s, the system was straining under rural flight and increased costs from modern medical treatment.

In 1968, Salazar suffered a head injury in a fall. He was quietly removed from power and replaced by Marcelo Caetano. The Estado Novo lost its central stabilizing figure. In 1971, under Salazar’s successor, the state began building public district hospitals and primary care clinics. It established unified medical standards and began converting hospital employees into civil servants. However, this national system was not completed before the Carnation Revolution in 1974. While people were unhappy with political repression and economic stagnation, the Colonial War was the trigger of the 1974 revolution.

Portugal’s Collapse: Revolution, Land Occupations, and EEC Reversal

The revolutionary government completed the process of nationalizing hospital infrastructure, transferring management to state hospital boards. In 1979 they introduced a law establishing a universal, tax-funded, secular national health service for acute care.

Right after the Carnation Revolution on April 25, 1974, the rural poor did not wait for the new government to act. Backed by the Portuguese Communist Party, they launched the Agrarian Reform, physically occupying massive private estates. They did not want to abandon their land; they wanted to own the fruits of their labor on that land. They formed collective farming units and cooperatives, aiming for a self‑sustaining, localized agricultural economy where workers were paid fair wages, shared profits, and could raise families in their home villages. For a brief moment, they believed they had won.

The turning point came in late 1975 and 1977. Moderates and right‑leaning parties gained power in Lisbon, and the revolutionary climate cooled. The European Economic Community (EEC) made it clear: if Portugal wanted to join modern Europe and receive financial support, it had to stop communist collectivization and respect private property.

The state passed the Lei Barreto in 1977, stripping collective farms from workers and returning land to wealthy owners. Backed by European modernization grants, landowners mechanized the farms, replacing hundreds of workers with a single tractor. At the same time, the EEC flooded Portugal with cheap, industrialized agricultural imports from Spain, France, and the Netherlands. Subsidized corporate farming made traditional, small‑scale Portuguese agriculture financially impossible.

The older generation stayed behind on meager agricultural pensions. The younger generation faced a stark choice: stay in the village and starve, or move to Lisbon and Porto to work in construction, textiles, shipyards, and services. Later, as the economy shifted, those villages were re‑colonized by tourism. Expats with romantic notions of village life retire to farms, enjoying the aesthetics of rural life without the economic pressure.

Today, while acute medical treatment in Portugal is delivered through a fully secular public national health service, the state’s long-term care network (Rede Nacional de Cuidados Continuados Integrados) relies heavily on public funds paying Catholic institutions to deliver the care inside their historical facilities. While acute care was truly secularized, long-term care remains a service provided by Santas Casas da Misericórdia and Catholic charities.

Quebec’s Technocratic Realignment: Autonomy Through the State

Framing pre‑1960 Quebec as “feudal” or “backward” is largely a political narrative popularized by a rising technocratic elite to legitimize their own expansion of state power. When stripped of this “Great Darkness” framing, mid‑century Quebec reveals a sophisticated alternative model of modernity rooted in Catholic social theory, papal encyclicals, anti‑statism, and agrarian‑paternalist capitalism. Quebec’s mid-century social framework sought a “third way” between unbridled industrial capitalism and state socialism. This manifested as support for credit unions, agricultural and consumer cooperatives, Catholic trade unions, and local parish-level social relief. Politically, this married ultra-liberal, pro-business economic policy with a fierce resistance to federal state intervention.

The Quiet Revolution was not a leap from backwardness into civilization; it was a structural realignment. It succeeded where other mid‑century transformations failed because it aligned a rising Francophone technocratic elite, an empowered urban working class, and the broader institutional architecture of the Canadian federal state.

Unlike Portugal, pre-revolution Quebec encouraged industrialization and urban growth, while preserving a welfare system governed by Catholic institutions. This produced a dual structure: a Church monopoly over welfare, education, and healthcare, and an Anglo‑Canadian and American monopoly over capital and corporate power. Major industries (mining, finance, manufacturing, hydroelectricity) were owned and managed by Anglophones, while Francophones were largely relegated to low‑wage labor and blocked from executive roles, with English functioning as a prerequisite for economic mobility.

This dual structure made Quebec’s welfare system unusually brittle, especially as Ottawa pushed for federal oversight and a new technocratic elite of doctors, economists, and social workers demanded authority. These two existing elites (the Church and Anglo-capitalists) did not share the same priorities, administrative logic, institutional culture, or language and Quebec’s Francophone political class had to balance both. This allowed the third group (technocratic experts) to ultimately emerge as the new elites.

Doctors, economists, social workers, and administrators emerging from Université Laval and Université de Montréal saw themselves as the rightful modernizers. They believed welfare should be run by professionals, not clergy; economic development should be run by Francophones, not Anglophones; and the state should coordinate modernization, not parishes or foreign capital. The Church attempted to collaborate with these emerging professionals without surrendering control, while the new elite refused to rest until they had the final say.

The Quiet Revolution coincided with Vatican II, a modernization of the Catholic Church, moving away from clerical authority and state-enforced religious monopolies. This eased the transition in Quebec. In Portugal, this created a split, with progressive Catholics joining the opposition.

Quebec’s structural transformation offers a stark contrast to post-revolutionary Portugal. Following the 1974 Carnation Revolution, many of Portugal’s radical reforms were rolled back through a combination of domestic political shifts and international pressure. Fearing a Soviet-aligned state on NATO’s southern flank, Western powers (led by the United States and West Germany) applied diplomatic leverage, economic conditioning, and covert assistance to back moderate political factions. However, the ultimate stabilization of a parliamentary democracy was driven internally by the 1975 counter-coup, electoral victories for moderate social democrats and centrists, and resistance in the north. In Quebec, while radical Marxist groups existed on the periphery, the governing parties were firmly committed to parliamentary democracy, market economies, and NATO alignment. Whereas Portugal’s revolution forced a high-stakes geopolitical compromise under international scrutiny, Quebec’s modernization succeeded because it operated within the accepted boundaries of market capitalism and federal law.

Quebec’s modernization succeeded because it replaced one fully realized social model with another. The Lesage Liberals replaced religious governance with a secular civil service. Quebec’s most radical economic intervention — the 1962 buyout of eleven private electric utilities — still respected market mechanisms. When Quebec passed language legislation requiring French in business and instruction, Anglo-Canadian capital fought the laws through Canadian courts rather than through foreign diplomatic intervention. By leveraging constitutional protections, market-compliant mechanisms, and state capital, the new technocratic elite executed a profound structural realignment without triggering external intervention or risking full economic collapse.

Quebec’s replacement of Church authority with state administration was not an isolated modern anomaly; it was the continuation of a structural playbook first written four centuries earlier during the Protestant Reformation.

A Less Quiet Revolution: Protestant Precedents for Elite Realignment

The Protestant Reformation is often remembered as a spiritual awakening sparked by the printing press, but its real engine was structural. It was a moment when a failing institutional system—the late‑medieval Catholic Church—collided with rising economic pressure, new information technology, and a crisis of legitimacy. The Reformation was an infrastructural coup carried out by rising domestic elites who used new information technology to break a failing system and seize control of its assets, redirect revenue, and build new administrative systems. In other words, it was a precedent for the kind of institutional realignment Quebec experienced in the 1960s.

Humanism created a new elite class — educated, literate, mobile — who were predisposed to challenge medieval authority structures. Luther succeeded because he was embedded in this ecosystem. Behind Luther stood a network of German princes, wealthy merchants, and university elites who backed him not out of pure piety but because Rome’s financial extraction had become intolerable. The Church owned enormous tracts of land, raised rents, sold indulgences, and drained liquidity from local economies. The Reformation succeeded where political fragmentation created administrative gaps. Supporting Luther allowed regional rulers to keep tax revenues at home, nationalize Church wealth, and build state‑aligned churches that answered to domestic law rather than a transnational hierarchy based in Rome.

The printing press made this possible by collapsing the “speed of consensus.” Luther’s theses spread across Europe in weeks, bypassing traditional gatekeepers. Ideas moved faster than institutions could suppress them, giving elites a powerful tool to redirect public anger. When peasants interpreted Luther’s message as a call for economic equality, elites neutralized those demands by shifting the debate toward technical theological disputes. The public won symbolic access to scripture, but their material grievances were crushed—often violently.

Contrary to what I learned in Sunday School as a child, the Reformation’s real legacy was administrative. By transferring record‑keeping, taxation, and legal authority from the Catholic Church to territorial states, it created the data infrastructure of the modern nation‑state. Parish registries became civil registries. Sacramental records became demographic records. Local ministers became de facto bureaucrats. Over time, this system evolved into the statistical machinery that enabled modern biopolitics, welfare administration, and eventually eugenics. The revolution was not about theology; it was about jurisdiction, data, and control.

As we know, the Catholic Church didn’t collapse in response to the Reformation; it modernized. And it modernized in ways that mirrored the administrative logic of Protestant states. Catholicism became centralized, bureaucratic, and data‑driven.

The Quiet Revolution followed the same structural pattern. A new political class used moral language (modernity, rights, dignity) to justify a massive transfer of power from a transnational Church to a centralized provincial state. Quebec’s reforms were part of a centuries‑long Western tradition of using moral narratives to reorganize administrative authority.

Seen through this lens, deinstitutionalization and modern welfare reforms are not unprecedented disruptions. They are the latest iterations of a very old pattern: institutional collapse, elite realignment, technological acceleration, and the reorganization of power under a new administrative logic.

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Modern healthcare is built the same way. What looks like one system is actually a patchwork of parishes, Protestant charities, municipal boards, medieval Catholic orders, frontier hospitals, all awkwardly stitched together. Each piece was created to solve a specific crisis, each with its own logic, all modified by waves of reforms. The façade is modern, but underneath it is centuries of incompatible structures forced to function as one.

Before the mid‑1900s, the idea of a state‑run Ministry of Social Services simply did not exist. In Catholic regions such as France, Italy, Portugal, and Quebec, the Church held a legally sanctioned monopoly over care work funded by the agricultural tithe. When Britain broke from Rome, it did not dismantle this model; it merely replaced the Catholic hierarchy with the Church of England and kept the same administrative logic.

Because North America didn’t have deep-seated, medieval parish networks already in place, state architects could import, adapt, or reject contemporary European ideas onto an almost blank slate—or in Quebec’s case, deliberately double down on a centralized, neo-feudal Catholic network to preserve cultural sovereignty.

The story of care work is the story of waves of struggling to deal with poverty, mental illness, and disability. The 19th-century strain was far from the first time parish care failed, but it was the moment when demographic scale permanently outgrew localized charity models. Each province responded according to its own legal and cultural foundations, producing care systems that looked similar on the surface but were built on fundamentally different administrative logics.

In societies that could not force a diverse population into a single state church (such as the Netherlands, the United States, and most of Canada) welfare fractured into a system known as pillarization. Each religious or cultural group built its own parallel institutions: hospitals, schools, charities, and burial societies. Families lived, received care, and died inside their own self‑funded silo. Crossing into another pillar often meant encountering proselytizing, discrimination, or severe cultural mismatch.

When 19th‑century histories describe the rise of “secular” hospitals or poorhouses in Britain, Canada, or the United States, it’s easy to misunderstand. Today secular means neutral, non-religious, or state-run without faith elements. Religious groups run non-religious institutions providing culturally sensitive care. In the 19th century, secular meant non‑sectarian Protestant. Secular institutions were not bound to a single Protestant denomination (such as Anglican, Presbyterian, or Methodist), but were still rooted in Protestant morality. Catholic, Jewish, or non-believing residents were expected to conform to daily Protestant prayers and Bible readings. These institutions were funded by municipal property taxes or civic donations rather than a centralized church tithe, but they were staffed and governed by Protestant elites.

The Anglo-Bureaucratic State: Ontario, New Brunswick, and Western Canada

In Ontario, New Brunswick, and much of the United States, early welfare systems developed within an Anglo‑Protestant administrative tradition shaped by British governance. These were civic institutions built by municipal councils, county governments, and state-appointed superintendents. Their organizing principles were rooted in 19th-century “scientific charity”—the belief that public relief for the elderly and disabled should be systematized, categorized, and managed by experts rather than driven by unregulated Christian almsgiving. Administrators sought to address a genuine crisis: overwhelmed family care networks, acute physical impairment, and severe cognitive decline during rapid industrialization. They attempted to solve this through strict cost containment, standardized intake, and institutional segregation.

The English Poor Laws created a local, parish‑based system where each township was legally responsible for supporting its own poor, elderly, and disabled residents. Relief was divided into outdoor relief (aid at home) and indoor relief (poorhouses/workhouses), with strict residency rules determining who qualified. Because funding came from small local tax bases, parishes were incentivized to minimize costs, producing practices like pauper auctions, forced labor, and punitive institutionalization.

The Maritime provinces inherited an older 18th-century British model: Poor Laws where vulnerable residents were managed at the local level. New Brunswick was one of the few Canadian jurisdictions to formally adopt this system, creating a strict “settlement” framework where parishes were financially liable only for proven local residents. Because local tax bases were small, parishes had little funding for long-term care. Fragile elderly and disabled residents without family support were routinely boarded out through public “pauper auctions.”

At a pauper auction, an official would stand up with a person who required public support. Anyone could bid to provide for them (room, board, and basic care). Each bid had to be below the previous. The lowest bidder won the contract and received a small stipend from the local parish or town taxes for that amount. Care was treated as a business transaction aimed at saving taxpayers money. The winning bidder had an inherent incentive to spend as little on food, heating, and medicine as possible to make a tiny profit. This is an individual, face-to-face version of the way we still do this today—the government chooses a provider who promises to meet the terms at the lowest cost per person. Of course, today public procurement involves statutory regulations, minimum standards of care, professional licensing, background checks, and legal accountability. Pauper auctions (much like placing orphans and poor children in the care of adults with virtually no vetting or oversight, a la Anne of Green Gables) were largely unregulated. However, since it was happening within the local community, there was a certain amount of oversight baked into small town life.

In English-Protestant counties, municipal almshouses remained the primary solution when funding was sufficient to build and run them. In northern and eastern Acadian counties, Catholic leaders resisted Poor Law property taxes and successfully petitioned for municipal grants to support Catholic-run hospitals and hospices staffed by religious orders like the Religious Hospitallers of St. Joseph. This created two parallel regimes within New Brunswick—one civic-municipal, one Catholic-charitable—to house frail and sick residents.

Ontario took a radically different path early on, explicitly rejecting the English Poor Laws in 1792 to avoid creating a legal right to relief or imposing mandatory welfare taxes on property owners. Without formal poorhouses or public care homes, local magistrates managed disabled or deeply disruptive individuals using criminal vagrancy and public nuisance laws. County jails routinely held elderly paupers and individuals experiencing severe mental illness simply because it was the only publicly funded accommodations available. When provincial psychiatric asylums were built in the mid-19th century, they remained perpetually overcrowded, leaving long-term care for the destitute elderly and disabled anchored in local correctional facilities.

To resolve this reliance on local jails, Ontario constructed a structured institutional network for dependent populations over the late 19th century. The Charity Aid Act of 1874 established per-diem provincial subsidies for voluntary and religious institutions, such as houses of refuge and hospitals for the incurably ill, provided they met provincial reporting and inspection standards. The Prisons and Asylums Inspection Act of 1868 standardized provincial institutions. The Houses of Refuge Acts of 1890 and 1903 established formal provincial oversight for state institutions and provided capital grants for construction. This created a mixed welfare system: public money, private management, and standardized oversight.

By 1912 it was mandatory for all counties to build Houses of Refuge specifically designed to provide basic shelter for elderly residents who could no longer farm or labor, and for disabled adults who lacked family support. When provincial asylums were built in the mid-19th century, they were perpetually overcrowded. Getting someone admitted required a legal certificate of insanity and a willingness by the province or municipality to pay for their bed. If the asylum was full (which was often the case), the person stayed in the county jail.

Anglo‑Protestant civic systems were among the first in North America to require formal intake records, classification systems, and regular inspections. Anglo‑Protestant regions adopted medical superintendents, trained nurses, and public health officers earlier than Quebec. Residents were divided into “deserving” and “undeserving” based on age, disability, and work capacity, reflecting the administrative logic of the period rather than explicit religious doctrine. Residents were managed as dependents of the state, recorded in institutional ledgers, and supervised according to standardized regulations.

Ontario’s houses of refuge were legally required to admit residents regardless of faith. While they suffered from the cultural and linguistic factors that made life uncomfortable for a patient (English speaking staff, unfamiliar food, Protestant rituals embedded with care, morally based rules) there was no formal requirement that patients be baptized as Protestant or accept the faith. There was an emphasis on administrative criteria (age, disability, work capacity) rather than spiritual worthiness when determining placement.

Ontario’s Catholic minority responded by building a voluntary parallel network of hospitals, orphanages, and charitable homes. Orders such as the Sisters of St. Joseph established institutions in Toronto and London. Without a mandatory tithe or guaranteed public funding, these facilities relied on donations and remained chronically under-resourced. Their existence highlights the structural reality: public welfare in Ontario was built around municipal taxation and Protestant civic administration, leaving Catholic institutions outside the main funding pipeline.

Western Canada mostly bypassed this 19th-century Victorian poor house phase, although some early poor relief existed in BC and Manitoba. Settled during the peak Progressive Era between the 1890s and 1920s, the Prairie provinces lacked an established parish baseline. Sparse rural populations made reliance on local private charity or county almshouses impossible, forcing the state to design public health and long-term care infrastructure immediately. Alberta and Saskatchewan pioneered municipal hospital districts in the 1910s—tax-funded, community-owned institutions that provided local medical and infirmary care, laying the early groundwork for modern public healthcare. However, access to these systems was explicitly stratified: while municipal health networks served white settlers, Indigenous elders and disabled individuals were legally excluded from municipal systems and subjected to federal control.

Because welfare systems were designed simultaneously with the provinces themselves, welfare was deeply tied to state-building and “nation-building.” In the West, state social engineering (the pass system, residential schools, industrial farms) directly targeted Indigenous populations to clear land for Anglo-Protestant settlement while creating Western municipal health infrastructure. The Métis model demonstrates that Anglo-Protestant institutionalization was not the only way North American communities handled vulnerability; it was a specific, imposed administrative choice. Relief and health systems were explicitly structured around Anglo-conformity and public health.

Funding determined how care was provided. Ontario and Alaska both found ways to arrest and jail people needing care because that was the only way to get funding for their care. New Brunswick auctioned paupers to local families, while Alaska later shipped people to Oregon because contracting out care was cheaper and administratively easier than building local public infrastructure. I can’t know the motivation of the administrators, but evidence suggests that these were the only options they could manage in an incredibly rigid system.

The Quebec Model: Total Ecclesiastical Control

If you sought care in 1800s Quebec, you entered a fundamentally different administrative world from the Anglo‑Protestant systems in Ontario or New Brunswick. Quebec operated under a social philosophy rooted in subsidiarity: the belief that the state should only step in when families and local communities are completely unable to provide for themselves. The provincial government avoided building a public welfare bureaucracy, instead providing modest grants while delegating nearly all care functions to the Catholic Church.

Catholic orders operated some of the largest, most technologically advanced medical facilities in North America for their time. The medical care they provided was as good as in Toronto, Boston, and Philadelphia. In 19th-century Quebec, the distinction between acute medical hospitals and long-term custodial facilities was far less distinct than it is today. Institutions like the Hôpital-Général or Saint-Jean-de-Dieu served simultaneously as hospitals, poorhouses, psychiatric facilities, and long-term care homes for the frail elderly. While welfare institutions everywhere relied heavily on underpaid female workers and volunteers, Catholic nuns and priests did not have to be paid salaries, allowing them to fund supplies, equipment, and buildings.

Your point of entry into long-term care within this system was often your local parish priest. Care was intimate and relational, with someone who knew your family and community deciding where to refer you. He assessed your family’s circumstances, moral reputation, and community ties before petitioning a Mother Superior for assistance. Admission to a hospital, orphanage, or hospice was an act of charity and grace, rather than a right that could be upheld by civil law. Patients became dependents of the Church, supervised by religious orders whose mandate combined spiritual guidance with custodial care.

For English-speaking Protestants, seeking care meant entering a French Catholic world. Because every hospital, hospice, and orphanage was run inside convent walls by Quebecois nuns, receiving care without absorbing the faith and language was an impossibility. Treatment sometimes required formal conversion. Even when it did not, placing a disabled child in long-term care meant accepting that they would be raised as a French-Catholic ward of the Church. In response, Montreal’s wealthy English‑Protestant merchant class built a parallel network of voluntary institutions (such as the Montreal General Hospital established in 1821) funded through private philanthropy. Poor Protestants relied entirely on these voluntary charities; communities without affluent benefactors had few options.

Long before a family ever reached the doors of a convent-run institution, they had to navigate a local safety net controlled by their parish priest and supported by lay Catholic organizations. In 19th-century Quebec, these groups formed an informal triage system. The parish priest acted as the primary gatekeeper. If a family hit a crisis, the priest would typically dispatch a lay organization to conduct home visits. If the lay volunteers could stabilize the household, the family stayed at home. But if home aid was not enough, the priest and lay leaders would arrange a formal referral to a hospice or asylum run by a religious order.

The Société de Saint-Vincent-de-Paul, established in Quebec in 1846, provided extensive local relief, home visits, and financial assistance to the elderly and people with disabilities. They also provided support to the poor and the larger community during hard times. Unlike the female religious orders that dominated institutional care, the SSVP was an exclusively male, middle- and upper-class lay fraternity. The home visit served a dual purpose: material assistance and moral regulation. Lay visitors evaluated hygiene, marital status, temperance, and church attendance. A family deemed “undeserving” or morally delinquent risked having their relief cut off or conditionalized on behavioral changes.

While male organizations like the Société de Saint-Vincent-de-Paul focused heavily on moral surveillance and distributing fuel or small cash stipends to working-class men, the Dames de la Charité developed a far more expansive and hands‑on model of social care. Founded in 1827, the Association des Dames de la Charité brought together wives and daughters of wealthy merchants, seigneurial families, and prominent political figures who dedicated themselves to home nursing, emergency shelter, orphan protection, and fundraising for major urban institutions.

Because they operated as a lay association rather than a formal religious order, the Dames had unusual flexibility. They raised money not through state grants but through large public bazaars, charity lotteries, and subscription drives among affluent Montreal households. Their fundraising capacity allowed them to purchase land, sit on early boards of directors, and finance the construction of hospices, orphanages, and other foundational welfare institutions. During the cholera epidemics of 1832 and 1834, this independence enabled them to rapidly establish temporary orphanages and crisis shelters that the Church itself could not mobilize as quickly.

Although not officially part of the Catholic Church, the Dames worked in close partnership with clergy and religious orders. When the Dames established an asylum for elderly, infirm women yet found they could not provide adequate volunteer staffing, some members took holy vows, becoming the Sisters of Providence. This transition from lay initiative to consecrated order reflected a common pattern in 19th-century Quebec, where successful projects were frequently absorbed into the formal Church hierarchy to secure long-term operational stability.

As industrialization accelerated in Montreal and Quebec City in the late 19th century, urban workers created their own self-funded safety nets to protect against sickness, workplace injury, and death without relying on clerical charity. French-Canadian Catholic workers established Mutual Benefit Societies organized along trade, parish, or ethnic lines.

Members paid an initial entry fee alongside monthly dues into a centralized treasury. In exchange, the society provided sick pay (a daily wage replacement during temporary illness), covered funeral costs, and disbursed lump-sum death benefits to widows and orphans. Members visited sick or injured brethren to deliver benefits and verify claims, serving a dual role of peer support and fraud prevention. To remain solvent, societies enforced strict administrative rules: members were subject to fines or expulsion for missed dues, and claims required medical verification.

While explicitly Catholic in identity, these societies were lay-governed and financially independent of the clergy. Catholic bishops routinely attempted to assert control over their constitutions and treasuries to enforce ultramontanism (a conservative doctrine emphasizing absolute papal and clerical authority over civil society) hoping to ensure strict moral discipline and prevent these independent worker funds from evolving into secular trade unions.

Outside the French-Catholic majority, non-Catholic and immigrant workers relied on parallel relief networks, including the Irish Protestant Benevolent Society, Scottish national societies, and secular fraternal lodges. Both networks solved the exact same industrial problem: providing cash safety nets during sickness, injury, or death in an era without state welfare. National societies were explicitly designed to handle the arrival of new immigrants, including emergency repatriation. While these groups appointed Protestant chaplains for ceremonial duties, they operated under parliamentary procedure, democratic voting, and lay board governance, free from ecclesiastical control or episcopal vetoes. Because the Anglo-Protestant merchant class controlled much of Montreal’s banking, shipping, and manufacturing wealth, Protestant and ethnic national societies were often backed by wealthy patrons and endowment funds. They frequently funded or maintained dedicated beds in parallel private institutions, such as the Montreal General Hospital or Protestant orphanages.

For elders with savings or a cash annuity, a different path existed: boarding as a paying guest (pensionnaire) in a religious community. These were not the same orders that operated charity hospices. Paying boarders lived in convents or monasteries that specialized in education, contemplation, or genteel residence—places designed for quiet living rather than nursing care. To board at one of these institutions, you needed assets to pay recurring fees. In practice, this made pensionnaire life the closest analogue to modern assisted living: a private room, predictable meals, and a measure of independence within a religious household. If a wealthy boarder’s health deteriorated to the point where they required constant physical nursing, the convent would typically require the family to hire private nurses or move the individual to a dedicated hospice.

In rural Quebec, eldercare typically relied on a formal civil arrangement rooted in French customary law: the donation entre vifs. This was a legal contract. An aging parent transferred title of the family farm to an heir in exchange for a contractually required life annuity—typically specifying exact quantities of food, housing, firewood, pocket money, and transportation to church. If the heir defaulted on these obligations, the parent could sue in civil court to rescind the property transfer. For rural families, this contract functioned as a private, enforceable care plan: a way to guarantee daily support long before modern social programs existed.

Urban elders, especially workers without land, had no such tool. Without property to trade for guaranteed care, aging meant entering a Catholic hospice run by religious orders such as the Grey Nuns or the Little Sisters of the Poor. These institutions were communal and strictly regimented, characterized by fixed schedules, gender segregation, and mandatory daily religious observance. Charity care required living entirely within the monastic rhythms of the order—an arrangement that prioritized custodial stability over personal autonomy.

In 19th-century Quebec, the primary, expected unit of care was always the family. Children were sent to institutions primarily when a family’s capacity to care for them completely broke down. Children with intellectual or physical disabilities were integrated into the household and local farm or workshop labor as much as possible. Families cared for severely disabled children at home, often keeping them hidden within the household due to social stigma, lack of mobility, or to protect the child. Institutionalization required either private fees or a priest’s petition for an indigent bed.

Families often sent children who were deaf, blind, or physically disabled to specialized schools (like those run by the Grey Nuns or the Clerics of Saint Viator) on a temporary basis. They lived there to learn a trade (like shoemaking, sewing, or bookbinding) so they could return home as economically contributing adults. A stay could be anywhere from 3 to 10 years depending on the student’s age at entry, academic ability, and trade. The students’ daily work in the school’s shops produced goods sold to the public and there were continual fundraising projects. Since these were charitable institutions, fees were based on what the Church felt the family could afford to pay.

If a child had severe intellectual disabilities or violent behavioral breakdowns that physically endangered the family, they were committed to large custodial facilities. They were placed in large, centralized institutions such as Saint‑Jean‑de‑Dieu in Montreal, operated by orders like the Sisters of Providence. These facilities housed thousands of residents and provided basic custodial care. Staffing shortages and overcrowding were chronic, reflecting both limited public funding and the sheer scale of need. Large facilities were perpetually overcrowded not because every disabled child was sent there, but because those who were admitted rarely left, combined with rapid 19th-century population growth and urban poverty in cities like Montreal.

The Insane Asylum Acts of 1873, 1885, and 1890 established the rules for mental health treatment that lasted until the Quiet Revolution. Previously, Quebec used a system called “farming-out,” where the government paid a fixed per-patient fee to private owners (like doctors at the Beauport Asylum) or Catholic orders (like the Sisters of Providence) to board the mentally ill. If the institution spent less on food, clothing, heating, staff, and medical supplies than the state paid them per head, the owners or order kept the difference as profit or institutional revenue. There was essentially no state oversight and reports exposed severe overcrowding, patient abuse, dirty conditions, and heavy use of physical restraints. Farming-out was primarily handled through private lay physicians and by the early 1870s the cost of paying private doctors was straining the provincial budget.

The year 1873 was the pivotal moment when Quebec’s state government officially institutionalized and expanded the farming-out model, shifting it from a small-scale arrangement with private doctors to a massive, long-term partnership with Catholic religious orders. The Province of Quebec signed a landmark 20-year contract with the Sisters of Providence to construct and operate the Saint-Jean-de-Dieu Asylum in Longue-Pointe (near Montreal). This was the first time the government handed over the complete, long-term construction, administration, and daily care of a mega-asylum to a religious congregation rather than private physicians. Because nuns did not receive individual salaries, the Sisters of Providence agreed to accept a significantly lower per-patient fee than private lay doctors. This made the religious farming-out model irresistible to the provincial government. Saint-Jean-de-Dieu quickly grew into the largest mental health facility in Canada, housing thousands of patients under monastic rule.

The 1873 regulatory framework formalized the role of itinerant government inspectors under the Bureau of Inspectors of Prisons and Asylums. Inspectors were empowered to make periodic visits to evaluate hygiene, mortality rates, food quality, overcrowding, and the use of physical restraints. The 1873 rules gave inspectors the power to report on abuses, but no real enforcement power over the nuns or owners. The religious orders retained operational independence. Because funding was tied directly to patient counts, the 1873 system created a financial incentive to take in as many individuals as possible, especially since the Church took on debt to build institutions. This resulted in the asylum taking in people who were not “insane” in a clinical sense.

The conflict over 19th-century Quebec asylums was fundamentally a clash of eras: Catholic religious orders operated under a centuries-old tradition of holistic, moral charity, viewing the asylum as a sanctuary to provide shelter, prayer, and structured agricultural work for society’s most vulnerable. What the emerging medical establishment labeled as fraudulent admissions and unscientific care was the Church following a thousand years of tradition. The 1873 Act treated “insanity” primarily as a social and legal status rather than a specific psychiatric diagnosis. Because the law lacked clinical boundaries, “insanity” continued to legitimately function as a catch-all term for anyone considered socially unmanageable or dependent—including those with severe dementia, developmental disabilities, epilepsy, or simply individuals suffering from extreme poverty and homelessness.

The 1873 Act did not instruct the religious orders or asylum owners to provide active, scientific medical “cures.” Instead, the legal contract framed the asylum’s obligation around custodial maintenance: housing, food, clothing, hygiene, and supervision. The nuns were continuing to carry out a custodial model of spiritual care against early psychiatric “cures” like ice baths, bloodletting, blistering, and chemical sedatives, which we do not remember today as great advances in medicine, to put it politely. However, we also don’t look back fondly to massively overcrowded, unheated wards where people were often physically restrained due to understaffing. The province could not object to the labeling and lack of treatment because they did not violate the contract.

The state passed the 1885 and 1890 Acts to force a doctor-first model onto institutions. The Act of 1885 legally established a mandatory Medical Board inside each asylum, consisting of a medical superintendent (appointed and paid by the state), a house physician, and an assistant physician. This board was given statutory power over admissions, discharges, classification of patients, treatments, and physical restraints. Crucially, the 1885 law stated that the owners, nuns, and asylum staff were legally bound to execute the orders of the House Physician.

The 1885 Act defined who qualified for public funding. It stated that state and municipal funding applied only to indigent “insane” persons and “idiots or imbecile persons” who were dangerous, a source of scandal, subject to epileptic fits, or afflicted with monstrous deformity, and unable to pay for private care. Because the state was still dependent on the nuns to own the buildings and provide cheap labor, the government often had to compromise, meaning the “doctor-first model” took decades to truly dominate daily asylum life.

The 1890 legislation split asylum costs for indigent patients between the province and their home municipality. To dodge these fees, local councils routinely fought over where patients legally “belonged.”

While asylums had to admit patients immediately, these municipal disputes trapped residents long-term. Religious orders hesitated to discharge recovered patients whose financial responsibility was contested, fearing unpaid bills. If forced to pay, municipalities could sue family members to recover the funds, turning temporary respite or a temporary illness into lengthy, legally complicated detentions.

It’s bitterly ironic that Quebec originally paid doctors to treat and care for the insane. However, that was too expensive, so they signed a long-term contract with the Catholic Church to do it for less money. Only they then decided they didn’t like how the Catholic Church had been providing care for the past thousand years, so they changed the terms of the contract by passing new laws. This allowed them to use the cheap labor of nuns to carry out the treatment of the doctors. The nuns were left holding the bag: bound by long-term construction debts, forced to run massive facilities on shoestring per-diem rates, and now legally required to submit to state-paid physicians who challenged their traditional authority under their own roof.

Just as the state used religious institutions to house the mentally ill on the cheap, it relied on the exact same ecclesiastical infrastructure to handle the victims of Quebec’s rapid industrialization. Before 1909, a worker injured in a Montreal factory had no automatic right to compensation. To receive support, he had to sue his employer and prove sole negligence; a costly and often impossible task. Without family support, injured workers entered Church‑run poorhouses such as the Hôpital‑Général, where they performed basic labor in exchange for care.

Quebec’s 1909 Workmen’s Compensation Act introduced the principle of “professional risk”: accidents were treated as an inherent cost of doing business, eliminating the requirement for workers to prove employer negligence in court. Disabled workers typically received a percentage of their earnings (usually capped at 50% of their average wage) for the duration of their temporary or permanent incapacity. Employers were required to cover basic medical treatment, hospital care, and funeral expenses if an accident was fatal. If a worker was killed on the job, their widow and dependent children received a scaled annuity or lump-sum payout to prevent total financial ruin. The 1909 Act covered cash indemnities, but it did not provide state-run medical rehabilitation, job retraining, or long-term care facilities. That meant injured workers still had to rely on Catholic religious orders for physical convalescence, prosthetics, and daily assistance.

Things really began to change with the 1921 Public Charities Act. It was a watershed law that opened public funding to non-Catholic institutions and forced religious charities to accept state audits, marking the first real crack in the Church’s monopoly over health and social care.

Maternal feminism and Catholic maternalism

As health and social care shifted from unregulated religious charity to formal public policy, women claimed authority in this new system through maternal feminism and Catholic maternalism. Emerging in the late 19th and early 20th centuries across Canada, the US, and Britain, first-wave maternal feminists asserted that women possessed unique moral and nurturing qualities rooted in motherhood. Unlike classic liberal feminism—which fought for equal rights based on human sameness—maternal feminism framed political action as “public housekeeping.” To gain public authority, maternal feminists inverted the Victorian belief in “separate spheres” that confined women to the home and men to politics. They argued that rapid industrialization had turned the state into a dirty, chaotic household in desperate need of “state mothers” to manage public health, child care, and social support.

Maternal feminism served as the administrative engine for an interconnected cluster of reforms between 1880 and 1920. Activists argued that managing urban health proved women deserved suffrage, while their alignment with the Social Gospel reframed poverty from an individual moral failing to a structural issue. Through organizations like the Woman’s Christian Temperance Union (WCTU), women attacked the legal mechanics of coverture. Citing God’s command to protect children and elderly parents, they fought for independent legal personhood—the right to own property, retain paychecks, sign contracts, sue abusive husbands, and hold equal legal guardianship over their children. In doing so, they sought to transform marriage from legal ownership into an equal, “companionate” partnership.

The primary practical expression of this ideology was the creation of state-funded public health networks, most notably district nursing. In Canada, organizations like the Victorian Order of Nurses (VON), founded in 1897, alongside municipal boards of health, deployed professional female nurses directly into rural communities, urban slums, and immigrant neighborhoods. In the US, this work was carried out by Visiting Nurse Associations (VNAs) and settlement houses. On the Canadian Prairies, where doctors were scarce and sparse settlement made traditional hospitals impractical, outpost nurses provided essential care, supported by groups like the United Farm Women of Alberta, who lobbied local governments to fund municipal nurses and small community union hospitals focused on maternity and child care.

This operational blueprint—trained, uniformed women riding streetcars or bicycles into impoverished homes—directly mirrored the day-to-day mechanics depicted in the TV series Call the Midwife. However, while Call the Midwife reflects post-WWII London under the National Health Service, North American municipal nursing peaked earlier, between the 1890s and 1930s, operating without a unified national health apparatus and carrying a far more rigid, moralizing, and assimilationist edge.

In the 19th and early 20th centuries, families struggled to keep frail elders and disabled relatives at home, where a single chronic illness could push an entire household into financial ruin. Municipal nurses acted as informal case managers, bringing free dressings, mobility aids, and hygiene instruction to reduce the physical strain on family caregivers and prevent family breakdown. Municipalities also began using district nurses as de facto gatekeepers for chronically overcrowded poorhouses and Houses of Refuge. When an impoverished family applied for municipal relief, a nurse was dispatched to assess the home; if she determined the person could be safely managed at home, poorhouse entry was denied—saving tax dollars while keeping the individual in their community. If you have ever had a case manager decide whether your parent is “safe at home,” you have met this model.

State-funded hospitals and asylums explicitly refused “incurable” or “chronic” cases (paralyzed patients, stroke survivors, advanced dementia) to reserve beds for acute, curable patients. Municipal nursing networks created a vital buffer for this demographic, offering a middle ground between hospital rejection and poorhouse incarceration. This network operated as a crucial transitional bridge in welfare history, shifting public administration away from 19th-century punitive relief (poorhouses, pauper auctions, jails) and toward professionalized social work and preventive healthcare. Before municipal nursing, urban infant mortality reached 150 to 200 deaths per 1,000 live births, physicians were a costly luxury, and hospitals were places for the destitute to die. Municipal nursing offered a life-saving alternative by delivering free medical attention, clean dressings, safe milk, infant monitoring, tuberculosis management, school health inspections, and scientific hygiene instruction.

Yet, this support came at the price of conditional care and social surveillance, as the district nurse functioned simultaneously as a savior and an inspector whose unannounced visits brought intrusive scrutiny, blunt judgments of cultural diets, and the constant threat of child welfare intervention or institutional commitment. Led predominantly by middle- and upper-class Anglo-Protestant women, the movement weaponized municipal nursing as a tool of “Canadianization” or “Americanization” to enforce Anglo-Protestant standards of domesticity and morality on working-class and non-Anglo immigrant families. To elevate the professional status of trained nurses and secure alliances with male physicians, maternal feminists actively delegitimized traditional midwives (particularly Indigenous, Francophone, and immigrant midwives), framing them as unscientific and dangerous. Obsessed with “improving the human stock,” some prominent maternal feminists became vocal advocates for eugenics, mandatory sterilization laws, and the racial exclusion of non-white immigrants.

As a named ideology and administrative strategy, maternal feminism was distinctly Anglo-Protestant, deeply shaped by the Social Gospel and anxieties over immigration. Lacking a tradition of consecrated, celibate women, Protestant laywomen used the “public housekeeping” argument to legitimize their entry into civic governance, utilizing settlement houses to embed themselves in poor neighborhoods for social uplift. Where the Victorian Anglo-Protestant model focused on order, cost containment, classification, and municipal law, maternal feminism was the historical bridge that took the direct care of the religious tradition and fused it with the state funding and professionalization of the municipal tradition, laying the foundation for the modern welfare state.

Catholic society achieved similar institutional outcomes through Catholic maternalism. While lay Catholic groups like Quebec’s Fédération nationale Saint-Jean-Baptiste eventually emerged in the early 20th century to advocate for child protection and social reform, they explicitly distanced themselves from the term “feminist,” which the Church hierarchy viewed with deep suspicion. Instead, they argued that a mother’s duty naturally extended into la maternité sociale—caring for orphans, improving public hygiene, educating young girls, and fighting poverty. They framed their demands for higher education, civil rights, and legal reform as ways to make women better Christian mothers. In trying to be “good Catholic mothers,” they unintentionally built the administrative skills, political networks, and institutional cracks that helped dismantle the Church’s total monopoly over social life during the Quiet Revolution.

This Catholic care framework also drew on deeper historical and grassroots traditions. Long before Victorian nursing, the Beguines were lay Catholic women in Northern Europe who lived in semi-communal houses from the 12th into the 20th century. They took temporary vows of chastity and simplicity without joining a cloistered order or giving up personal property, financing themselves through work and devoting their lives to nursing the sick, caring for the elderly, burying the dead, and feeding the destitute. The Beguines proved that women could build an autonomous, community-based care network outside both the traditional patriarchal family and strict church enclosure, despite periodic ecclesiastical backlash.1

Ultimately, maternal feminists were the first in the Anglo-Protestant world to establish that caregiving was a public responsibility rather than a private family burden, embedding prototypes like district nursing, home visits, and health units into the modern state. Yet, their great administrative “innovation” was effectively a “secular” re-invention of the Beguine and Catholic lay orders—taking the direct, community-based care long practiced by uncloistered religious women and codifying it into state policy. In response, Catholic lay orders were forced to adapt and professionalize to maintain their footing alongside these new municipal nurses. Through this cross-pollination of secular “public housekeeping” and religious duty, the district nurse and charity worker transformed into the modern social worker—fusing the direct care of spiritual tradition with the state-backed authority of the welfare state.

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This visual transformation captured a profound intellectual shift reshaping the Western world: the transition from a traditional social order rooted in localized, personal obligations of Christian charity to a modern, secular infrastructure focused on economic utility, state discipline, and the bureaucratization of poverty. To the Romantics—including Pugin, John Ruskin, and Thomas Carlyle—the modern state’s mechanism for managing social welfare was a cold, spiritually bankrupt apparatus that criminalized destitution to satisfy the demands of industrial capitalism. Simultaneously, the emerging European medical and political consensus began treating architecture itself as an active tool of spatial discipline and clinical treatment. This trend manifested in British workhouses and the architectural layouts used to manage the vulnerable and mentally ill in Belgium and France.

However, when this British Romantic critique traveled across the Atlantic to the newly unified Province of Canada in 1840, its ideological function fractured along religious and linguistic fault lines. In pre-Confederation British North America, architectural styles and welfare philosophies were not simple colonial reproductions; they were active tools of geopolitical alignment and domestic survival. While the Anglo-Protestant elite in Upper Canada (today’s Ontario) deployed Anglo-Gothic paternalism and municipal Houses of Industry to enforce British monarchical loyalty and discipline the frontier, the French-Catholic majority in Lower Canada (today’s Quebec) deliberately rejected the Gothic style (viewing it as an instrument of British assimilation) and instead weaponized Roman Neo-Baroque architecture to assert their own autonomous, church-run social welfare grid under British colonial rule.

The Back-Door Revolution

When my grandparents eloped in 1940s New Jersey, it was a crisis. She was Catholic and he was Protestant. The divide triggered an estrangement, pushing my grandfather to relocate to Pennsylvania for work. Hearing this story as a kid, I didn’t understand why anyone would care. We tend to think of religion, law, and identity as separate things. For centuries they were intertwined, and the echoes of this system remained well into the mid-twentieth century.

Only a few decades before their wedding, the parish you belonged to was the core of your civic identity and the center of your social life. When my grandfather opened an appliance store in the 1950s, he became active in clubs—the Kiwanis, the Rotary—engineering a new social and commercial network. Civic clubs were the infrastructure of the rising merchant class, even if the parish still ruled your social life.

By the time my dad was born 15 years later, relationships with both families had been restored. My father was raised Catholic until the death of his mother. After my grandmother’s death, my grandfather returned to his Protestant roots. However, when he won a trip to Rome (a reward for the success of his appliance store) he took my young father for a “private audience” with the Pope and brought back rosary beads blessed by the Pope for his Catholic mother-in-law.

My father’s Catholic family would spend their summers in Ocean Grove, New Jersey—yes, the town founded as a Methodist camp meeting ground—staying with my grandfather’s Protestant relatives. Yet, this summer ecumenism hit a wall the moment it seemed like more Protestants would join the family.

When my aunt decided to marry one of my grandfather’s appliance store employees—a Protestant—it was too much. Her parents refused to attend the wedding. He issued an ultimatum: “If you walk out that door and marry that man, you’ll never walk back in again!”

My aunt’s legendary response—”That’s fine, I’ll just use the back door”—captures the moment the rigid machinery of religious conformity fell apart. She refused to be disowned, the family dynamics quickly normalized, and the sheer pragmatism of mid-century life bypassed the dogmas of the past.

Her ability to simply walk through that back door and step into a legally unquestioned marriage was the result of a century-long, legalistic tug-of-war. New Jersey, Ontario, and Québec each moved from church‑based recordkeeping to state‑run civil registration, but they did so on radically different timelines that reveal their underlying political cultures.

New Jersey made its first attempt in 1848, shifting legal responsibility for births, marriages, and deaths from churches to municipal and county clerks, though real compliance only arrived with standardized, mandatory reporting in 1903. Ontario moved earlier and more decisively: in 1869 it created one of North America’s first modern, province‑wide civil registration systems, achieving reliable, bureaucratic coverage by the late 19th century. Québec, by contrast, retained Catholic parish control over vital records far longer than either jurisdiction; the Church’s registers remained the authoritative legal documents until 1926, and even then civil registration was partial and subordinate to ecclesiastical authority. While the 1968-1975 period of the Quiet Revolution stripped the Catholic Church of its monopoly over education, health, and welfare, the transition of the secular civil status system was not complete until 1994. That was when the province created the centralized Directeur de l’état civil and officially stripped religious institutions of their primary record-keeping duties.

To understand why these transitions required such a prolonged bureaucratic effort—and why, throughout the 1800s, religious affiliation remained the absolute legal foundation of your civil existence—one must realize that before these state registries were fully established, there was no secular civil infrastructure capable of tracking human life. If you needed to prove who you were, who your parents were, or whether you had a right to inherit land, you turned to the parish. Baptismal records functioned as birth certificates, and congregational registers served as the only authoritative record of family structure. Courts required proof of identity and standing. If you’ve ever had to get the government to accept a secondary document, you can imagine what it was like to lack a record of your baptism. Without a baptism certificate you might not be allowed to bring a case, you might not be allowed to testify, and your contracts could be considered unenforceable. In some jurisdictions, especially Anglican ones, only baptized Christians had full legal standing.

Even in the newly formed United States, which constitutionally eschewed a national church, comprehensive state-run civil registries for births and deaths did not exist throughout most of the 1800s. If someone needed to prove their age to vote, inherit property, or avoid military conscription, they had to produce a baptism certificate, a sworn affidavit from a local pastor, or a physical page torn from a family Bible—documents routinely accepted by US courts as legally binding vital records.

Marriage sat at the center of this system because it was the legal hinge through which property, land, and status passed from one generation to the next. For centuries, both canon law and English common law treated mutual consent between a man and a woman as sufficient to create a valid marriage, even without a priest or ceremony. These informal unions were common but precarious: if a spouse died or denied the marriage, the surviving partner had to prove its existence before ecclesiastical courts.

As early modern states consolidated power, they needed more dependable ways to police inheritance and legitimacy, but they lacked civil registrars, standardized bureaucracies, and officials embedded in every village. The Church, by contrast, already operated a continent‑wide legal system with trained courts and reliable parish registers. So when the Council of Trent banned clandestine marriages in 1563 and required weddings to be performed before a parish priest and witnesses, secular governments didn’t try to replace ecclesiastical authority — they relied on it. Only the Church had the administrative machinery capable of recording marriages consistently enough to keep property ownership clear.

England followed the same logic in Protestant form. Lord Hardwicke’s Marriage Act of 1753 declared that, with narrow exceptions for Quakers and Jews, only marriages performed in an Anglican church by an Anglican minister were legally valid. This transformed religious nonconformity into a serious legal hazard. If you were a Catholic, Baptist, or Methodist who married within your own tradition, the British state treated your union as nonexistent and your children as illegitimate.

Illegitimacy carried sweeping civil disabilities that touched every part of a person’s legal and social life. An illegitimate child had no automatic right to inherit land, and in many jurisdictions a father could not even leave real estate to an illegitimate child in his will. Because the law did not recognize a legal father, he could not act as guardian, and courts treated the child as under the sole authority of the mother’s parish—an arrangement that shaped custody, apprenticeship, and settlement rights. If a marriage was ruled invalid after a husband’s death, his partner was not legally a widow and lost her dower right, allowing relatives or the state to seize the home and evict the family.

Illegitimacy also blocked access to skilled trades and civic roles: people born outside wedlock could be barred from apprenticeships, guild membership, municipal offices, jury service, and even acting as executors or trustees, all positions that required “good fame.” Marriage itself became harder; illegitimate individuals often needed special permission, extra witnesses, and proof they would not become a burden on the parish, and some communities discouraged unions between two illegitimate people to avoid creating “pauper families.” In poor‑law systems, they were more vulnerable to being classified as vagrants and less likely to receive relief. Courts treated illegitimate people as less trustworthy and more morally suspect, which damaged their credibility as witnesses and could influence sentencing. By monopolizing the registration of valid marriages, religious institutions—and the states that relied on them—effectively controlled who could inherit, who could work, and who could claim full membership in the community.

The Parish State and the Great Chain of Being

To understand why the church parish originally became the baseline unit of government survival, we have to look back at its deep historical scale. Across Western Europe and England, the parish functioned as the primary unit of local governance for centuries, defining a geographic jurisdiction where the church vestry or parish council handled daily civic administration: maintaining roads, appointing constables (who was responsible for arrests, warrants, and enforcing poor‑law rules), collecting poor rates, and distributing welfare.

To be in good standing with the parish vestry or churchwardens was a public certification of your character, allowing merchants, builders, and tradespeople to secure credit, sign leases, and form partnerships. Crucial to this far-reaching trust was Latin. During the medieval period, its use as the immutable, universal language of law, contract, and notary systems bypassed local dialects to bridge fragmented European states. While this medieval foundation later transitioned into early modern vernacular merchant law and credit instruments written in Italian, French, or English, Latin established the initial transnational legal infrastructure that made globalized commerce possible.

The Church’s civic authority rested on its immense land wealth. Historians estimate that in late medieval Europe, the Catholic Church owned roughly 20% to 30% of all arable land—and in some regions, like parts of Germany and England, that proportion was even higher. Monastic corporations were not quiet houses of prayer; they were major agrarian enterprises managing vineyards, mills, mines, and entire peasant villages. This economic base was reinforced by the tithe (a compulsory tax on agricultural output that funded both religious and civic functions). The Church also controlled the West’s information grid. Before the printing press, literacy was almost entirely confined to clerics, who monopolized access to Latin. Monastic networks provided the safest and most reliable long-distance communication routes, functioning as the default postal system in a fragmented world.

This institutional footprint shaped everyday life. Church bells served as the public clock in a world without personal timepieces, regulating labor, markets, and communal rhythms. The liturgical calendar structured the year, transforming holy days into legally mandated breaks from work. Religious institutions also operated the primary social safety net. Monasteries, diocesan funds, and confraternities ran Europe’s hospitals, orphanages, soup kitchens, and shelters.

This entire world suffered a massive structural shock during the Protestant Reformation. When Henry VIII initiated the English Reformation and dissolved the Catholic Monasteries between 1536 and 1541, he dismantled this primary social safety net. The closure of these institutions cut off traditional sources of relief, triggering widespread social chaos, rural displacement, and an influx of impoverished people flooding English towns. This resulted in the Elizabethan Poor Laws of 1597 and 1601, which turned the parish into the state’s frontline civil institution.

This transformation was driven by a profound shift in the cultural meaning of poverty. In Catholic theology, poverty carried a spiritual dignity. Coluntary destitution was seen as a holy mimicry of Christ and almsgiving was treated as a redemptive act of divine mercy that helped secure the donor’s salvation. The Protestant Reformers, particularly Calvinists, completely re-evaluated this framework: if God has already predestined who is saved, and a dedicated earthly “calling” is how an individual actively glorifies God, then persistent idleness is no longer a holy or tragic condition, but an outward sign of spiritual degeneracy.

This moral evolution radically altered the enforcement mechanisms of social welfare. In the traditional Catholic system, authorities carefully distinguished between the genuinely needy and the willfully idle. The idle poor were simply refused charity. The Protestant state-decreed system transformed this exclusion into a penal campaign. By centralizing relief and abolishing independent, sacred spaces of sanctuary, the state criminalized unsanctioned poverty, deploying the legal system to actively arrest, whip, brand, and confine the able-bodied underemployed inside early workhouses designed to compel labor.

This moral revolution closely dovetailed with the rise of industrial capitalism. The commercial infrastructure of late-medieval Italy and Flanders had already laid the groundwork for profit-driven enterprise. What the Protestant ethic added was a powerful psychological engine: the belief that the accumulation of wealth was righteous, but its expenditure on personal luxury or ostentatious display was sinful. Wealthy merchants were thus compelled to continually reinvest their profits rather than consume them, turning capital accumulation into a spiritual obligation. When this reinvestment impulse was paired with a domestic labor market strictly disciplined by Poor Law ideology, localized merchant capitalism was transformed into a compounding system of industrial growth.

By the early 19th century, the cost of parish‑based poor relief had exploded, especially in fast‑growing industrial towns. Reformers influenced by Benthamite utilitarianism—the belief that cities and social systems should be redesigned for maximum efficiency, minimum cost, and measurable outcomes—argued that traditional community care was too expensive and too hard to monitor.

Under this logic, the British state passed the Poor Law Amendment Act of 1834, which aimed to abolish outdoor relief—the system that let people receive support while living at home. Outdoor relief was the historical equivalent of today’s subsidized home‑care services, disability supports, and community‑based assistance: help that allowed people to remain in their own homes, surrounded by familiar routines and caregivers. The New Poor Law replaced all of that with a centralized, institutional model. Most people seeking aid were required to enter a parish‑union workhouse, and although some categories (like the sick, the elderly, orphaned children) could be routed to other institutions such as infirmaries or “poor‑law schools,” the principle was the same: no home‑based support, no community care, no relief that allowed people to stay where they lived. In Benthamite terms, this was “rational” urban governance; in human terms, it dismantled the last remnants of local, flexible, community‑rooted care.

To deter individuals from seeking relief, these new institutions were explicitly designed to be as unpleasant as possible. Families were segregated, and incoming individuals were stripped of their civilian clothes and required to wear institutional uniforms, a process contemporary critics and later social historians described as a deliberate assault on individual identity and personal dignity. Daily life within these walls was governed by grueling labor such as oakum-picking or stone-breaking.

Michel Foucault later characterized this systemic shift as a core component of the Great Confinement—a transition where the marginalized were swept out of the public square and placed into rigid, panoptic institutions designed to optimize the economic utility of the populace. While Foucault originally based his theory on the French model (where absolute royal decrees, such as the 1656 establishment of the Hôpital Général in Paris, created centralized, state-run holding facilities by administrative fiat) the English confinement was fundamentally different. Rather than top-down royal edicts, England’s confinement was a decentralized, legalistic process driven by local parishes and parliamentary legislation, culminating in the nationwide network of New Poor Law workhouses.

As the 19th century opened, medical reformers and state administrators across Western Europe embraced a new belief that architecture itself could act as a therapeutic instrument. Figures such as Jean‑Étienne Dominique Esquirol in France and Joseph Guislain in Belgium designed clinical asylums and rural agricultural colonies on the cutting‑edge assumption that a carefully engineered environment could cure illness, reshape behavior, and restore fractured minds. Their projects reflected a broader political consensus: the modern state could use specialized institutions and spatial design to manage populations more efficiently than traditional community care.

The British Romantic counter‑reaction emerged from this same recognition of architecture’s power, but turned it sharply against the state’s utilitarian ambitions. Thinkers like Augustus Welby Northmore Pugin, John Ruskin, and Thomas Carlyle argued that industrial Britain was deploying its new architectural machinery in a way that treated poverty as a moral failing and reduced people to economic units. In response, these Romantics weaponized the Gothic Revival, invoking medieval forms as a blueprint for an “organic” society grounded in reciprocal obligations, personal bonds, and faith-rooted community life. Where Esquirol and Guislain imagined architecture as a clinical tool of state management, Pugin, Ruskin, and Carlyle imagined it as a moral language capable of rebuilding social relations from the ground up.

In Contrasts (1836), Pugin used the soaring spires and communal streets of medieval towns to dramatize what he believed industrial Britain had lost. But the social world he idealized was built on rigid hierarchy, hereditary authority, and legally enforced dependence — structures that would be unacceptable today, especially to anyone whose ancestors were enslaved, landless, or excluded from civic rights. Carlyle pushed this nostalgia even further. He argued that medieval serfs, though bound to the land and denied personal freedom, enjoyed a more secure social safety net under their lords than factory workers did under industrial capitalism. Carlyle’s critique of laissez‑faire was powerful, but his admiration for feudal “protection” rested on a system that depended on coercion, inherited inequality, and the subordination of entire classes of people. By invoking medieval forms, Pugin and Carlyle sought to recover a sense of communal obligation and moral responsibility — even as the historical models they drew from were inseparable from deeply hierarchical and exclusionary social orders.

The Romantics did not just look back at medieval serfdom with idle nostalgia; they actively used these idealized feudal frameworks to make policy suggestions for the British Empire. Following the abolition of slavery in the colonies in 1834, Carlyle and his contemporaries argued that newly freed enslaved populations should not be left to the whims of free-market capitalism, which they believed would lead to economic ruin and moral decay. Instead, they proposed that the colonies should be run under rigid, paternalistic, and authoritarian hierarchies modeled on medieval feudalism, where laborers were bound to the land but guaranteed protection and sustenance by their superiors.

This Romantic narrative relied on a highly curated myth of the Middle Ages. In his polemics, Pugin conveniently whitewashed the historical realities of 1440, omitting the routine feudal litigation, the aggressive monopolies held by monastic landlords over local economies, and the rigid exclusion practiced by medieval merchant guilds. Nevertheless, the Romantic idealization of medieval charity provided a powerful language of resistance against the modern industrial state.

European empires exported this geographic parish model everywhere they settled, including the Spanish parroquia, the French seigneurial parish grid along the St. Lawrence, and the Anglican vestry system from Virginia to Jamaica. When these systems arrived across the Atlantic, they were adapted to solve local political, spiritual, and national identity crises on the frontier.

Ontario’s experience reflected this dynamic but took the form of a prolonged political struggle against an imposed Anglican monopoly. The Marriage Act of 1793 granted the Church of England exclusive authority over legally binding marriages, allowing Justices of the Peace to officiate only when couples lived far from an Anglican minister. Roman Catholics gained the right to marry within their own faith and keep registers in 1798, and that same act extended limited marriage and record‑keeping rights to Presbyterians, Lutherans, and Calvinists who passed loyalty tests and met strict membership rules.

But rapidly growing denominations like Methodists and Baptists were branded “unauthorized sects.” Their marriages were legally void and their children technically illegitimate. Political pressure mounted until 1831, when the colonial assembly finally opened marriage rights to Methodists, Baptists, Congregationalists, Mennonites, Tunkers, and Moravians. As Ontario moved toward a more democratic model, the government abandoned the practice of naming specific approved sects. The Marriage Act of 1847 granted universal access to all Christian denominations, and in 1857 the province extended the right to solemnize marriages to Jewish rabbis. Over time, Ontario transformed marriage registration from a tool of British elite control into an inclusive framework that reflected its changing religious landscape.

In colonial America, the Anglican vestry in the South and the Congregational parish in New England operated as the literal municipal governments, levying tax rates, managing roads, and supervising the local constable. Even after the American Revolution forced the legal disestablishment of these churches, the geographical boundaries of these parishes became the borders of American counties and townships. Their moralizing welfare practices were absorbed by newly formed county commissions, leaving the structural logic of the parish intact under secular labels.

This civic ordering was mapped directly onto the Ontario landscape via the built environment. High-church Anglican networks and British missionary societies aggressively promoted the Gothic Revival style, viewing the installation of a proper stone parish church as a critical civilizing mission. In the eyes of colonial administrators, planting a structured, geometrically ordered Gothic church in the Canadian bush was an act of moral anchoring, introducing traditional British hierarchies to stave off the existential threats of radical secularism and American democratic individualism. Where capital and skilled stone masons were scarce on the frontier, settlers dynamically adapted this ordering impulse into wood. This gave rise to “Carpenter Gothic,” a vernacular architectural translation that used local timber to erect pointed arches, steep gables, and board-and-batten siding, embedding visual reminders of traditional British communal structure directly into the rural landscape.

Yet, despite the deliberate absence of a formal poor law, the socioeconomic volatility of the 1830s and 1840s—compounded by massive waves of impoverished Irish immigration—pushed Upper Canada to abandon its reliance on unorganized private charity. Immigration policy was controlled in London, not Toronto. As part of Britain’s imperial strategy, the colonies were expected to absorb migrants, strengthen settlement, and relieve demographic pressure in the British Isles. Local officials had no authority to regulate entry; they were responsible only for managing the consequences. The resulting crisis was the result of a structural mismatch between British imperial goals and Upper Canadian administrative capacity, combined with the catastrophic poverty produced by famine, disease, and discriminatory land policies in Ireland.

To manage this emergency, Upper Canada turned to a distinct variation of the very institutional confinement its domestic Romantics despised: the municipal House of Industry. Beginning with the House of Industry Act of 1837 and the subsequent establishment of facilities in Toronto (1837), Kingston (1850), and Waterloo County (1869), the colony began constructing its own network of poorhouses.

The Toronto House of Industry was originally envisioned by reform‑minded citizens as a humane alternative to the notoriously cruel British workhouses. But the sheer volume of destitute newcomers (many sick and malnourished) combined with entrenched frontier poverty, quickly overwhelmed its charitable foundations. Within a few years, the institution devolved into the same mechanism of moral surveillance and penal‑style labor it had been designed to avoid.

These state‑subsidized municipal poorhouses primarily served the “deserving poor”—the aged, infirm, widows, and orphans—but still imposed a labor requirement. For the able‑bodied, this meant physically demanding tasks such as stone‑breaking or wood‑chopping. For others, the work was often symbolic or light, but the principle was universal: labor functioned as a moral test and a deterrent, not as a realistic expectation of productivity. Entry was tightly restricted, and those admitted were subjected to strict segregation, moral scrutiny, and uniform regulations. While poorhouse residents were called “inmates,” the term at the time simply referred to anyone living in a shared dwelling, though its 19th-century use was increasingly narrowing to denote the occupants of large public or charitable institutions.

What began as a benevolent civic experiment hardened into an apparatus of behavioral correction, shaped less by compassion than by the pressures of imperial migration policy, local fiscal limits, and the era’s deep suspicion of poverty. Able‑bodied poverty, however, was more often treated as a criminal matter. Those deemed “idle” or “vagrant” were sent to local jails, where confinement functioned as a deterrent rather than a form of relief.

Operating alongside this institutional network was a parallel system of social welfare: the explosive rise of secular, fraternal, civic, and ethnic clubs between the 1870s and 1970s. Groups such as the Independent Order of Odd Fellows (IOOF) and various Masonic lodges grew rapidly across Ontario, constructing prominent Gothic Revival halls in burgeoning urban centers. Far from being merely recreational, these highly segregated organizations operated as self-funded micro-insurance pools, offering members critical safety nets—such as healthcare, life insurance, and character-vetted credit—in an era before comprehensive government programs existed. By organizing these services through secular bylaws and democratic administration, the clubs proved that social welfare could be managed as a contract rather than as religious charity, designing the bureaucratic templates the state would later adopt.

Quebec followed a different path because the British could not afford to alienate its large French Catholic population. The Quebec Act of 1774 confirmed the Roman Catholic Church as the primary keeper of the civil registry. To accommodate the incoming British ruling class, the Protestant Registry Act of 1795 granted the Church of England and the Church of Scotland equal legal standing to maintain registers and perform marriages. Rather than waging a culture war against non‑Anglicans, Quebec’s colonial administration adopted a pragmatic strategy: when a religious group grew large enough to matter socially, the state co‑opted its leaders by recognizing them as official, unpaid civil registrars.

Between 1825 and 1830, targeted legislation extended record‑keeping and marriage authority to dissenting Protestants such as Methodists, Congregationalists, and Baptists. In 1831, Quebec passed a landmark emancipation act granting Jews full civil rights and explicitly authorizing rabbis to keep official civil‑status registers—decades ahead of much of the British Empire. Quebec built a decentralized system in which Catholics, Protestants, and Jews each operated parallel registries under the supervision of local courts.

In the early decades of the 19th century, the architectural landscape of Lower Canada reflected a degree of aesthetic fluidity. This was exemplified by the construction of Montreal’s colossal Notre-Dame Basilica in 1829, designed by the American architect James O’Donnell in an early, theatrical Gothic Revival style for a French-Catholic congregation. However, as the century progressed and the British state intensified its efforts to solidify imperial control—culminating in Lord Durham’s 1839 report, which explicitly advocated for the systemic cultural and linguistic assimilation of French Canadians—architectural style became highly politicized.

As Pugin and the British Ecclesiologists increasingly defined the rigorous, archaeologically accurate Gothic Revival as the exclusive visual language of “true Englishness” and Anglican historic legitimacy, the French-Canadian clergy underwent a profound ideological pivot. The local hierarchy began to view the Anglo-Gothic style as an aggressive visual weapon of British-Protestant cultural hegemony and colonial assimilation.

To resist this assimilative pressure, Bourget and the French-Canadian elite bypassed both London and an increasingly secular, post-Revolutionary Paris, turning to Rome for structural and spiritual inspiration. This movement, known as Ultramontanism, advocated for the supremacy of papal authority and the total rejection of modern liberal philosophy. Architecturally, Bourget issued a firm mandate across Quebec: French-Catholic institutions must reject the medieval Gothic style entirely, turning instead to the Neo-Baroque and Italian Renaissance styles modeled directly on classic monuments of Rome. By blanketing the landscape with massive, symmetrical, silver-domed churches and institutions, the French-Canadian Church visually declared its direct allegiance to the Vatican.

This architectural shift mapped onto an exceptionally powerful, autonomous, and total-institutional welfare state. While Upper Canada was cautiously building its municipal Houses of Industry, the French-Catholic Church in Quebec maintained control of the social welfare of the province, operating entirely independent of the British colonial state. Massive social safety nets (including hospitals, orphanages, and insane asylums) were established, financed, and managed by traditional Catholic religious orders. The Church wrapped these sprawling, highly centralized institutional complexes in imposing Roman classical and Neo-Baroque facades. By doing so, they utilized the authoritative visual language of the Counter-Reformation to project an image of permanence and social control.

However, this Catholic charitable grid primarily served the “deserving” poor, leaving the British colonial state to manage the “undeserving” or idle poor through the criminal justice system. Because Lower Canada lacked the municipal poorhouse network of Upper Canada, the colonial government addressed extreme destitution through strict vagrancy laws. By the mid-19th century, colonial statutes and municipal ordinances criminalized idleness and begging. Those caught sleeping on the streets were sent to provincial jails. In the 19th century, these jails were overcrowded, unsanitary lockups where people awaiting trial were confined alongside hardened felons. Once inside, vagrants and the homeless were subjected to the same penal discipline and compulsory labor (stone‑breaking, wood‑chopping, or picking oakum) as sentenced offenders. In effect, poverty itself became a carceral offense under British law.

This divided institutional grid served a dual purpose: it enforced strict moral discipline and social order among the French-Canadian population, while simultaneously functioning as a defensive shield. It provided an indispensable social infrastructure that the British colonial government could neither afford to replace nor successfully assimilate, securing French-Catholic institutional sovereignty within a British empire.

The United States presented a different structural paradox. By enshrining the separation of church and state in the First Amendment, the US constitutionally rejected a single national church monopoly. Yet, this legal disestablishment did not create a secular bureaucracy. Throughout the 1800s, the American state had almost no domestic civil administrative apparatus. Instead, states devolved civil registry and moral policing to local county clerks and a decentralized patchwork of Protestant denominations.

To accommodate a vast, rapidly expanding frontier where ordained clergy were scarce, American courts retained the English common-law tradition of informal, non-ceremonial marriage, despite England abolishing it in 1753. This legal flexibility allowed couples to establish recognized unions through mutual consent and cohabitation alone, bypassing the church entirely. However, as cities grew and industrial capital consolidated, the state clawed back this autonomy. Local governments began requiring formal licenses issued by county clerks, but they structurally relied on local Protestant clergy as their de facto enforcement officers to solemnize the contracts. Those outside the mainstream (Catholics, Mormons, and free Black populations) faced severe administrative discrimination, as local clerks and judges routinely weaponized licensing and zoning laws to enforce racial and religious hierarchies under the guise of public morality.

The Great Sorting: How Science Expelled the Incurable

To understand how this mid-19th-century struggle evolved into the modern care systems we recognize today, we have to look at the pre-modern hospital. For most of human history, hospitals and doctors had nothing to do with each other. Etymologically and historically, hospital, hospice, hostel, and hotel all share the exact same linguistic root: the Latin word hospes, which means both “guest” and “host.” For centuries, these terms were used interchangeably because they described the exact same social function: a place providing hospitality to travelers, strangers, and the vulnerable. In Lower Canada, this took the form of the grand Catholic convent-asylums; in Upper Canada, it was found in early, charity-funded voluntary facilities. In both cases, the hospital was a religious or charitable refuge for people with nowhere else to go.

Long before hospitals specialized in scientific treatment, they existed primarily to provide spiritual care, moral supervision, and custodial shelter. Physicians did not work in these institutions; they treated paying patients in private homes. Hospitals were reserved for the vulnerable (orphans, widows, migrant laborers, the chronically ill, and the elderly poor) people who had no family left to care for them or whose families could no longer perform this care work. Entering a hospital meant surrendering one’s daily life to a religious or civic charitable order, where care was explicitly defined in spiritual terms. Nuns and priests prayed over patients, urged confession, and interpreted illness as a sign of moral or spiritual imbalance. Residents of religious hospitals were expected to live under the discipline of the order, much like lay brothers and sisters, whether in the 13th century or the 19th.

Furthermore, these institutions controlled death itself. In the 19th century, burial was not a neutral municipal service; almost all cemeteries were owned by churches, and burial in a particular plot legally tied a person to that denomination. Because church burial registers served as the official civil record of death, being buried in the “wrong” religious cemetery had concrete consequences. The church that interred the body became the authority that certified the death, and its records were required to recognize a widow’s marital status, assign guardianship of children, settle debts, and transfer even the smallest property. For Protestant or Jewish families, a Catholic burial—or worse, burial in unconsecrated ground—meant that all legal documentation flowed through a church they did not belong to. Families had to petition an unfamiliar clergy for certificates, probate courts could question identity or kinship, municipal authorities sometimes refused to accept the burial record, and guardianship or inheritance claims could be delayed or contested.

For households already living on the edge of poverty, these bureaucratic obstacles were not symbolic affronts but material hardships that determined whether dependents were recognized, property was transferred, or basic civil claims were honored. Even for the indigent, burial in the wrong denominational cemetery carried real consequences. Municipal authorities sometimes refused to accept burial records issued by the “wrong” denomination, delaying widow’s benefits, guardianship petitions, and parish relief. Hospitals, therefore, were not merely spaces of physical care; they determined the religious identity under which a person’s death was legally recognized, shaping the spiritual, social, and legal fate of the family that survived them.

This traditional, faith-governed world collapsed in the late 19th century with the arrival of anesthesia, antiseptic surgery, and laboratory diagnostics. Medical treatment now required specialized equipment, sterile environments, and rapid intervention. Rather than resisting these changes, religious orders and voluntary boards were often highly receptive to clinical modernization, actively collaborating with licensed doctors and integrating new scientific protocols into their facilities.

However, these technical upgrades required immense capital, forcing hospitals to rely on new state funding structures that systematically shifted administrative control away from religious orders. To manage public funds and ensure safety, governments introduced per-diem funding tied to acute, curable cases and passed strict medical licensing acts. Because only state-licensed, university-trained physicians could legally certify patient admissions, verify diagnoses, and document the measurable clinical outcomes required to trigger state payments, religious administrators lacked the legal authority to manage these critical revenue streams. To remain eligible for government subsidies, voluntary boards and religious orders were required to yield control over clinical decisions and hospital policies to licensed medical boards, systematically relegating traditional religious caretakers to auxiliary roles.

This administrative realignment was solidified through a radical structural change: the state-backed professionalization and secularization of nursing. While Catholic sisters had always worked within a strict, male-dominated church hierarchy, their labor was now transferred to a secular, corporate equivalent. By converting nursing into a rigid, military-style hierarchy overseen exclusively by male physicians, the modern hospital successfully co-opted the existing female labor pool. This process stripped nursing of its traditional spiritual framework and turned it into a low-wage workforce managed by and for the financial and operational interests of the medical establishment.

This transition from religious to secular nursing shifted the baseline of a nurse’s lifelong security from a non-monetary, communal covenant to a highly volatile wage contract. While Catholic sisters subordinated their personal autonomy to a strict church hierarchy, they did so in exchange for absolute lifelong protection; the wealth of their order guaranteed them food, shelter, and medical care through sickness, old age, and death. They then continued to care for them in the afterlife. In contrast, the newly engineered secular nurse was treated as a disposable, low-cost resource. Rather than receiving a safety net, secular nurses faced intense exploitation as unpaid student laborers, and once they graduated, they were subjected to the cold realities of a capitalist labor market. Up until the late twentieth century, hospitals enforced strict “marriage bars” and immediately fired nurses the moment they became pregnant, offering no maternity leave, job security, or retirement pensions.

An almost identical structural transition occurred in teaching, social work, and clerical work, establishing a system that valued women for their perceived natural aptitude, but structurally relied on them remaining single and without dependents. The moment a female worker married or became pregnant, established policies legally required her resignation.

To finance these expensive new surgical theaters, diagnostic laboratories, and sterile wards, the hospital underwent an economic pivot away from the destitute and toward the “paying patient.” Whereas no one with financial means would have willingly stepped foot inside a pre-modern hospital, late-nineteenth-century establishments began constructing luxury private wings with hotel-like amenities.

When physicians seized administrative control of hospitals, they did more than reorganize clinical practice—they dismantled an entire social order. The religious nursing orders who had long governed these institutions possessed real authority, recognized expertise, and security within the church hierarchy; under medical rule, they were stripped of autonomy and reduced to subordinate labor. At the same time, doctors expelled the very populations hospitals had been founded to protect: the elderly, the disabled, the chronically ill, and the long‑term dependent poor. Once these “incurables” were excluded, the medical profession declared their abandonment to be a new social emergency, a problem now requiring the intervention of secular reformers and social engineers. In other words, the modern hospital first displaced its traditional caregivers, then disowned its traditional patients, and finally rebranded the void it created as a crisis of society itself.

The modern care system emerged as the definition of citizenship and healing changed. Religious membership stopped being a civic requirement, and the state took over demographic tracking through birth certificates, marriage licenses, and death certificates. Healing shifted from a spiritual rescue mission to a technical, measurable science managed by licensed physicians. Once identity became a matter of state data and survival became a matter of clinical technology, the faith-based, architecturally distinct systems of the early 1840s gave way to the bureaucratic medical machine we recognize today.

The history of the Canadas in the mid‑to‑late 19th century shows that Romantic ideas about social welfare weren’t fixed doctrines. They shifted depending on who used them and why. Pugin and other Romantic thinkers saw the Gothic Revival as a humane alternative to industrial discipline and state poorhouses. But once these ideas crossed the Atlantic, they were reshaped by local politics and the pressures of empire.

In Upper Canada, the Anglo‑Protestant elite separated Gothic architecture from its original anti‑capitalist message and turned it into a symbol of British loyalty and civic order, even as municipalities built stone‑breaking Houses of Industry to manage poverty. In Lower Canada, the French‑Catholic majority rejected this imported medievalism and built their own welfare institutions in a Roman Baroque style that expressed cultural independence from the British Crown. Both paths fed into the rise of secular, clinical systems. By the 1970s, as modern welfare programs expanded and commercial banking formalized social supports, the older parish networks and fraternal clubs lost their practical purpose and survived mainly as cultural or social organizations.

As the older, faith‑based hospes broke apart and its long‑term care functions were spun off, hospitals aligned themselves with a more utilitarian, efficiency‑driven model: focus on population health, streamline services, and treat chronic conditions as outside the hospital’s core mission. Earlier institutions (parishes, guilds, mutual‑aid societies) had also provided care for people with chronic conditions, but they did so as part of a living community. The people they supported remained connected to the same networks that governed the institution itself. When modern hospitals and state facilities replaced these community‑rooted forms of care, they created institutions that stood apart from everyday life. The result was a level of segregation and isolation that earlier models had not produced. The sense of distance people often feel in modern hospitals isn’t accidental—it reflects a system designed around clinical throughput rather than spiritual or communal meaning.

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Care in Canada did not emerge from a single tradition. Along the St. Lawrence, French colonial institutions—seigneurs, parish priests, and the Hôtel‑Dieu network—created a tightly regulated, land‑based care system that shaped rural Quebec for centuries. Far to the west, a completely different world existed: Rupert’s Land, a vast Hudson’s Bay Company territory where Métis families built their own care networks around river‑lot land, kinship, and mobility. When the British reshaped both regions, it preserved one care infrastructure, dismantled the other, and set in motion the land and legal transformations that would define how people across Canada cared for one another.

When France ceded Canada to Britain in 1763, the colony was a narrow chain of French settlements along the St. Lawrence River. Britain’s initial plan, outlined in the Royal Proclamation, was to anglicize the territory: impose English common law, suppress Catholic authority, and attract large numbers of Protestant settlers. By 1774, that plan had collapsed. Roughly 70,000 French‑speaking Catholics remained, supported by a dense network of institutions and elites, while only a few hundred British merchants had arrived. The British quickly realized that a tiny Protestant minority could not govern a deeply rooted Catholic majority, and that dismantling existing institutions would destabilize the colony.

The Quebec Act of 1774 reversed course. Britain restored French civil law, legalized the tithe, and formally recognized the Catholic clergy and the seigneurial system. This was not an ideological concession but a pragmatic one: these were the structures that held the population together. Meanwhile, the land that would become Ontario remained entirely Indigenous. The Great Lakes and Ohio Valley were governed by powerful nations—the Anishinaabek, Haudenosaunee, Huron‑Wendat, Miami, Shawnee—not by the British mapmakers who claimed them.

Rupert’s Land was a vast territory stretching across the entire Hudson Bay drainage basin—covering much of what is now Manitoba, Saskatchewan, Alberta, Nunavut, and parts of Ontario and Quebec. It came into being in 1670, when King Charles II (who ruled England, Scotland, and Ireland) granted an enormous charter to the Hudson’s Bay Company. The charter gave the company exclusive trading rights and effective governing authority over all rivers flowing into Hudson Bay. The territory was named after Prince Rupert of the Rhine, Charles II’s cousin and the HBC’s first governor.

For nearly two centuries, Rupert’s Land was not a colony like Nova Scotia and Jamaica, but a corporate jurisdiction: the Crown held ultimate sovereignty, yet the region was not administered by British civil institutions, was not settled under imperial authority, and did not belong to the colonial administrative hierarchy. Only in 1869, when Canada purchased Rupert’s Land, did this change. The Crown revoked the HBC’s governing charter, transferred sovereignty and administrative control, imposed British and Canadian legal systems, and began surveying, parceling, and settling the land. That is when Rupert’s Land was truly absorbed into the British imperial state.

A major demographic shift came only after the American Revolution, when thousands of Loyalists fled north. They settled primarily in the future Ontario and in the cities of Montreal and Quebec, creating a parallel Anglo‑Protestant world with its own legal norms, commercial networks, and institutions. From this point forward, Quebec and Ontario developed along sharply different cultural and administrative lines.

Events in Europe reinforced this divide. The French Revolution was violently anti‑clerical, abolishing feudalism and stripping the Church of its lands. Quebec’s elites framed loyalty to the British Crown as the only safeguard against the upheavals in France, persuading the rural population that political stability was necessary to preserve their language, religion, and way of life. As a result, Quebec did not join the American rebellion, nor did it have a French‑style revolution of its own.

Because Quebec became British before Napoleon’s reforms, it missed the Napoleonic Code entirely. When the colony finally modernized its laws in 1866, it relied on older French customary law blended with British commercial law, producing a civil code distinct from France’s. The Quebec Act also clarified that the region would maintain the existing seigneurial system, a medieval framework of landholding transplanted directly from feudal Europe. Under French rule, the Royal Intendant had regulated this system; under British rule, that office disappeared, and common‑law judges treated seigneurs as private landlords, intensifying pressure on rural tenants.

Why did Quebec’s rural population tolerate a system that peasants in France violently overthrew in 1789? The answer lies in material conditions and political context. Along the St. Lawrence, land was abundant and fertile, offering a standard of living far higher than that of the overcrowded French countryside. More importantly, French Canadians were a conquered minority surrounded by expanding Anglo‑Protestant settlements. Revolting against their own elites risked fracturing the fragile coalition protecting their cultural survival. Compliance, however bitter, became a strategy for preserving identity.

By guaranteeing the clergy their tithes and the seigneurs their rents, Britain created a conservative alliance that stabilized the colony and locked ordinary people into a care system they did not control. This alliance—religious, legal, and territorial—set Quebec on a trajectory distinct from Ontario, New Brunswick, and the emerging United States, and it laid the groundwork for the care institutions, land regimes, and legal frameworks that led to the 19th‑century welfare state, the Quiet Revolution, and modern healthcare systems.

The seigneurial system: land, obligation, and embedded care

For two centuries, rural Quebec operated under the seigneurial system. A seigneur was not simply a modern landlord; he was legally obligated to invest in and protect the community living on his estate. He held monopolies over essential infrastructure, especially the grain mill, but in exchange had binding duties. If someone wanted to farm, the seigneur was required to grant them a plot (a concession) at a fixed, customary rent set by the state. He could not raise rents based on market demand or evict a tenant who was farming properly. To legally evict someone, a seigneur had to prove in court that the tenant had completely abandoned the property or fundamentally breached the tenir feu et lieu obligation (the requirement to maintain a physical hearth and home on the land to help populate the colony). Many habitants and Métis families spent months away from their farms participating in the fur trade. As long as they maintained their home, kept some land cleared, and paid their annual dues (cens et rentes), the seigneur had no legal grounds to evict them.

Because his wealth depended entirely on the physical presence and labor of the habitants, he had a vested interest in keeping them alive. During crop failures, the seigneur and the parish priest routinely forgave rents, distributed stored grain, and provided basic community charity.

In modern terms, this system combined regulated housing, public infrastructure, and embedded welfare. The “rent” was predictable and legally constrained; the mill functioned like a guaranteed public utility; and the landlord was obliged to act as a crisis backstop. In practice, this meant that housing, food security, and basic crisis relief were structurally embedded in the land system itself. It was deeply unequal, but it was not yet a pure market.

Independent farmers, not commoners

Tenants in New France—known as censitaires or habitants—were not part of “the commons” in the European feudal sense. Although the seigneurial system was transplanted from France, the social and legal reality of the colony diverged sharply from medieval norms. In Europe, the commons consisted of shared pastures, forests, and fields governed by unwritten customary law. Peasants used these spaces collectively because land was scarce, tightly controlled, and embedded in a rigid hierarchy. In New France, land was abundant and labor was scarce. Each family held a clearly defined farm under a written notarial contract, and instead of working communal fields, habitants operated their own long, narrow river lots that provided access to transportation, fishing, forest, and farmland.

To see what the habitants were escaping, it helps to understand how different the European system was. In France and England, rights to the commons rested on custom, not contracts. A peasant’s ability to graze animals or gather wood depended on traditions stretching back “from time immemorial,” not on individual legal documents. If a lord enclosed the commons or changed the rules, peasants had little recourse because they lacked personal deeds to defend their rights. Even the regulation of grazing was unequal: European villages used stinting, where a manorial court decided how many animals each cottage could send to the commons. Some ancient cottages had extensive rights attached to them, while newer cottages built right next door had none, creating deep inequalities within the same village.

New France re‑imagined this entire system. The commune, a small pasture set aside by the seigneur, was governed by clear, written contracts, not unwritten custom. Fees were fixed and symbolic (a few chickens, a bit of grain) and could never be raised. Grazing rights were proportional to the size of each habitant’s private lot, not tied to ancient cottages or manorial politics. As the colony expanded, new rows of farms were added further into the woods, and newer settlers negotiated their own contracts rather than being trapped in a closed, static village system. The entire structure operated more like a regulated utility than a feudal commons.

This contract-based system directly shaped how the habitants viewed themselves. By rejecting degrading European terms like “commoner” or paysan (peasant), they proudly claimed the title habitant—a name that stood for permanent residence, independence, and personal dignity. They operated not as a medieval underclass, but as self-reliant farmers who managed their own land while sharing local, contract-regulated utilities.

Their leverage came from the realities of the New World: seigneurs needed settlers far more than settlers needed seigneurs. A habitant who disliked his landlord could leave for another seigneurie or vanish into the interior as a fur trader. They accumulated property, supplemented their income through the fur trade, and took seigneurs to court—often successfully—over mill fees, boundaries, and contracts. Visitors from France frequently remarked on how different these farmers were from European peasants: well‑fed, well‑dressed, mounted on good horses, and speaking to officials with a confident equality that startled outsiders.

Disability and old age: Old France vs. New France

In mainland France, a disabled or chronically ill peasant lived under a legal world shaped by ancient, unwritten customs and the immense power of the manorial court. The lord’s court was not simply a venue for disputes; it was an instrument for protecting the estate’s productivity. If a peasant became too old or too sick to work, the court could intervene directly in the household. It could order the family to take in boarders or hired laborers to keep the fields producing, or it could declare the household vacant and evict the family so a more productive tenant could be installed. Even when families tried to arrange care on their own, their options were constrained by rigid inheritance customs—such as strict primogeniture in many provinces—and by heavy transfer taxes (lods et ventes) that made passing land to a caregiver financially impossible. If the family could not pay the tax, the transfer was blocked. And if a disabled peasant had no kin to rely on, the situation was bleak. Rural parishes were impoverished, charity boards could offer only meagre rations, and access to hospitals for long-term care was limited to major cities. Many disabled peasants without family support ended up as beggars, surviving on scraps from the village poor fund.

New France operated on an entirely different foundation. Instead of a patchwork of medieval customs, the colony was governed by the Custom of Paris and direct royal oversight. Seigneurs did not have the authority to micro‑manage a tenant’s household, force boarders into their home, or alter a lease. A habitant’s rights were spelled out in a notarial contract, and if a landlord attempted to change the terms, the tenant could appeal to the royal courts. The only serious obligation was tenir feu et lieu—to keep a hearth and home. If a tenant abandoned the land entirely or allowed it to revert to wilderness, the seigneur could seek forfeiture, but eviction was a last resort monitored by the king’s Intendant. A tenant who was visibly trying to maintain the property, even while ill or disabled, could not be evicted, nor could the seigneur impose strangers on them to keep the land productive.

Instead of manorial coercion, New France relied on a legal mechanism that gave tenants control over their own care: the donation entre vifs, a contract in which a habitant transferred the farm to a child, relative, or trusted neighbour in exchange for lifelong support. The new owner was legally obligated to provide housing, food, clothing, firewood, and personal care until the original tenant’s death, and if the caregiver failed, the disabled habitant could sue in a royal court and reclaim the property. When a tenant had no family or trusted associates to assume the farm, responsibility shifted not to the seigneur but to the Catholic Church. The colony had a dense network of religious institutions that provided long‑term care for the chronically ill, disabled, or elderly. These institutions were funded through Church resources, royal subsidies, and private donations, forming a reliable safety net for people without kin.

Financial obligations, however, were rarely softened. Seigneurial dues were fixed by contract and already low, but because they were legally locked in, seigneurs were rigid about collecting them. A disabled tenant who could not pay would accumulate debt, which had to be settled by heirs or through the eventual sale of the land. The system offered legal protection and social care, but not financial forgiveness.

In short, a disabled peasant in Old France lived under a coercive, intrusive manorial regime that prioritized the lord’s revenue over individual autonomy. A disabled habitant in New France lived under a modernized, contract‑based legal system that protected their household, allowed them to negotiate care through enforceable agreements, and provided institutional support through Catholic hospitals.

The end of the seigneurial system

The seigneurial system was officially abolished in Quebec in 1854. On paper, abolition freed farmers from feudal dues; in practice, it converted them into long‑term financial obligations. To compensate seigneurs, the law required tenants to buy out their historical rights. Because most rural families lived in a barter economy with almost no cash, the buyout was transformed into a permanent annual interest payment, the rente constituée. Every time a farm was inherited or sold, this debt followed the property. The state eventually centralized the process in 1935, issuing provincial bonds to pay off remaining seigneurial families and recouping the money through a temporary municipal tax. Due to the sheer volume of records and delays from World War II, the last of these taxes were not fully closed out until 1970.

When abolition took effect, the seigneur’s obligations vanished overnight. The mill became a private business that could charge whatever it wanted or shut down entirely. Land that had been governed by rules became a commodity: seigneurs could sell it to speculators, raise rents to market rates, or evict tenants who could not pay. What had been a paternalistic, regulated housing system turned into something much closer to the modern world of mortgages, unregulated rent hikes, and foreclosures. Communal obligations were privatized; security became debt.

The British kept all the tenant’s obligations (paying rent, giving a cut of grain at the mill, doing corvée forced labor), but they stopped enforcing the seigneur’s obligations. British courts viewed the seigneurs as absolute owners of the land who could exploit it for profit, leaving the habitants with all of the burdens and few of the traditional protections. With the landlord’s obligations gone, rural care became precarious overnight; families who lost their land also lost the informal welfare that had once buffered them.

Quebec’s timeline sits in the middle of a global 19th‑century trend. France abolished seigneurialism during the Revolution of 1789. In regions Napoleon did not permanently conquer, like Prussia and the Austrian Empire, elements of feudal dues and serfdom survived until the Revolutions of 1848. The United States had its own version: under Dutch rule, massive estates along the Hudson River were granted to Patroons, who ruled over tenant farmers through feudal leaseholds. When the British took over New York, they kept the system. Only after sustained uprisings did the state constitution of 1846 outlaw feudal land tenures and end the patroonships. In Russia, Tsar Alexander II issued the Emancipation Reform of 1861. Across these cases, the pattern is similar: industrial capitalism could not function alongside legal regimes where hereditary landlords controlled movement, infrastructure, and property transfers.

For early capitalists—bankers, railway tycoons, industrial merchants—the seigneurial system was an economic chokehold. They needed land to be a liquid, tradeable asset that could be bought, sold, mortgaged, and cleared for factories and tracks. Under seigneurial law, if a railway company wanted a strip of land across ten farms, it had to buy out the farmers and pay an additional 8.3% fee (lods et ventes) to the seigneur just to transfer the title. Seigneurs held legal monopolies over rivers and water rights. If an industrialist wanted to build a water‑powered textile mill or factory, the seigneur could block it or demand a cut of the profits. The business class in Quebec pressured the government relentlessly, and in 1854 they succeeded.

For subsistence farmers, the consequences were brutal. A subsistence household grows its own food, makes its own clothes, and barters with neighbors. It does not earn wages, buy manufactured goods, or take out bank loans. By forcing habitants to buy out their seigneurial rights or face compounding interest debts, the 1854 Act injected a lethal dose of commercial pressure into a countryside that had never operated on cash. Thousands of farmers could not afford the buyout. They lost their land to foreclosure and migrated to Montreal, New England, and emerging industrial towns. They traded a life of customary farming for fourteen‑hour shifts in textile mills and boot factories. In theory, they became free citizens entering voluntary labor contracts; in daily reality, many had simply exchanged a rural landlord for an industrial boss.

This shift also shattered the informal care structures embedded in the old order. Under seigneurialism, the landlord and parish priest were obligated—by law and custom—to provide basic relief during crises. After abolition, those obligations disappeared, and industrial capitalism did not immediately replace them with a modern welfare state. Rural families who lost their land entered cities without the safety nets that had once existed in the countryside. The result was a new working class that depended on wage labor, urban charity, and eventually state welfare.

Land, law, and the erasure of Métis care systems

People of mixed French and Indigenous ancestry lived in Quebec from the earliest days of New France in the 1600s. French coureurs des bois and voyageurs formed unions with Algonquin, Innu, and Huron‑Wendat women along the St. Lawrence River throughout the 17th and early 18th centuries, but these families did not form a distinct people. Their children were absorbed either into French colonial society—speaking French, practicing Catholicism, and living within the seigneurial system—or into their mother’s First Nations communities. Because they joined existing cultures, they did not develop a separate language, political structure, or collective identity. This is why historians and courts distinguish between lowercase métis, meaning mixed‑ancestry individuals, and uppercase Métis, referring to the distinct Indigenous Nation.

The story changes when the fur trade moved west. Beginning in the late 1600s and accelerating through the 1700s, French and British traders pushed beyond the Great Lakes into the vast interior territory known as Rupert’s Land. This region—covering the entire Hudson Bay drainage basin—was granted to the Hudson’s Bay Company in 1670. It was not a colony but a corporate jurisdiction, governed by the HBC for nearly two centuries. As the fur trade expanded into this territory, mixed‑ancestry families from Quebec, the Great Lakes, and the western missions followed the trade routes north and west. They settled around key HBC posts such as Red River, Cumberland House, Norway House, and Fort Edmonton, forming communities far beyond the reach of French or British civil administration.

It was in this environment—isolated from colonial governments but deeply embedded in Indigenous trade networks—that the Métis Nation emerged in the 18th and early 19th centuries. Cree, Ojibwe, and Saulteaux women and French or British men formed families whose children married among themselves and built a new people with their own language (Michif), legal customs, and a mobile economy based on bison hunting, freighting, and river‑lot agriculture. The HBC relied heavily on these communities: Métis hunters provisioned the posts, Métis boatmen moved goods across the interior, and Métis farmers supplied food to the trade. By the late 1700s, the Métis were indispensable to the corporate monopoly.

The arrival of Thomas Douglas, the 5th Earl of Selkirk, in 1812 added a new layer to this landholding world. Selkirk was a Scottish philanthropist who believed that impoverished tenant farmers in Scotland could rebuild their lives in North America. He purchased a large tract of land from the HBC to establish the Red River Colony, introducing formal leases and surveyed river lots for incoming settlers. Inside the boundaries of Selkirk’s official survey, land was distributed through written contracts. But outside those surveyed lines, Métis families continued their longstanding practice of customary settlement: they claimed river lots, cleared land, built homes, and farmed according to community consensus. The HBC recognized these customary lots in its ledgers because evicting the Métis—who supplied food, labour, and transport—would have crippled the company’s operations. Thus, two land systems coexisted: formal HBC leases for some families, and customary Métis occupation for others.

Governance in the Red River region fell to the Council of Assiniboia, an HBC‑appointed body that handled basic administration: it collected taxes, maintained roads, and recorded land transfers. But it provided no social welfare. Everyday care—food, shelter, child‑raising, elder support—was carried by kin networks, community reciprocity, and Catholic religious orders such as the Grey Nuns and the Oblates. Unlike Quebec, where the Church arrived as a state‑backed institution with tithes, landholdings, and legal authority, Catholic missionaries in the Northwest arrived as guests. They had no tithe, no army, and no jurisdiction, surviving on donations from European missionary societies. Because the Church lacked institutional power, Métis communities retained control over their own care systems, blending Catholic practice with Cree and Saulteaux worldviews.

This mattered because care depended on land stability. The Métis river‑lot system created dense, interdependent communities where families lived within shouting distance of one another on incredibly long, narrow lots with houses between the river and the road. Each lot combined a house site, fertile bottomland, pasture, and woodlots, giving families the resources to support elders, share food, and respond collectively to crises. When land is stable and resources are abundant, care can be local and relational.

When the Hudson’s Bay Company sold Rupert’s Land to Canada in 1869, it promised that all land titles it had conferred would be recognized by the Crown. For Métis families who held formal HBC contracts (written leases or recorded river‑lot titles) this promise mattered. Their deeds took years to process, but they were eventually recognized, and these families could remain on their land while they waited.

The situation was entirely different for Métis families who held land through customary occupation, the system that had governed most river‑lot settlement for generations. These families had cleared land, built homes, grazed animals, and farmed according to community consensus, and the HBC had acknowledged these lots in its ledgers and taxed them. But when Canada took over, federal lawyers adopted a strict de jure stance: because the Council of Assiniboia was a corporate creation rather than a sovereign government, its land records had no legal authority. Incoming settlers with paper deeds could call the North‑West Mounted Police to evict Métis families who had lived on their lots for decades. When elites control the infrastructure of survival, they can erase entire communities simply by refusing to recognize them on paper.

This triggered the Red River Resistance. In late 1869, Louis Riel and the Métis National Committee blocked Canadian surveyors, seized Upper Fort Garry, and established a Provisional Government to negotiate terms of entry into Confederation. Riel’s government drafted a List of Rights demanding bilingual institutions, local control, and—critically—protection of Métis land. Canada could not legally govern the territory without Métis cooperation, and Ottawa eventually agreed to negotiate. The result was the Manitoba Act of 1870, a constitutional compromise that created the province of Manitoba and promised 1.4 million acres for Métis children, along with recognition of existing landholdings.

Although the Crown finally agreed to recognize customary possession, federal officials interpreted “possession” in ways incompatible with Métis land use. This was a deliberate narrowing of the agreement: Canada recognized the existence of customary tenure, then defined it so narrowly that Métis families could not exercise it.

Those who did manage to convince the Crown of their “possession” hardly fared better. Métis river lots were huge, typically 100–300 metres wide along the river and running two miles back, plus an additional two‑mile hay privilege beyond that. In practice, a single family’s holding could span hundreds of acres of mixed‑use land: gardens, pasture, woodlots, hay meadows, and fertile bottomland. The Crown issued deeds only for the house and garden plots — often 1–3 acres — and stripped away the remaining hundreds of acres of land and the two‑mile privileges. It meant families could not afford to stay in their homes, because their ability to earn an income had been taken away when they lost the vast majority of their land.

Ottawa refused to grant Métis children land directly. Instead, it issued scrip—paper coupons that could be traded for land, but only after years of bureaucratic delay. While families waited, they faced harassment, violence, and economic collapse. Many were forced to sell their children’s scrip to speculators simply to avoid starving. By the time the scrip was finally redeemable, over 80% of the land intended for Métis children had already been bought up by outsiders.

The consequences were catastrophic. Métis families with customary tenure lost their land base and were forced to scatter across the prairies or leave Canada entirely. When the land base vanished, so did the dense, relational care networks that had sustained Métis communities—networks built on river‑lot proximity, shared labour, kinship, and mutual aid.

Ultimately, the fate of these two regions reveals a stark contrast in how Canada approached land rights. In Quebec, the transition of the seigneurial system prioritized stability and legal continuity. When the system was abolished in 1854, the state protected existing holdings by converting feudal duties into fixed cash rents, allowing families to retain their farms. They urbanized due to economic pressures, not direct dispossession. In the Northwest, the Crown actively dismantled the Métis way of life through bureaucratic administration, leaving families economically broken and driving them from their homelands. Where Quebec’s land system was forced to evolve, the Métis land system was systematically destroyed.

Customary Landholding in the Prairies, British Isles, and France

In medieval Europe, ordinary people often held land through customary right rather than formal deeds. A peasant’s claim to pasture, forest, or field rested on the simple fact that their family had used it “from time immemorial,” and everyone in the community recognized that right. The European commons (such as shared pastures and woodlands) were governed not by paperwork but by tradition, consensus, and manorial court records.

New France adapted these European traditions to North American conditions. Instead of crowded villages surrounded by shared commons, the colony used the river-lot system. Habitants held their farms through formal contracts, but the underlying logic was familiar: land use was shaped by community norms, practical necessity, and long‑standing occupation.

Métis landholding followed this same European pattern of customary tenure. Along the Red River, Saskatchewan River, and other waterways, Métis families established river‑lot farms identical in structure to the long‑lots of New France. They cleared land, built homes, grazed animals, and farmed according to community consensus. Seasonal bison hunting grounds and hay meadows were used collectively, governed by local rules and long‑standing practice. Their claims rested on occupation, recognition, and continuity — the same foundations that had sustained European peasants for centuries. Métis families were following the European system of customary landholding, adapted to the realities of the prairie.

In England, this system of customary tenure survived astonishingly late: millions of people held land as copyhold until the Law of Property Act of 1922 finally abolished customary tenure and converted these medieval rights into modern freehold deeds. Tenants had unfavorable terms and forced purchase or debt, like in Quebec. France went the opposite direction. During the Revolution, peasants refused to buy out their landlords, rioted until feudal dues were abolished without compensation, and by 1793 were recognized as the absolute owners of the land they had farmed for generations. Napoleon’s cadastre later formalized these customary holdings into state‑backed property titles.

What made the Métis vulnerable was not a lack of legitimacy but a change in legal regime. When Canada purchased Rupert’s Land in 1869 and imposed British property law, customary tenure — perfectly valid under European tradition — was suddenly treated as non‑existent unless backed by a modern deed. The Métis were not breaking rules; the rules changed underneath them.

Law, land, and community survival

While the modern housing crisis does not carry the violence or physical displacement that devastated the Métis Nation, it shares a deeper, structural blueprint: both demonstrate how a sudden shift in the legal and economic rules by elites can rupture the fabric of community care.

For centuries, Western land values were tied strictly to local geography and agricultural productivity and came with obligations, making land difficult to liquidate or sell in bulk. The modern housing crisis, however, was engineered by a deliberate shift in elite priorities.

Rather than reacting to organic market demand, financial and political elites altered the regulatory framework to transform land into a highly liquid, global financial asset. While elites have always dictated mortgage terms and infrastructure, their focus shifted from maintaining a stable local resource to maximizing global capital extraction. By combining historically low interest rates and loose monetary policies with the introduction of Real Estate Investment Trusts (REITs), bulk corporate purchasing, and anonymous numbered corporations, they made land incredibly easy to trade globally, causing values to rapidly escalate.

As a result, the rules of the game have changed for regular people. Those who inherit property or have lived in one place for many years see their wealth increase exponentially while keeping their established local care networks. Meanwhile, renters, young people, and newcomers are forced farther and farther away from their support systems by these changing financial structures.

To focus clearly on the underlying machinery of displacement, this text intentionally leaves aside the physical violence that devastated the Métis Nation—a human tragedy thoroughly captured in other histories. Modern real estate achieves its displacement through financial mechanisms rather than force, but the core truth persists: land systems are never neutral. When the infrastructure of daily life is rewritten to serve global capital rather than community survival, the human networks that keep us safe are the first things to fracture.

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It was that month in Montreal that sparked my desire to see how caregiving worked in different places. Touring facilities, having lunch with staff, and visiting the homes of clients was a world apart from reading case studies. It really demonstrated that the important things can’t be quantified. Anyone can use the right lingo, but all the branding in the world can’t obscure how it feels to be in a space.

I was surprised when the people who tirelessly explained how the system in Montreal worked and how it had evolved during their careers knew almost nothing about how things worked in the rest of Canada, the US, or anywhere else. They just knew Quebec had a unique system and it was a better match for people’s needs than programs in other places.

When I immigrated to Canada, I did quite a bit of reading about Canadian history to get up to speed. As I traveled around to learn about care work, I also visited historic sites and museums. When I was home, I volunteered at the Mackenzie House in Toronto. The citizenship exam was a breeze. My French classes were not a breeze. Yet Quebec remains a mystery to me. The facts are floating around in my brain, but I just don’t know how to put them together.

This past Independence Day, I was skimming an article on the American Revolution when I noticed that the Quebec Act was listed among the ‘Intolerable Acts’—the set of measures that helped push colonial discontent toward open demands for independence. That’s when I learned that the Quebec Act of 1774 is the domino that set up the modern geopolitical map of North America. And it’s when things started to finally click for me about what makes Quebec…Quebec.

I knew that by guaranteeing French Civil Law and protecting the Catholic Church, the Quebec Act allowed French-Canadians to maintain their language, religion, and distinct legal identity. Without this act, French culture in North America likely would have been systematically eroded by British rule.

What I hadn’t realized was that, for the 13 colonies that became the United States, it was the final straw that triggered the First Continental Congress. I didn’t know that the Catholic clergy in Quebec used their immense influence to warn the population that the Protestant Americans would destroy their churches if they ever took control. This is why when the war started, Quebec refused to join the American rebellion.

Roughly 40,000 United Empire Loyalists (those Americans who stayed loyal to the King) had to flee the newly formed United States. The British then created two new English speaking colonies for them: New Brunswick in 1784 and Upper Canada (aka Ontario) in 1791.

Perhaps Quebec’s history doesn’t make sense to me because I couldn’t force it into my preconceived notions of how history is supposed to work. Typically, social welfare institutions emerge gradually as communities grow and become more specialized. In Quebec it was backwards. It was the creation of a French Catholic welfare system in New France that led to the creation of Quebec.

The Imperial Domino

In the early 1750s, the British and French empires in North America were growing toward each other. They collided in the Ohio River Valley (modern-day western Pennsylvania and Ohio). What started as a regional border skirmish in 17541 exploded into a global war by 1756.

In North America and the Caribbean, Britain captured a number of French and Spanish possessions. In India, British and French forces—often operating through chartered trading companies—competed for influence and territory. In Europe, Prussia fought against a coalition that included Austria, Russia, and France.

At the end of the Seven Years’ War, both Britain and France were functionally bankrupt. To recoup its losses, the British Parliament made the fateful decision to begin directly taxing its American colonists. Under the 1763 Treaty of Paris, France ceded Canada and all territorial claims east of the Mississippi River to Britain,2 effectively exiting mainland North America and losing its dominant foothold in India. Spain traded Florida to the British to get Havana and Manila back. Britain became the global superpower.

Suddenly, the Protestant British Empire found itself ruling over roughly 70,000 French-speaking, Roman Catholic subjects in Quebec—people who had been Britain’s bitter enemies for generations.

By 1774, the American colonies to the south were growing increasingly rebellious, especially after the Boston Tea Party in late 1773. Fearing a massive multi-front rebellion, the British Parliament passed the Quebec Act as a pragmatic, preventative measure.

To appease the residents of New France, the Act did three major things:

1. Religious Freedom: It allowed French Canadians to practice Roman Catholicism openly and restored the Church’s right to collect tithes (taxes, but administered by the Church). At the time, Catholics in Britain itself were heavily persecuted and banned from holding public office.

2. French Civil Law: It allowed Quebec to retain its traditional French civil law for property and private matters, rather than imposing British common law. The seigneurial system endured well into the 19th century and payments were still being made into the 1970s.

3. Territory: It expanded the borders of Quebec all the way south into the Ohio River Valley, covering modern-day Ohio, Michigan, Indiana, Illinois, and Wisconsin. New France had already claimed this territory. By assigning it to the British Province of Quebec, Britain formally recognized those former French claims over the competing land claims of several English‑speaking colonies.

While the Quebec Act successfully defused things in Canada, it acted like gasoline on a fire for the American Patriots. They saw it as a direct threat to their existence. They lumped it in with the punitive Coercive Acts aimed at Boston, branding the entire package the Intolerable Acts. It was intolerable because:

• Colonies like Virginia, Pennsylvania, and Connecticut had already claimed the Ohio Valley for their own future expansion. Britain had handed that land over to their former French enemies after they fought the Seven Years’ War to keep it out of French hands.

• The American colonies were overwhelmingly Protestant and very anti-Catholic. They genuinely feared that Britain was trying to establish a centralized Catholic powerhouse right on their northern border to keep them surrounded and contained. Empires often look for loyal minorities or distinct groups to act as buffers against more dangerous adversaries.

• The Quebec Act set up a government in Canada that had no elected assembly—it was ruled directly by a Royal Governor and an appointed council. American Patriots worried this was a test run for how Britain intended to strip away democracy in the 13 colonies next.

The combination of Boston’s port being blockaded by British warships and the passage of the Quebec Act convinced the colonies that a coordinated response was life-or-death. They could no longer act as 13 separate entities. On September 5, 1774, delegates from 12 of the colonies met in Philadelphia to form the First Continental Congress.

Their primary goal was to organize a total economic boycott of British goods and issue a unified declaration of rights. In their official grievances, they explicitly pointed to the Quebec Act as proof of a British conspiracy to destroy English liberties in America.

Crown, Cloister, and Orphans

New France began in 1534, when Jacques Cartier entered the Gulf of St. Lawrence and claimed the surrounding lands for King Francis I. In 1608, Samuel de Champlain established Quebec, the colony’s first permanent settlement.

The Hôtel-Dieu network is what shifted New France from a network of fur traders, soldiers, and priests (who often partnered with locals) to a colony of Quebecois. Nuns established the first hospitals, such as the Hôtel-Dieu de Québec (1639) and Hôtel-Dieu de Montréal (1645). These were not rudimentary frontier clinics. They were massive, permanent complexes run by cloistered orders of nuns (such as the Augustines Hospitalières).

They weren’t built for thriving cities. When the Hospitalières nuns stepped off the ship in 1639 to build their hospital, Quebec was essentially a muddy compound consisting of a fort, a warehouse, a church, and a few rudimentary stone and wooden homes clinging to the cliffside. The population was somewhere between 100 and 300 (probably closer to the higher end).

The Augustine Hospitallers arrived in Quebec as part of a fully funded initiative from France. Backed by wealthy patrons—most notably the Duchesse d’Aiguillon, Cardinal Richelieu’s niece—they brought trained personnel, medical supplies, and a royal mandate to establish a permanent hospital in the colonial capital. Their mission was not a local undertaking but a metropolitan project: France intended to transplant a functioning religious‑medical institution into New France to care for settlers, support missionary work, and signal that the colony was meant to be a stable, enduring outpost rather than a temporary trading station.

Montreal (originally named Ville-Marie) was founded in 1642 by a group of religious mystics led by Paul de Chomedey de Maisonneuve and Jeanne Mance. Their initial group consisted of fewer than 50 settlers. By 1645, when Jeanne Mance established the Hôtel-Dieu de Montréal, the colony was a tiny, heavily fortified compound. It was under constant existential threat of military attack from the Haudenosaunee (Iroquois) Confederacy, and the population barely hovered above 50 people. Yet, even as the population barely hovered above fifty people, the institutional architecture of care was already operating at the center of the community.

Catholic social‑welfare institutions3—financed by powerful patrons in France and supported by the French crown—were the driving force behind population growth in New France and played a foundational role in shaping the culture that would become Québécois.

Between 1663 and 1673, the French crown sponsored the voyage of about 800 young women to Quebec, the Filles du Roi. They were mostly poor orphans from Paris, rural areas, or girls whose families had fallen on hard times, chosen by the Catholic Church.

The Filles du Roi program was explicitly designed by King Louis XIV and his minister, Jean-Baptiste Colbert, to build a purely French agricultural society on the banks of the St. Lawrence River. However, the plan didn’t stop interracial marriage across the board. Instead, it inadvertently split French-Canadian society into two distinct worlds: the settled farmers of Quebec and the nomadic fur traders of the West, the latter of whom went on to birth the Métis Nation.

In the 1640s, the gender imbalance in Canada was severe, with men outnumbering women roughly seven to one. Initially, the French Crown had encouraged intermarriage with Indigenous populations. By the 1660s, however, both the Catholic Church and the French government realized this strategy had backfired. Instead of Indigenous peoples assimilating into French Catholic culture, the reverse was occurring. Young Frenchmen—the coureurs des bois, or fur traders—were abandoning the strict, moralistic colonial settlements, moving into Indigenous villages, taking Indigenous wives, and adopting their languages, clothing, and lifestyles.

Louis XIV did not want his subjects disappearing into the interior; he required permanent, tax-paying, wheat-farming peasants. The Filles du Roi were dispatched to serve as cultural anchors. By providing soldiers and fur traders with French Catholic wives, the Crown successfully tied these men to local seigneurial land grants, inadvertently splitting French-Canadian society into two distinct worlds: the settled farmers of Quebec and the nomadic traders of the West, the latter of whom would go on to birth the Métis Nation.

The connection between this demographic project and the French welfare state was direct. Many of the Filles du Roi were recruited directly from the Hôpital-Général de Paris and the Salpêtrière, institutions closely linked to the Hôtel-Dieu network. In 17th-century France, a Hôpital-Général was not a medical facility, but rather an instrument of what historians call the Great Confinement—a massive network of state-subsidized facilities designed to house orphanages, poorhouses, and shelters for the destitute.

The King paid for their passage and provided a modest dowry consisting of money, clothing, and essential household goods. In 17th-century Europe, where marriage was strictly a financial transaction, a poor, orphaned girl in Paris possessed virtually zero economic prospects; without a dowry, she was doomed to grueling poverty or domestic servitude. In Quebec, the dynamic was entirely different. Within days or weeks of landing, these women chose husbands, married, and established households.

Similar demographic experiments were deployed across the French Empire. In the early 1700s, France sent the “Casquette Girls” (filles à la cassette) from Parisian orphanages to New Orleans and Mobile, Alabama, where they remain fixtures of Gulf Coast folklore. France also shipped hundreds of poor women and orphans to the West Indies in the late 17th century to marry tobacco and sugar planters, though tropical diseases and a harsh climate resulted in horrific mortality rates compared to Canada.

In Quebec, however, the climate was forgiving, and the Filles du Roi thrived. Rather than entering domestic servitude, they became the founding matriarchs of Quebec’s agrarian society. Today, they are celebrated as the literal mothers of the French-Canadian nation, with historians estimating that the vast majority of French Canadians alive today are descended from at least one of these 800 women. By honoring them, modern Quebec continues to recognize the resilience, bravery, and institutional framework that birthed their society.

This deep architectural divide set the stage for a century-long divergence in how North Americans took care of one another. While Ontario and the United States spent the 19th and early 20th centuries building secular, tax-funded municipal bureaucracies, Quebec doubled down on this foundational blueprint—intentionally outsourcing the entire weight of modern industrial poverty, disability, and eldercare to cloistered religious orders working in close coordination with the state and corporate entities granted monopolies.

A common argument about the modern “caregiving crisis” begins with a familiar claim: that living into old age, and especially living for years with disability or chronic illness, is largely a modern phenomenon. The argument often points to historical life expectancy figures—frequently summarized as “people only lived to 45”—and concludes that in the past people were either healthy or they died before they required long-term care. Plenty of people, including me, have picked this idea apart as a misreading of statistics and medical history.

Gordon’s research suggests that this argument—one of my personal pet peeves—might turn out to be pretty accurate. It’s not because hardly anyone lived to be 65, which remains a misreading of statistics. It’s because medicine is only part of the story.1

Some of the biggest gains came from something much less dramatic: We made everyday life safer.

The Surprisingly Modest Shift in Adult Longevity

To understand changes in longevity, we need to focus on people who had already reached older adulthood. In 1870, a man who made it to age 60 could expect to live another 14.1 years on average. By 1960, after nearly a century of industrialization, that figure had only increased to 15.9 years. That’s a gain of less than two years over almost a century.

By 2010, remaining life expectancy at age 60 had risen to roughly 22 years. That’s a meaningful increase, and modern medicine deserves part of the credit. Advances in cardiovascular care, infection treatment, surgery, and chronic disease management have undoubtedly helped people survive conditions that would once have been fatal. But the pattern is still striking.

The enormous gains in life expectancy that transformed human history were concentrated in reducing infant mortality and early death. Gordon includes a Murphy and Topel quote:

“In 1900, nearly 18 percent of males born in the United States died before their first birthday; today [in 2006], cumulative mortality does not reach 18 percent until age 62.”

Compared to that, the gains in life expectancy for people who’d already reached 60 seem pretty modest. And, as most of us know, gains during the years between 74 and 82 are different than gains in childhood. A child who survived diphtheria or influenza in the early twentieth century had a good chance of going on to live a normal life. Today, a 74-year-old who survives heart disease gains additional years, but survival doesn’t mean bouncing back.

What I found so interesting about Gordon’s book was the way he took the data and turned it into a story about what daily life was like. And as much as modern medicine is miraculous, that’s not the most important factor in making it possible for people to live longer into old age.

The Hidden Miracle

When we think about technologies that support older adults, we tend to imagine sophisticated tech and medical devices, pharmaceutical research, and the treatments we have to fight to get insurance to cover because they’re so new.

What we’re overlooking is the modern home itself. In 1870, a home was a completely isolated capsule. If you wanted heat, light, or water, you had to physically haul it in yourself, process it inside the house (by burning wood, coal, or kerosene), and then physically haul the waste back out. Simply existing in a house in 1870 required an astonishing amount of physical effort and exposed people to risks that have largely disappeared from daily life.

There was no central heating or air conditioning. Indoor temperatures fluctuated dramatically with the seasons, and most bedrooms were unheated. Maintaining body temperature required constant physiological work, especially during harsh winters and summer heat.

Cooking and heating depended on wood or coal fires. Lighting came from candles, oil lamps, or kerosene lamps. Indoor air contained smoke, soot, and combustion byproducts that people breathed every day.

Water had to be pumped, carried, heated, and disposed of by hand. Keeping a person, their clothing, and their home clean required sustained physical labor. Waste did not disappear; it was handled through chamberpots, privies, and cesspools.

Food preservation was far less reliable. Seasonal shortages, contamination, and spoilage were routine concerns. Without screens, flies travelled between manure, outhouses, and the kitchen table.

The overwhelming majority of Americans over 65 today—between 82% and 87%—live either entirely alone or as a couple. Not only was this not feasible in the 1870s,2 but people with certain disabilities simply could not survive even if they lived with other people who took care of the household labor.

Gordon explains how the “networked home” changed everything by connecting the individual structure to five massive, centralized urban grids. Suddenly, infrastructure did the heavy lifting, replacing physical labor with physical connections.

Gordon’s networked home relies on five critical prongs:

1. Electricity: Replaced kerosene lamps and wood stoves with clean, instant power, removing the baseline indoor air pollution and open-flame hazards.

2. Gas: Provided steady, controlled heat without the physical labor of chopping wood or shoveling coal.

3. Telephone: Instantly ended the total physical isolation of the home, creating a lifeline to the outside world.

4. Clean Running Water: Water flowed in automatically, eliminating the need to haul tons of water by hand.

5. Internal Plumbing/Sewer Systems: Waste flowed out automatically, eliminating the necessity of the outhouse and drastically cutting down exposure to deadly pathogens.

The transition to the networked home did something far more profound than just making life more convenient: it fundamentally revolutionized the standards of household cleanliness and safety.

When a home switched to central heating, the indoor woodpile vanished, taking the rodents and ticks with it. And when the washing machine and high-heat electric dryer arrived, they acted as a sterilization chamber. Parasites and the blood-borne infections they carried went from being a normal part of life to an occasional problem.

As Gordon famously points out, the greatest part of this revolution can be summed up in a simple phrase: “Water flows in and flows out.” When water has to be physically hauled into a house by hand, it becomes a precious commodity. Because carrying 27 tons of water a year is a back-breaking task, families in the 19th century practiced extreme water recycling. This meant that the home environment was constantly cross-contaminated.

Modern sanitation systems mean flies are less likely to be carrying germs from cesspools to the kitchen table. No one is going to fall into an outhouse pit or down an open well in the yard. Municipal water treatment systems mean no one is catching typhoid, cholera, dysentery, and the other water borne ailments that used to be routine.

The shift to piped, treated water fundamentally altered the household’s exposure structure. It reduced the need to reuse water across tasks, removed much of the physical labor involved in obtaining it, and made frequent washing and sanitation practically routine rather than exceptional.

We spend a great deal of time worrying about medications, specialists, and treatment plans. Those things matter. But we sometimes overlook the fact that much of what keeps a vulnerable person alive has nothing to do with medicine.

It’s infrastructure: the kitchen sink dispensing treated water, the shower, the thermostat, the refrigerator, the microwave, the washing machine, the smoke detector, electric lights. It’s hard enough to provide care in a home with these things. But without them, the everday risks are so much higher.

The World Used to Be More Dangerous

Take someone who doesn’t yet quite qualify for a dementia diagnosis and put them in an 1870s home. It’s dim and stuffy, but you aren’t only worried about wandering or falls. You’re worried about open flames being used for routine heating and lighting. Kerosene lamps were notorious for tipping over, shattering, and instantly spreading a wall of liquid fire. For an older adult with a tremor, failing eyesight, or cognitive decline, simply moving around a dark house at night was a high-stakes safety hazard. You’re worried about a simple household accident becoming a life-threatening injury because it’s so difficult to keep wounds clean. The environment itself demands a level of resilience and labor that many vulnerable people simply do not have.

Around 1900, accidental death rates in the United States were roughly double what they would become by the early twenty-first century. Part of that decline came from making everyday environments safer.

Workplaces routinely exposed people to machinery with few safety protections. Many men continued working physically demanding jobs until age or illness made it impossible. In 1870, 94.5% of men over 60 were participating in the labor force.

Transportation was hazardous in ways that are easy to forget today. Streets were crowded with horses, wagons, streetcars, and trains moving through towns with relatively few safety barriers. For older adults experiencing declining vision, slower reaction times, frailty, or cognitive impairment, these dangers carried an especially high cost.

Yes, it is amazing that we have antibiotics and the miraculous technology of the ICU. But a far bigger driver of longevity is the incredible number of accidents, infections, and physical crises that never happen in the first place, thanks to the modern infrastructure of the networked home.

Countless injuries never occur because we replaced open flames and dark hallways with stable electricity. Countless infections are prevented or managed without ever needing a doctor because a flushing toilet and running water maintain an automated baseline of sanitation. Vulnerable bodies are no longer constantly exposed to the baseline tax of disease-carrying insects, fungus, and parasites. And hearts and lungs no longer have to work overtime just to maintain a stable body temperature, because we have outsourced our metabolic homeostatic work to an HVAC system.

Medicine is what saves people after something has gone wrong. Infrastructure is what keeps so many of those things from going wrong at all.

What We Overlook

The modern home is not a backdrop to caregiving. It is part of the caregiving system itself.

In the 1870s, there was only so much a family caregiver could do. Once someone reached a certain threshold of frailty—once they required constant supervision or could no longer safely navigate the basic demands of their environment—the home itself offered very little margin for continued survival. Care was operating inside conditions where accidents, infections, and environmental hazards were constant and difficult to fully control. Even sustained family effort was often not enough.

Survival at home has become possible in a much broader range of circumstances than it once was. People who are profoundly frail—people who require 24/7 supervision, complex medication regimens, or have significantly compromised physical or cognitive function—can now remain alive for years, and in many cases for decades. Not because caregiving itself has become fundamentally different, but because the environment in which caregiving takes place has changed.

Even perfect caregiving cannot overcome environmental risks for long.

We tend to notice the dramatic stories: the ethical dilemmas, the prolonged periods of severe decline, the cases where people appear to be “circling the drain.” These cases are real, and they raise important questions. But they can obscure the larger shift: that many more people now pass through stages of severe frailty that would not have been survivable in earlier environments at all.

In that sense, the arc over the last century is not simply one of people living longer, or even of people living more independently for longer. It is a deeper shift in what kinds of lives are possible to sustain at home in the first place.

It is easy to measure how many people live alone, because that data is visible. But living alone is not the goal, and it is not a reliable measure of autonomy. It says little about whether someone is supported, or whether they are living in conditions that allow for safety, dignity, or meaning.

In earlier eras, the limits of the home often meant that care and survival collapsed into the same struggle. Today, care can often sustain survival even under extreme frailty. The next question is not simply how to extend that survival further, but how to improve what that survival contains—what it allows a person to still do, still experience, still contribute.

This shift is already underway. Universal design reduces the need for constant physical management and makes daily life more navigable for people across levels of ability. And beyond that, whatever comes next will likely continue the same pattern: fewer situations where safety depends on continuous vigilance, and more situations where safety is built into the environment itself.

The pattern is the same one Gordon traces through the twentieth century. The most important changes are not always the ones that feel like breakthroughs. They are the ones that quietly remove entire categories of failure from everyday life. The underlying capacity for attention, effort, and commitment within families is relatively stable across time, even as families themselves have evolved.

And in caregiving terms, that may be the most important change of all: not that care is easier, but that care is more often enough.

The last time I’d seen her, she was miserable. She felt stuck in every corner of her life. Work was an exhausting dead end, her marriage felt impossible, and relationships with family and friends were stressful. She was exhausted from trying so hard and getting so little in return.

So when we met for lunch again a few days ago, I was startled by her transformation.

She looked lighter. Relaxed. Hopeful. She positively glowed.

When I asked what had changed, she told me about her realization. For years, she never doubted that she was committed to her marriage, her career, her family, and the rest of her life. After all, she was working hard. Showing up. Sacrificing. Doing all the heavy lifting responsible adults are supposed to do.

But in the middle of a recent crying jag, she was struck by a sudden moment of clarity: Effort and commitment are not the same thing.

Beneath all that effort, she realized she was still holding herself at a distance from her current life. She was guarding herself against disappointment, fantasizing about roads not taken, and comparing her actual life to imaginary versions of how things should have been.

The resentment she’d been carrying wasn’t proof that she was committed. It was proof that she wasn’t—not fully, anyway.

While she was showing up and doing the work, her heart was still protecting itself… and longing for something different.

There’s nothing wrong with being guarded. Walls and boundaries exist for a reason. Sometimes they protect us. Sometimes they create the space a relationship needs to grow. But my friend realized that some of the walls she thought were protecting her had quietly become barriers to fully participating in her own life. She was physically present, but emotionally she still had one foot out the door.

Acceptance doesn’t mean approving of everything. It doesn’t mean liking it, or pretending everything is fine. It just means seeing things exactly as they are: This is my job. This is my spouse. This is my family. This is the life I am in. This is my life.

As she talked, I felt the prickle of my own recognition.

When we’re resentful, it’s easy to assume the problem is that we’re giving more than we’re getting. Sometimes that’s true. But sometimes resentment comes from spending enormous amounts of energy fighting reality. We want people to be different than they are. We want circumstances to change overnight. We want our efforts to produce outcomes they simply cannot produce.

Because we are so busy arguing with reality, we never actually engage with it.

My friend shared another insight that hit me hard. She realized that whenever loved ones told her they were hurt or frustrated with her, her instinct was to present evidence that she was a good person. She would remind them of everything she’d sacrificed, all the ways she’d tried, and all the reasons she shouldn’t be blamed.

And she’s right—she is a wonderful, warm, generous, brilliant woman.

But the effect was that she never actually listened during the conversations that mattered most. She was so busy defending her record that she couldn’t hear what they were trying to tell her. Without realizing it, she was shutting them down and creating distance.

She couldn’t bear the thought of letting anyone down, so the mere hint of criticism triggered a wave of shame that completely shut the conversation down.

I think many of us do some version of this, and it doesn’t mean we are bad people. We are good people under immense pressure, deeply attached to the story that we’re trying our best. And we are. But trying our best isn’t the same thing as seeing clearly or being a good listener.

This time, my friend was able to look at her own behavior with true compassion. When we see other people scramble to defend themselves, it doesn’t stop us from loving them. We recognize it for what it is: a knee-jerk human reflex to feeling overwhelmed.

She was living in a defensive crouch. Looking honestly at her relationships felt dangerous. Letting people all the way in felt dangerous. So she kept trying harder instead.

No matter how smart and capable you are—and she is incredibly smart and capable—you cannot fix a life you aren’t willing to look at.

Trying harder doesn’t help if you’re trying to solve the wrong problem.

What excited my friend was the realization that she wasn’t actually stuck.

If the problem was that her boss, her husband, her family, and her friends simply didn’t appreciate her enough, there was very little she could do. You can’t force people to see you differently. You can’t earn someone’s love.

But love was the very thing that unlocked her insight.

Despite feeling unappreciated and misunderstood, she knew, deep down, that her husband, family, and friends loved her. That sense of safety made it possible to consider a difficult possibility: what if the story she’d been telling herself wasn’t the whole story?

If part of the problem was that she had stopped really listening to them—or if she was acting like she was waiting for her real life to start—then suddenly she had options. She could listen. She could learn. She could adjust. She could stop pouring energy into proving she was right, and start investing it in understanding what was actually happening.

In caregiving, there are many realities we did not choose and cannot change. A diagnosis. Constant schedule disruptions. A loss of abilities and options. The endless paperwork nonsense. The uncertainty. It’s all too easy to get stuck fighting to return to a future we’d planned for, rather than creating a new life that feels worth living.

Sometimes, we resist making actual changes to our routines or adjusting our lives to fit this new landscape because doing so feels like a capitulation. To unpack our bags and build a life here, in this reality, feels like giving up on the life we actually wanted. It feels like surrender.

We refuse to find our footing in the present because we are holding space for a past or a future that no longer exists. We remain emotionally camped out somewhere else, waiting for our real life to begin again.

Refusing to adapt won’t change the diagnosis or fix the system; it only keeps us suspended, trapped in an exhausting argument with the life we are already living.

I’ve been wondering lately whether some forms of resentment are actually invitations. Not invitations to give more or sacrifice more, but invitations to look more honestly at what is right in front of us.

To ask ourselves:

• What reality am I still resisting?

• What am I refusing to see?

• And what might become possible if I stopped spending so much energy wishing things were different, and started engaging with things as they are?

I don’t have all the answers. But I haven’t been able to stop thinking about my friend’s insight. And usually, that means there’s something there worth looking at.

Of course, having this realization hasn’t exactly changed anything for me overnight. It didn’t stop me, for instance, from literally crying with frustration yesterday and then yelling at my wife for trying to help when I got trapped in an endless multi-factor authentication loop with my bank.

Apparently, accepting reality is a practice. And clearly, it is still not my forte.

But I’m working on it. One password reset at a time.

A few months ago, I tried to leaning into that “Web 2.0” community spirit by reviving our website forums. As much as the Facebook groups are still thriving, a lot of us really missed the forums. Replies that trickled in. No infinite scroll. No algorithm. No ads. It was a tricky technical puzzle, since a lot has changed since bbpress was everywhere, so reactivating the plugins did not work. We got it running, and watching you all start to connect there was incredibly rewarding.

But here’s a little behind-the-scenes truth: our website has been chugging along since 2012. It hadn’t been truly rebuilt since 2014, despite having undergone a lot of changes.

• It used to be a full social network, with the forums, messaging, profiles, private and public blogs, and tons of traffic. Jonah was producing videos for our YouTube channel and organizing at least one video call every day. This was super cool, but not sustainable for a volunteer organization! I was carrying my laptop everywhere so I could deal with website emergencies and our moderators were working around the clock. We reduced the features to just a forum and the blog.

• That was followed the “BuzzFeed for Caregivers” phase. We had a group of volunteers and ambitious authors who were churning out several posts a day to our “online magazine.” I had a daily newsletter. Then I met the folks at BuzzFeed Canada and learned that our site had more traffic than they did, even though they had a staff and a budget. For the first time I stopped to ask myself why was I so obsessed with traffic when we weren’t funded by ads?! This was also not sustainable for a volunteer organization.

• I shifted gears to focus on curating the best outside publications and resources we could find. I was finding a ton of great writing, podcasts, videos, and other stuff that talked about care work without ever using the term “caregiver.” However, people didn’t really embrace this curated directory idea. There was a backlash against companies like HuffPo and BuzzFeed not paying their authors, making us uncomfortable asking people to write for our site, even though there was no profit involved. Soon, most of our post submissions we advertorials, which went straight into the trash. Our community mostly used the Facebook groups, sometimes without even realizing we even had a website.

Now, that the web has been taken over by “amateur” content that’s actually polished stuff produced by professional influencers and AI slop and Facebook has become…not the best place to feel safe being honest about private experiences…it felt more important than ever to bring back the blog. The HuffPo era of user-generated content had it’s pros and cons, but it made it possible for anyone to share their experiences. That’s the part we miss.

BBpress forums are clunky and don’t get instant replies. They’re just a quiet, stable space to talk. And since a lot of us are dealing with issues that are basically eternal, if not literally eternal, it’s nice to be able to easily find posts from 12 years ago.

We have thousands of posts in our archives. I’m rebuilding our "Library" page to make it easier to find things. I’m channeling those old Yahoo / AltaVista / DMOZ directories to make it easier to find what you want—whether that’s stories written by someone in your exact situation, weirdly specific practical advice, or a curated list of the best podcasts about care work.

Over the last decade, every new feature, facelift, and cool custom tweak I added to the website was layered on top of that 2014 WordPress foundation. That code bloat became a massive liability. The site was getting heavy, slow, and all our fancy typography had become unreadable.

I couldn’t put it off anymore. I started completely from scratch and rebuilt our website from the ground up. All the reasons that made the old site impossible to fix also made it a real treat to try to recreate. Luckily for me, my wife actually knows how to work with backend databases, while I know how to, uh, get things done.1

What’s new (and why it matters to you)

I stripped away the bloat so we can focus on what actually matters: connection.

Here are two ways you can get involved today:

• Dive Into the Forums: Caregiving comes with heavy emotions, tough questions, and moments where you just need to vent without judgment. If you want to protect your privacy, you are completely welcome to post anonymously.2 Come share a win, ask for advice, or just let off some steam with people who truly get it.

• Submit a Guest Article: Your lived experience is the most valuable resource we have. Have a caregiving tip that saved your sanity? A personal story that might help someone else feel less alone? We want to publish it. You don’t need to be a professional writer—just a caregiver with a story to share.

In order to keep the community as a safe space, people request accounts through a form on our login page. Our moderators manually review each request, create the account, and email you to welcome you to the community.

Once you have an account, you can post to the blog. I’m super excited to see that people are already submitting posts for the blog. I’ve been slow to respond and get them scheduled, because I’ve been hunting down bugs, but I’m catching up. If you don’t have an account, you can submit a post through our contact form.

You don’t need an account to comment on posts, either. Our old posts have so many comments. They were such a great way to have a conversation and Substack makes it clear that we still know how to have a great discussion in the comments.

You also don’t need an account to participate on the forums. If you don’t have an account (or our spam checker is feeling particularly suspicious) things are held in the moderation queue. Sit tight and a moderator will review and approve it.

This website isn’t a corporate social responsibility project for a conglomerate—it is a living, breathing home for caregivers, built to support you.

The Caregiver Space is a DIY project

In the early days, I had this idea that everything needed to look “professional.” Adrienne and I come from graphic design backgrounds, so it was automatic for us to set up a style guide and obsessively follow it. We knew how to make things look and sound professional. But honestly? That set up expectations we could never actually meet.

We aren’t a big organization with a team of paid editors, designers, and database managers. When you try to force a volunteer-driven passion project into a corporate mold, it just doesn’t work. We do not have dozens of experts standing by, ready to help. We don’t have cheques to mail out. It’s just us, creating what we want for each other. Doing what we can, with the tools we have, in the time we have.

If you poke around the site (especially as I continuing cleaning up legacy formatting and fixing the bugs), you are going to find the digital equivalent of a community garden:

• There are abandoned projects from years ago that we never quite finished.

• The writing quality varies wildly, from polished essays to raw, late-night forum vents.

• The categories and tagging system is inconsistent, depending on who was helping out that month and how things evolved.

And you know what? That’s exactly how it should be.

This is fundamentally a DIY project. The mess is proof that real people navigating the incredibly heavy reality of care work built this place themselves.

Everyone who shows up is invited to be part of it. Whether you want to share a raw personal story, drop your hard earned wisdom, or help me make sure the archives actually have tags, this is our collective garden. Let’s keep it weird, real, and helpful.

Thank you for being the heart and soul of this community since the beginning, and for sticking with me through every facelift and pivot.

Visit The Caregiver Space

This awakening creates an inevitable social chasm. Because you spend your days confronting the “natural unhappiness of our weak and mortal condition,” you have lost the capacity for distraction. Conversations about bad Wi-Fi or awkward brunches, social media brags about vacations and job promotions – it all feels absurd, even offensive.

When you speak, you inadvertently “puncture” the diversions of others, serving as a walking reminder of the mortality they are desperate to forget. This makes them uncomfortable, leading to their withdrawal or the “toxic positivity” of those who refuse to hear what you are saying.

Pascal’s philosophy explains this disconnect perfectly: you are operating in different orders of existence. He taught that the order of charity cannot be understood by people in the lower orders of worldly power or mere intellect. Pascal wouldn’t suggest you “fix” your friends or force them into the dark, despite his writings all doing that to the reader.

Once you realize they literally cannot see what you see, your resentment might turn into a strange kind of pity. They aren’t being cruel; they are simply still asleep on the pillow. Even in your loneliness, you are in the “highest” company. Your life feels out of proportion with theirs because your soul has grown to accommodate a larger reality. This lonely ache is not emptiness – it is the newfound spaciousness of your own heart.

The modern world adds a layer of guilt to this isolation by framing “advocacy” as the caregiver’s primary moral duty. We are told that love means never accepting a “no” from a doctor, making Pascal’s advice—to acknowledge our “weak and mortal condition”—feel like giving up. We feel a moral weight to exert constant control, fearing that to accept mortality is to betray the patient. Pascal would argue the opposite: the true betrayal is pretending the patient isn’t a mortal being just to satisfy our own need for agency.

To embrace this truth is to intentionally dismantle the 21st-century illusion that we are the masters of our fate. We must admit that billions of dollars in research haven’t closed the “gap” Pascal identified 350 years ago. Our desires remain infinite, but our power remains finite. Doctors and medicines have their limits, and grieving that reality is not a failure—it is the honest acknowledgment of the human condition.

You can survive this “pre-modern reality” by practicing what Pascal called finesse. You can chit chat and make trivial small talk. Just do it without letting it touch your core, without denying the reality in your heart. You can be in the world of diversion without being of it.

Pascal surrounded himself with other people he knew were living their lives in the order of charity. You can find other people who are also “sitting in the room.” Find the other caregivers and those who have moved through deep grief—the people who have made an honest estimate of life. With them, the need to perform ends. You can simply be.

Lack of courage

For people who rely on constant activity to keep their inner demons at bay, the silence of a sickroom is terrifying. They flee the room because they are fleeing the thoughts that the room forces them to have.

Pascal’s explanation for why friends and family withdraw from the terminally ill isn’t based on a lack of love, but on a lack of courage. In his view, a dying person is a mirror that forces everyone else to look at their own mortality—and most people find that sight unbearable.

When a friend enters a sickroom, they can no longer pretend they are immortal. Their diversion from the realities of the human condition is punctured. They withdraw because they want to go back to the “pillow of ignorance” where they don’t have to think about death.

Most people want to “fix” things. When a friend is dying, there is nothing to fix. This creates a radical psychic disequilibrium. Because the friend cannot fulfill their desire to “make things better,” they feel helpless. To avoid the honest estimate of their own helplessness, they stay away.

The result is that friends make excuses not to visit. They change the subject and only discuss trivial things. They refuse to acknowledge reality and insist the person will recover and everything will be fine. Or they vanish entirely. They cannot handle the reality of the human condition.

These friends are not yet strong enough to face the truth of what we are. They are choosing the “pillow of ignorance” over the honest acknowledgment of unhappiness.

It is a failure of their philosophy, not a failure of your relationship.

Grief and inefficiency

Today, we pathologize what Pascal considered the most honest part of being human. If you grieve “too long,” the modern world offers a pill or a productivity hack to get you back to living like everyone else…those everyone else’s who are busy keeping their heads on the pillow of ignorance.

The DSM-5 (the manual for mental disorders) now includes “Prolonged Grief Disorder.” While clinical help is vital for survival, Pascal would argue that “prolonged” grief isn’t a malfunction; it is a recognition of a permanent hole in the universe. To cut grief short is to lie about how much that person mattered.

Following Pascal’s advice today requires a quiet, rebellious commitment to inefficiency. Don’t try to meditate to clear your mind, since that’s often just another way to achieve a “result.” Instead, simply notice the discomfort. If you feel sad, bored, or anxious about mortality, that’s the start of the truth.

Pascal talks about hunting and gambling as a diversion. His idea of what might be a diversion is pretty broad. It includes feeling like you must “optimize” your grief or “learn a lesson” from it. It includes using social media to feel “connected” so we don’t feel the “incertitude” of our own minds. He doesn’t want us to find the bright side. The questions to ask are: Does this need to be done? Am I afraid of what I’ll feel if I don’t do this?

At first this seems a little ridiculous. Of course we need to clean the house, pay the bills, do all the things on our to do list. But I know I’m not the only one who has a sudden compulsion to clean when I’m overwhelmed. Sometimes I jump into action on chores because I need to feel like I’m doing something. This is exactly what Pascal is talking about.

Pascal’s idea of honesty can feel heavy, but it is meant to lead to a deeper kind of peace—one that doesn’t depend on things going well.

Pascal’s famous indictment—that we cannot sit quietly in a room—is the caregiver’s daily existence.

Through Pascal’s eyes, that room is no longer a prison or a waiting room for the void; it is a laboratory of the soul. Through Montaigne’s eyes, that same laboratory is also a living room. While we are thinking reeds contemplating the abyss, we are also physical creatures who require the small, earthly consolations of a warm cup of tea, the weight of a sleeping cat, or the simple finesse of a shared glance.

Pascal tells us not to scroll away the ache or run from grief. That emptiness is not a malfunction; it is the spaciousness of your own heart finally making room for the infinite. But in that spaciousness, allow yourself the Montaignian grace of the ordinary. Pascal gives you the courage to look mortality in the eye and choose to stay, but Montaigne gives you the permission to find a soft pillow in the small pleasures that remain. Not every pillow or small comfort is the pillow of ignorance.

You may feel like an alien to the “somnambulists” around you, but by merging Pascal’s depth with Montaigne’s humanity, you find a home that is both vast enough to hold the truth of death and cozy enough to sustain the reality of life. You are finally, profoundly, and truthfully home—standing in the light of the stars, but with your feet firmly on the ground.

Each role corresponds to an “Order.”

• The Order of the Body: This is the world of physical things that the eye can see, such as kings, wealth, medicine, and power.

• The Order of the Mind: This is the world of science, philosophy, and logic. It is more important than the physical world.

• The Order of Charity (or Heart): This is the supernatural world of love and grace. Pascal says this order is “infinitely more infinite” than the others.

The son: order of the body

The role of the son was the messy role. Pascal, despite his own frail health, performed the physical labor of care. This is the realm of the Order of Bodies. It involves the heavy lifting, the cleaning, the sleepless nights, and the witness to physical pain. This is the raw, hands-on work—the changing of bandages, the helping with mobility, and the physical presence at the bedside.

By serving his father’s physical needs, Pascal was forced to confront the “weakness” of the human condition. He didn’t look away from the physical decline. He realized that we are all “reeds” susceptible to a “drop of water” or a slip on the ice. This role grounded his philosophy in empathy rather than just abstract thought.

The manager: order of the mind

As the manager, Pascal used his Order of the Mind. He didn’t just pray for a miracle; he acted with cold, scientific precision. This is the caregiver who researches clinical trials, manages the medication schedule, and negotiates with insurance or doctors.

This role is necessary but insufficient. Pascal realized that even the best managers eventually hit a wall where the body cannot be managed any further. He saw that the Order of Bodies (medicine) can fix a hip, but it cannot fix the misery of knowing that the hip—and the body it belongs to—is ultimately temporary.

The student: order of charity

Pascal was a student of reality while his father slept or recovered, Pascal used the room as a laboratory for the soul. He read, he observed the silence, and he allowed the anguish of the situation to teach him. This is the caregiver who uses the long hours of sitting to reflect on life’s meaning, to read philosophy or scripture, and to stop running from the reality of death.

This is where the Order of Charity begins. As a student of the sickroom, Pascal learned that human greatness doesn’t come from being “invincible” (the manager’s goal) but from being “conscious” (the student’s goal). He realized that the time spent in the sickroom was not wasted time, but the only time in his life where he was truly awake.

In the modern world, “charity” usually refers to a transaction: giving money to a non-profit, donating clothes, or volunteering. It’s seen as a moral “add-on”—something good people do in their spare time. For Pascal, Charity is not an action you do; it is a reality you enter. It is a specific Order of existence that is fundamentally different from the world of physics or logic.

Pascal has a famous quote: “All bodies together and all minds together... are not worth the least impulse of charity.”

It means that the simple, quiet act of loving a person who cannot “give back” is more significant than all the scientific breakthroughs or political power in the world. You are operating in the highest possible tier of reality.

All three roles pull us in different directions, creating an uncomfortable values conflict. An “ideal” caregiver will find a way to balance them. Focusing entirely on the manager role becomes a diversion from reality. Focusing entirely on the son or daughter role leads to self obliteration (or, as we’d put it today, burnout). Focusing entirely on the student role is, as Pascal demonstrates, a huge bummer that leads to despair.

By shifting between the three roles, we find a healthy balance that allows us to navigate challenging times. We accept while doing what we can to find a cure. We serve while maintaining our intellectual self. We are both present and distracted in turn.

One of the reasons I think Pascal is so important is because, while modern caregivers are typically excellent managers and devoted sons and daughters, they are less often competent students. They are always doing something, be it navigating systems or disinfecting everything. It’s presence that many of us struggle with. We stay so busy we fail to witness the human condition.

Sitting in a room

Pascal famously noted that all of humanity’s problems stem from our inability to sit quietly in a room alone. We fear our own thoughts. Caregivers are often forced into long periods of “sitting in a room”—watching a bedside, waiting in clinics, or staying home.

While the rest of the world is running away from the reality of death through modern equivalents of the diversions he mentions – like video games, online shopping, reality TV, and endless scrolling – you are doing the hard work of staying. By facing misery and death, caregivers are achieving a level of self-knowledge that most people spend their entire lives avoiding.

Caregiving puts you face-to-face with the very things the rest of the world tries to ignore: fragility, the limits of the human body, and mortality. Caregiving is not difficult because we are failing as a caregiver. The human condition is inherently fragile and we continually grieve this. Grief is the only honest response to seeing life as it is.

We often try to “fix” our sadness or treat it as a clinical problem to be solved. Pascal gives you permission to grieve—not just for the person you are losing, but for the difficulty of the situation itself. It suggests that your sadness isn’t a “breakdown”; it is an honest acknowledgment of reality. There is a quiet dignity in that honesty.

Pascal noted our “unceasing effort to get outside ourselves.” As a caregiver, you might feel guilty for wanting to scroll on your phone, watch TV, or “get away” for a moment. Pascal tells us that the urge to escape is a universal human reflex, not a personal failure. You aren’t “weak” for wanting a distraction; you are reacting to the “misery of our weak and mortal condition” which you see more clearly than anyone else.

Resilience, not success

Things have changed a lot since Pascal left his writings unfinished. While the human condition hasn’t changed, our relationship to it has become more dishonest. In the 1600s, you knew you were at the mercy of God or Nature. Today, we believe we are at the mercy of the right doctor or the right diet. When we still face death, we feel betrayed rather than just mortal. We have moved the sickroom out of the house and into the hospital. This creates a society that is death-illiterate. As a caregiver, you are one of the few people forced to be literate in a society that has forgotten the alphabet of grief.

In Pascal’s time, distraction took more effort. Today, distraction is frictionless. You don’t have to leave your chair to get outside yourself, you just reach for your phone. Pascal would be horrified—not because we are “worse” people, but because the pillow of ignorance is now so comfortable and accessible that we might never wake up.

Until the mid-20th century, our weak and mortal condition was not a philosophical concept—it was a daily, visceral reality. Disability, illness, and aging were not hidden in institutions. Infant mortality was high, and infectious diseases could wipe out a family in a week. Almost everyone literally sat in a room with a dying relative by the time they reached adulthood. In the modern world, every death can feel like a lawsuit, a medical error, or a failure to find the “right” specialist. This creates a psychological layer of indignation that Pascal didn’t have to contend with.

Modern philosophy often focuses on progress, while ancient philosophy focuses on endurance. A lot of modern advice is about optimization: how to get better, how to live longer, how to fix the problem. Past philosophers like Pascal, the Stoics, and the Buddhists lived in worlds where the “problem” couldn’t be fixed. Therefore, they developed mental muscles for acceptance that we lack. When a caregiver turns to Pascal, they are accessing a survival kit built for an era where loss was the baseline, not an anomaly.

Loss of self

Pascal is famous for saying, “The self is hateful”, because he believed focusing on our own egos, pride, and desires leads us away from truth. However, Pascal would likely view the caregiver’s “loss of self” not as a holy achievement, but as another form of “diversion.”

Pascal argues that we use “busy-ness” to avoid sitting quietly with our own souls. For a caregiver, the endless list of tasks—medications, appointments, cleaning—can become a shield.

If you are so busy caring for another that you never have a moment to face your own “mortal condition,” you are technically using the patient as a way to “get outside yourself.” Pascal might suggest that some caregivers cling to the “utility” of their role because if they stopped for one hour, the sheer weight of their own grief and mortality would become overwhelming.

There is a difference between selflessness (loving the patient) and self-obliteration (forgetting you exist). By becoming a “tool” of utility, the caregiver stops being a “being” who thinks and feels. Pascal would argue that you cannot have a truthful relationship with the patient if you aren’t having a truthful relationship with your own soul.

Part of honest self awareness is acknowledging one’s own limits and suffering. When caregivers ignore their limits and give far beyond their capacity, this is a sign that they are using the patient and the labor as a very unpleasant form of diversion. It’s not selfless, it’s self-obliteration.

Pascal isn’t telling us to be obliterate ourselves. If you lose every aspect of yourself that isn’t “useful,” you are treating yourself like a machine. But a machine cannot grasp the truth or feel the “fitting and proper reaction” of grief. To be a truly “human” caregiver, you must remain a person who has desires, fears, and a life outside the sickroom—even if those things make you feel more vulnerable.

Pascal’s philosophy is famously unsentimental, but it offers a kind of comfort. He would argue that the “devastation” after a death isn’t just because the loved one is gone, but because the diversion is gone. When the caregiving ends, the “busy-ness” stops, and the caregiver is left alone in that quiet room Pascal so famously feared.

Pascal believed that we often turn our activities—even noble ones like caregiving—into “idols” to avoid facing our own void. While care work is a moral good, it cannot be the total definition of your existence. If you define yourself purely by your “utility” to the patient, you are building your house on a “mortal and weak condition” that is guaranteed to change.

For people currently providing care, Pascal would suggest intentionally carving out moments to “sit in the room” with yourself now. Don’t wait for the death to face your own mortality or your own identity. By facing the “misery” of the human condition while the patient is still alive, you process the grief in small doses rather than being hit by a tidal wave of reality later.

When the caregiving stops, the silence is deafening. Rather than rushing to fill the void with new diversions, like we’re often encouraged to, lean into the grief. If you feel empty, Pascal would say that emptiness is actually the truth. The caregiving was a veil; now the veil is lifted. Instead of fearing the emptiness, see it as the beginning of self knowledge.

You are a conscious being who has witnessed the ultimate truth of life: its fragility. Pascal would encourage you to use this time not to “get over it,” but to contemplate what it means to be a “mortal being” who is capable of such immense love and labor despite the inevitable end.

Anger, resentment, and guilt

Pascal would likely view anger, resentment, and guilt not as character flaws, but as the inevitable friction caused by our mortal condition. In his view, these emotions are the sparks that fly when our infinite desires hit the brick wall of our finite reality.

Pascal believed that every human heart has the instincts of a king but the reality of a pauper. We want to be in control, to be happy, and to have our world be orderly. Resentment arises because your life has been hijacked by a situation that you cannot control. You are incapable of not wanting happiness, yet you are trapped in misery. Your anger is a protest against the gap between the life you want and the life you have. Pascal would suggest that you are angry at the human condition itself. By redirecting your anger toward the tragedy of mortality rather than the person in the bed or the insurance company, the resentment loses its target and becomes a form of grief.

When we try to become kings and immortal gods, we become less human. Science, medicine, and technology are amazing tools, but they cannot save us from the human condition. When we view death as a “system failure” rather than a natural part of our “weak and mortal condition” we delude ourselves. This “cure-all” mindset and faith in science can be devastating. If death is seen as a conquerable enemy, then the death of a patient feels like a personal failure or a technological error rather than an inevitable human transition. Once you admit you cannot conquer death, you are finally free to live truthfully within the time you have.

Caregivers often feel guilt for wanting their “old life” back or for feeling relief at the thought of the end. We are the only creatures who can judge ourselves. We have an ideal of perfect love, but we get tired, cranky, and selfish. Pascal might suggest this guilt is a sign of your greatness. Only a “great” being could feel guilty for not being perfectly selfless. Humans cannot be angels. He famously said, “Man is neither angel nor beast; and the misfortune is that he who would act the angel acts the beast.”

Pascal wants us to accept that we are weak creatures. Guilt is often a form of pride—the belief that you should have been stronger than human nature allows. Admitting you are “mortal and miserable” allows you to forgive yourself for being exhausted.

When we feel resentment or guilt, our modern instinct is to “fix” it or “distract” ourselves from it. Pascal suggests the opposite. Pascal tells us, “No psychic equilibrium is possible for a being whose desires so radically out-strip his possibilities.” We cannot find equilibrium because the struggle of a caregiver is naturally unbalanced. If you accept that it is normal to feel like you are failing—because the task of facing death is too big for any human—the anger, resentment, and guilt begin to dissolve. You aren’t failing; you are simply being “shattered” by a reality that is “out of all proportion with the limits of mortal frailty.”

To accept the human condition as Pascal describes it, a caregiver must essentially stop fighting a war they cannot win. This doesn’t mean giving up; it means changing the goal of the struggle. You can fight for a medical breakthrough with your hands while holding the truth of mortality in your heart. The modern world views a patient with an illness or disability as a “problem” to be solved. Pascal views the patient and their relationship with the caregiver as a “mystery” to be witnessed.

As a caregiver, you are not a technician fixing a machine; you are a human being accompanying another human being through the “weak and mortal condition.” If you are a “solver,” you fail when the patient dies. If you are a “witness,” you succeed simply by staying in the room and being present. Pascal advises us to find joy in celebrating the human condition, including our frailty and dependence.

Acceptance

We are raised to believe that for every problem, there is a technical solution. If the car breaks, you fix it. If the app glitches, you update it. When caregiving enters the “mortal phase,” you are faced with a “problem” that has no technical solution. When we believe death is a “glitch” we haven’t patched yet, we stay in the order of minds and keep trying to solve the puzzle rather than moving to the order of the charity and accepting the person in their full humanity. We feel betrayed by medicine, so we keep fighting long after Pascal would suggest sitting in the room.

Pascal says misery comes from the gap between what we want (perfect health, infinite time, total control) and what we are (mortal and limited). Much of a caregiver’s suffering comes from the feeling that things should be different—that they should be able to fix the person they love or that they should be able to do it all without getting tired. By accepting that no psychic equilibrium is possible for a being with our limitations, you can stop blaming yourself for feeling overwhelmed. The gap isn’t your fault; it’s the nature of being human.

Sometimes, the most peaceful thing you can do is stop trying to “solve” the tragedy of life and simply acknowledge that it is, indeed, very hard.

He left behind honest, raw observations about how hard it is to be a person. He suffered from chronic, debilitating illness (likely a combination of stomach issues, neurological pain, and insomnia) from the age of 18 until his death at 39 in 1662. When he writes about the misery of the body and sitting still in a room, he is writing as a man who has been the patient confined to bed and the one sitting at the bedside.

Pascal was another man of privilege who also endured extreme suffering. He lived through the Fronde civil wars, where his family had to flee their home and live as fugitives. He was under constant threat of arrest or excommunication because of his religious views. His mother had died when he was too young to remember her and his genius was insufficient to save his father, his sister, or himself.

While Pascal is primarily remembered for his intellect, his life was defined by a profound “Order of Charity” that manifested in his hands-on care for his family. His experience caring for his father, Étienne, was a turning point that merged his scientific mind with a spiritual depth.

When Étienne Pascal broke his hip at age 58, it was essentially a death sentence in the 17th century. Hip fractures rarely healed, and the resulting immobility often led to fatal complications.

At 23, Blaise Pascal became his father’s primary caregiver, along with his sister Jacqueline. For three months, Blaise was confined to the house, managing the logistics of a pre-modern “hospital at home.” This included the constant repositioning of a man in pain, managing hygiene, and dealing with the psychological toll of a parent’s sudden dependency.

Pascal did not just provide emotional support; he used his intellect and connections. He sought out the best medical minds available—specifically two bone-setters, the Deschamps brothers, who lived in the Pascal home while treating Étienne.

It was during this period of caregiving that Pascal experienced his first major spiritual shift. The two bone-setters were followers of Jansenism, a rigorous, austere branch of Catholicism that emphasized human frailty and the need for grace.

While “sitting in the room” with his father, Pascal read the Jansenist texts provided by the bone-setters. He realized that the intellectual life he had led—full of mathematical fame—was a diversion. His father’s broken hip stripped away the family’s “pillow of ignorance.” It proved that a brilliant man like Étienne could be brought low by a slip on the ice. This reinforced Blaise’s belief that we are “thinking reeds”—fragile but conscious.

Pascal’s role was doubly difficult because he was a sick man caring for a sick man. By 1646, Blaise was already suffering from severe nervous ailments and digestive pain. He had to push through his own limitations to support his father.

After his father died in 1651, Pascal’s caregiving didn’t end; it expanded. In his final years, he sold his carriage and furniture to give to the poor. It was likely clear to Pascal that he would not live a long life. By 1661, his sister Jacqueline was on her death bed. She was a nun, so her sisters cared for her in her final illness. However, the two were incredibly close throughout their lives.

When he became terminally ill himself, he didn’t want a private room. He asked to be moved into a hospital for the “incurables” so he could die among the poor. When his doctors refused because he was too weak to be moved, he took a poor, homeless family into his own home and cared for them even while he was dying. He insisted that if he couldn’t go to the poor, the poor should come to him.

It’s much more difficult for me to relate to Pascal than Montaigne. Pascal’s Jansenism is pretty intense, especially compared to Montaigne’s mix of pragmatic and personal Catholicism. Montaigne remains popular, in part, because his essays are so relatable. It’s easy to imagine splitting a bottle of wine with him.

Pascal, on the other hand, is the friend who corners you to talk about the fact that we are all hurtling toward an infinite abyss. Since he believed that comfort is a trap, it’s harder to see where Pascal’s views fit into my own life. Somehow his wisdom still resonates with me.

Even when I agree with Pascal – he hates euphemisms for death and doesn’t want to sugar coat things – his insistence on refusing to play along with other people’s comfort levels seems cantankerous.

Despite Pascal’s demeanor and brooding on suffering, he was surprisingly popular. He was at the center of the scientific world. Before his final conversion, he hung out with “libertines” and gamblers. In his final years, he was part of a tight-knit group of scholars and monks. He was incredibly close to his sister, Jacqueline. Their relationship was intense, intellectual, and spiritual.

The pillow of ignorance

In Pascal’s philosophy, the “pillow of ignorance” is a metaphor for the psychological comfort we find by refusing to think about the difficult truths of our existence—specifically our mortality, our limitations, and our lack of absolute certainty.

The term actually originated with Michel de Montaigne, a philosopher whom Pascal studied deeply. Montaigne suggested that if the big questions of life (like “What happens when I die?”) are too painful, it is better to simply stop asking them and rest one’s head on a “soft pillow of ignorance.”

While Montaigne saw this ignorance as a form of peace, Pascal viewed it as a dangerous delusion. Sleeping on the pillow of ignorance is like a prisoner sleeping soundly the night before their execution—it feels peaceful, but it isn’t based on reality. You are living as a stranger to your own soul.

A caregiver who focuses only on the logistics of care is often trying to stay on that pillow. They focus on the doing to avoid the being. Pascal would tell you to stop using the work to hide from yourself. He would advocate for “sitting in the room” with your own fatigue and your own fear, rather than burying it under another chore.

A caregiver often loses their pillow of ignorance the moment a loved one receives a terminal diagnosis. While friends and family might try to offer you a new pillow through platitudes or toxic positivity, Pascal suggests that staying awake is the more dignified path.

For Pascal, the anguish a caregiver feels is primarily the act of losing the pillow. When you can no longer ignore the fragility of life, you are forced to wake up. It is uncomfortable, but for Pascal, an uncomfortable truth is always better than a comfortable lie.

The thinking reed

The pillow of ignorance and the thinking reed are two fundamentally different ways of surviving the human condition. One offers comfort through denial, while the other offers dignity through acceptance. The thinking reed acknowledges that we are physically the weakest thing in nature—a mere reed that can be crushed by a “drop of water” or a “vapor.” However, we are greater than the universe because we know we are being crushed.

Instead of hiding from the gap between our desires and our reality, the thinking reed stands right in the middle of it. The caregiver accepts: “I am fragile, and the person I love is fragile, but my awareness of this love and this loss makes me noble.” They don’t need a pillow because they have found a way to rest on the truth. The thinking reed cannot be defeated by death because it has already looked death in the eye and understood it.

Those who rest their head on the pillow of ignorance seek comfort, stick with small talk, view frailty as a misfortune, panic in a crisis, and lack self knowledge. Those who are the thinking reed seek truth and dignity, view frailty as the defining reality of being human, are truly present, experience grief in a crisis, and know their limits and values.

The pillow of ignorance is a lot of work to maintain, since you’re constantly afraid of being woken up. The thinking reed, however, is a position of stability. Once you admit you are a reed, you stop trying to be anything else. You can finally bend with the wind of the illness without breaking. You find contentment, not because the situation is good, but because you are finally living a life that is honest.

Montaigne’s pillow

I think it’s a useful metaphor, but it feels a bit like a straw man. While the pillow of ignorance comes from Montaigne, he doesn’t advocate for denial. Pascal’s recollection of his transformation from ignorance to knowledge feels a bit like the caricature before and after stories that remain a staple of self help books. It doesn’t sound like it’d be healthy or helpful to meditate on human frailty all the time. Small talk and distraction have their place.

Montaigne’s pillow of ignorance was a suggestion for intellectual humility. He was saying something like: Since our minds are limited and we can’t truly know the secrets of the universe, why keep hitting our heads against the wall? Let’s rest on a soft pillow of ‘I don’t know’ and enjoy our lives. To Montaigne, the pillow was a cure for the arrogance of scholars. Pascal, however, takes that pillow and turns it into a symbol of moral cowardice. He argues that Montaigne isn’t just resting his intellect; he’s resting his soul to avoid the terror of the human condition.

• Montaigne’s Pillow: I don’t know why this is happening, and I don’t know how it will end, so I will focus on making today as comfortable as possible for both of us.

• Pascal’s Pillow: If I don’t think about the end, it won’t happen. Let’s pretend everything is fine so I don’t have to feel the anguish.

Pascal creates this straw man because he wants to present a binary choice: total diversion or total awareness . He leaves no room for Montaigne’s middle way of being a happy, limited human. This is why I’ll be drinking wine with Montaigne. To be fair to Pascal, though, we can all think of someone who’s currently resting their head on his version of the pillow of ignorance. In fact, far more people are resting on Pascal’s version than Montaigne’s.

Pascal’s wager

Pascal’s most famous reassurance is that man’s greatness comes from his capacity for suffering. A rock cannot be “unhappy” because it cannot think. If you feel the “gap” between what you want and what is possible, it is because you have a soul that is too big for this world. There is a deep, rugged satisfaction in being a thinking reed” You are being crushed by the weight of caregiving and mortality, but you are greater than the thing that crushes you because you are aware of it. Your ability to stay and care despite the anguish is the ultimate expression of human dignity.

Even though Pascal sounds like a total bummer, his recommendations also seem sound. It’s about acknowledging that every human is frail. We want to be infinite, yet we are exhausted. We search for reasons for illness and suffering, but we can never truly know and we will never have certainty. Pascal encourages not to use our desire for a cure and for control as a way to deny the truth of human nature. We don’t need to “solve” grief and we cannot escape it; we can only accept it and allow ourselves to feel it.

Pascal’s wager is the idea that by living, you have to bet on whether there’s a higher meaning to life or not. If you assume there’s no meaning, you get to enjoy a life of ignorance and diversion and then disappear into the void. If you bet on meaning and you’re wrong, you still lived a life of love, presence, and dignity. If you bet on meaning and you’re right, you gain infinity. By betting on meaning and living a life in the order of charity, you can only gain. You lose nothing by acting as if your love matters infinitely, and you gain a satisfying life that the void can never offer.

Montaigne felt that constant questioning of one’s station leads to a “vertigo of the soul.” By embracing the role you were “born into” or “cast into,” you eliminate the exhausting friction of regret. There is a profound contentment in saying that this is the part I play. It turns a “trap” into a “context.”

Even though Montaigne had some pretty radical ideas, he didn’t try to topple the rigid world order he lived in. Montaigne was a “conservative by temperament” but a “radical by thought.” He remained a practicing Catholic and a loyal subject of the crown not because he believed they were divinely perfect, but because he believed that upending the foundations of one’s life usually causes more suffering than it cures.

For a caregiver bound by cultural expectations—the “good daughter” in a traditional family, the “devoted spouse” in a religious community—Montaigne’s brand of non-rational acceptance offers a way to stop fighting the reality of your life.

Montaigne argued that most of our lives are shaped by the customs of our culture. He didn’t waste energy trying to prove his culture was the best or even acceptable; he simply accepted it as the air he breathed.

When we are caught in a web of cultural expectation, it’s easy to spend a lot of mental energy asking: Why is this my job? Why doesn’t my brother help? Why is our society like this? Montaigne might advise we stop looking for a reason that justifies your burden. Accept that you are acting within a specific cultural “costume.” You did not choose the disease, the family dynamics, or the cultural pressures, but they are the “raw materials” of your life. By stopping the internal debate about whether your situation is fair, you preserve the energy you need to actually live.

Montaigne’s trick was to obey externally while remaining free internally. He followed the rites of the Church and the laws of France, but he kept his mind entirely independent. Just like Montaigne, You don’t have to believe the narrative. You can fulfill the expectation as a form of social “rent” you pay to live in your community, while privately maintaining a skeptical, humorous, or even detached perspective on the whole performance.

Authenticity as trap

Today, we prize authenticity—the idea that our “inner” and “outer” selves should be a seamless, transparent whole. To modern ears, Montaigne’s advice sounds like “masking,” which we often associate with the exhausting suppression of identity (especially in neurodivergent or marginalized contexts).

Montaigne, however, would view the modern demand for “total authenticity” as a different kind of trap—a tyranny of the ego that actually makes us more vulnerable to burnout.

To Montaigne, the mask isn’t meant to deceive others; it is meant to protect the self. He believed that if you give your entire authentic self to your role as a caregiver, you leave nothing in reserve. When the role gets criticized, or when the patient is ungrateful, it feels like an attack on your very soul.

By performing the role of the dutiful, patient caregiver, you keep your back shop safe. The patient interacts with the mask, leaving your true, private self unbruised and untouched. Masking is a form of emotional labor that prevents your core identity from being “used up” by the demands of others.

Modern culture tells us we must find our identity and life’s meaning in everything we do. Changing linens or managing medication rarely feels self-actualizing. Montaigne would argue that trying to be authentic while performing repetitive labor is an unnecessary burden.

If you accept that “caregiver” is a role you are playing, you don’t have to worry about whether that role represents the real you. You are free to be bored, or angry, or intellectual in your mind, while your hands do the work of the mask.

Montaigne lived through a time when people were killing each other over “authentic” beliefs. He saw external compliance as a way to maintain peace. In a family setting, speaking your truth at every moment can also lead to constant, draining conflict. Montaigne was one of the most honest writers in history, yet he never suggested we should be honest to everyone at all times. We can share what matters—our dedication to our family, our devotion to them, our commitment to the role—without telling them everything in our thoughts.

The danger of modern masking isn’t the mask itself; it’s when we forget we are wearing one and start to believe the mask is our only face. Montaigne’s back shop ensures that while the world sees a “caregiver,” you see a philosopher, a dreamer, and a free agent who happens to be doing a difficult job.

Surviving bullshit jobs

The French Wars of Religion were a chaotic time when the legal and social systems were nonsensical, corrupt, and broken. Montaigne’s approach was not to fight the system, but to accept the laws of one’s country as one accepts the weather. Seeing someone who had been in a position of relative power and having concluded that he was unable to effect meaningful change makes this an intriguing finding.

Montaigne saw that laws change based on who is in power or which way the wind blows. If you tie your peace of mind to the morality of the law, your peace of mind will fluctuate with the election cycle or the whim of a judge. Montaigne accepted laws because they were useful for keeping the peace, not because they were holy, moral, or just. By viewing the law as a clumsy human tool, you can use it when it works and circumvent it (mentally or strategically) when it doesn’t, without feeling like you are betraying the universe.

For a caregiver, the “laws” aren’t just the legal code; they are the Byzantine rules of health insurance, the maddening bureaucracy of government support, and the cold logic of the medical system.

Burnout often stems from a sense of moral injury—the feeling that the system should be better, fairer, or more efficient. We exhaust ourselves by being angry at the insurance company for being an insurance company.

When you stop expecting the medical system to be “humane” and accept it as a complex, flawed machine, you stop bleeding emotional energy. You navigate the bureaucracy with the same detached focus you would use to solve a difficult puzzle, rather than a personal crusade.

Montaigne famously noted that many laws are “vacillating and diverse,” yet he obeyed them to maintain order. He didn’t require the law to be just for him to follow it; he only required it to be the law. When a government form requires an absurd amount of documentation, or a legal hurdle prevents a simple solution, we can view it as a natural obstacle that just is, like a mountain in your path. Realistically, changing the policies required by a health insurance company, hospital conglomerate, or state government is not much easier than moving a mountain. You don’t get angry at a mountain for being tall. By accepting the rules as a neutral, if annoying, fact of your environment, you preserve your back shop from the corrosive effects of bitterness.

Montaigne found that by outwardly complying with the requirements of society, he bought himself the privacy and peace to do as he pleased in his personal life. The faster you “pay the tax” of bureaucratic compliance, the sooner you can get back to the actual work of living and caring. Do not fight the clerk; do not argue the “logic” of the policy with the person on the phone. Provide the external compliance they require as quickly and nonchalantly as possible.

Despair often comes from the feeling that we are failing because we cannot “beat” the system. Montaigne’s resignation wasn’t a sign of weakness; it was strategic conservation of force. We must maintain a whole life despite a system that is, at best, deeply flawed.

Acceptance and preparation

For Montaigne, Fortune was a capricious goddess who delighted in upending human plans. He lived through the plague, the violent collapse of civil order, and the agonizing kidney stones. He didn’t make peace with Fortune by trying to control her, but by refusing to give her a handhold on his soul.

Montaigne’s skepticism was his greatest defense. He realized that our despair often comes from our interpretations of events, rather than the events themselves. We label a change in health or a loss of fortune as a “catastrophe,” but Montaigne argued we don’t actually know the full story. By admitting ignorance, you lower the emotional stakes.

It’s not as if Montaigne always lived in the present and ignored the future and the past entirely. Montaigne practiced a form of mental rehearsal. He didn’t hide from the possibility of disaster; he invited it into his study to “domesticate” it. He famously spent a great deal of time thinking about death so that, when it arrived, it would be a familiar guest rather than a terrifying stranger.

Montaigne would tell you to look directly at your worst fears. If you imagine the worst-case scenario while you are calm, you strip Fortune of the element of surprise. Peace comes from knowing that even if the worst happens, you can handle the next ten minutes. He faced the possible future without falling apart with anxious worrying or obsessing over trying to control his fate.

Anxiety is a spiral that moves away from reality into a thousand “what ifs.” Preparation is a stare that looks directly at the most likely “what is.” Worrying is a scattered, frantic energy that provides no solution, only exhaustion. Preparation accepts that something will go wrong eventually and allows you to imagine the next steps. Preparation exhausts the fear by making it boring and familiar. Anxiety feeds the fear by keeping it vague and monstrous.

Montaigne’s most famous image is that of a man on stilts. He noted that no matter how high Fortune lifts us—through wealth, health, or status—we are still walking on our own legs. If Fortune gives you a “small life” of deprivation, she has only taken away the stilts. She hasn’t taken away your “legs” – your character, your ability to think, your capacity for small pleasures.

Contentment is found in realizing that your value is independent of your circumstances. Fortune can take your freedom or your sleep, but she cannot take your peace unless you hand it to her. I’m not entirely convinced of this one, but it’s a popular enough idea that it must help some people.

The patchwork life

Montaigne viewed life as a series of disconnected fragments rather than a smooth, logical narrative. He didn’t expect life to make sense or be “fair.” Some chapters of life are just filler and no lives have a happy ending. While he tried to steer his life trajectory – he didn’t just give up – he accepted that the plot would go wrong and there would always be a new crisis.

Rather than trying to make peace with the uncertainty and suffering of his whole life or even the next few years, he tried to take things one day at a time. The goal was not to contemplate and accept life without his soulmate or his daughter. The goal was to accept today’s weather and make it through the day.

The medical system, the trajectory of a disease, and the whims of the legal system are often incomprehensible. But Montaigne reminds us that we don’t need to “solve” the universe to survive it. By admitting we don’t know what tomorrow holds, we can finally resign from the exhausting work of trying to outsmart Fate. Instead, we can settle into the quiet, sturdy competence of today.

Before Montaigne, writing—and living—was expected to be authoritative and certain. He changed the rules by treating his life as a series of experiments, a collection of “trials” rather than final answers. He gave us permission to be walking contradictions: patient one moment, resentful the next; a caregiver in the parlor, yet a free soul in the “back shop.” He proved that we are allowed to feel the “ugly” emotions of boredom or bitterness without losing our integrity. We are simply, as he was, a patchwork of light and shadow.

The world may see us as a servant, a saint, or a functionary, but Montaigne’s greatest gift is the reminder that we belong only to ourselves. He discussed his failing memory and his love for his cat with the same weight he gave to classic philosophy, revealing a universal truth: the “small” life is the only life we actually have. To care for another, to breathe in a quiet room, to taste a piece of fruit, or to simply endure a difficult hour with equanimity is not a waiting room—it is a masterpiece.

We are not waiting for life to start once the caregiving ends. This—right now—is the life.

I owe a debt to Montaigne for opening the door to my own meandering and inexpert thoughts. He championed the idea that wisdom begins with admitting our own ignorance, and that the world’s greatest cruelties often come from those who are too sure of themselves. In a world demanding perfection, he suggests a different goal: a life lived with humor, a bit of pleasure, and the radical courage to be exactly as flawed as we are.

To Montaigne, most relationships were “common” or “ordinary”—bonds tied by blood, social contract, or what we could get from one another. But he reserved his highest praise for a singular, transcendent category: Ideal Friendship.

His relationship with Étienne de La Boétie was the emotional North Star of his life. Their relationship was not about family ties, obligation, or utility. It was a pure love that was entirely optional, where they were themselves and not their roles or functions.

Montaigne believed that while we owe the world our public face, we owe our friends our “entire transparency.” A true friend is the only person allowed into the deepest part of your back shop. A friend who isn’t involved in the daily grind of your caregiving provides a “neutral territory.” Talking to a friend allows you to vent the “un-saintly” thoughts without fear of judgment, because a true friend knows your soul and accepts the dark threads with the light.

Caregiving is the ultimate relationship of utility: someone needs, and someone provides. This can be dehumanizing for both parties. Friendship, on the other hand, is a “gratuitous” act. It serves no purpose other than the joy of the connection itself. You need people in your life for whom you do nothing practical. You need friends who don’t need your “nursing” or your “duty,” but simply your company.

Montaigne claimed that in a perfect friendship, the two souls “mix and fade into each other” so completely that you cannot see the seam. Caregiving is inherently isolating. By maintaining a deep connection with a friend, you “double” your capacity to handle the world. You have another set of eyes to see the beauty you’re too tired to notice, and another heart to hold the weight.

From soulmate to patient

People with close bonds often see their complex relationship flattened out as they go from the multifaceted role of spouse, child, parent, or friend to someone who primarily provides necessary labor. Montaigne would likely view this transformation with a mixture of profound sorrow and clear-eyed, unsentimental realism. He was acutely aware that the “soul” of a relationship—the wit, the shared philosophy, the equality—is housed in a fragile vessel of flesh. When the flesh fails, it often drags the spirit down with it.

Montaigne believed that what makes a relationship transcendent is the “inter-communication” of two minds. If illness (such as dementia or chronic pain) has ended that communication, it is okay to mourn the person who is still sitting in front of you. To Montaigne, a relationship of utility is a “common” bond, whereas what you had was “special.”

When a relationship loses its intellectual or emotional spark and becomes a matter of bathing, feeding, and scheduling, this is a fact of nature. You are no longer “conversing” with a partner; you are “tending to a fellow creature.” When a relationship is stripped of its complexities, you are left with the most basic human reality: one human helping another suffer a little less.

There is a quiet dignity in performing the duties of the body. If the “complex” part of the relationship is gone, you are released from the struggle of trying to “fix” it. You can settle into the simpler, albeit harder, role of being a faithful steward of their physical existence.

Montaigne’s biggest fear was that our external circumstances would “cake” over our inner selves. If you spend 24 hours a day in a relationship of “pure utility,” your own mind risks becoming a utility-driven machine. If you only think about symptoms, medications, and hygiene, you lose your own humanity alongside theirs. This is where the back shop becomes a moral necessity. Because your external relationship is now one of utility, your internal relationship with yourself must be twice as rich, twice as intellectual, and twice as free.

Montaigne might tell you that while the “utility” of the role feels like a prison, it is actually the most honest encounter with reality you will ever have. To care for someone who can no longer offer you anything in return—no wit, no gratitude, no complex love—is to act with a purity that the “fame and fortune” seekers will never understand.

You are witnessing the “unvarnished man,” and in doing so, you are discovering the unvarnished strength of your own character.

Detachment

Not every one sided relationship involves someone who is incapable of reciprocating. I’ve seen many situations where the “patient” denies any responsibility for their health and wellbeing, expecting the “caregiver” to manage their emotions and cure them without their cooperation. I’ve also seen a shocking number of relationships where the “patient” has an emotional affair while treating their spouse as a provider of services. There are so many situations where the “patient” is simply unpleasant, rude, uncooperative, and unhelpful.

Montaigne was not a fan of martyrdom. He believed that while we owe a debt to nature and family, we have no obligation to allow ourselves to be taken advantage of. In a situation where a relationship has become a one-sided burden—and specifically where the other party is willfully negligent or actively betraying the bond—Montaigne would suggest a radical psychological withdrawal.

Montaigne argued that we should only “lend” ourselves to our duties. If the person you are caring for is choosing to be a “servant-master” rather than a partner, Montaigne would tell you to withdraw the “gift” of your spirit.

You can continue to provide the “utility” (the food, the meds, the schedule) because that is your external duty or “custom.” But you must stop offering your vulnerability, your emotional intimacy, and your expectation of reciprocity. Treat the care as a civil contract, not a romantic or familial one. If a contractor is rude to you, you don’t feel betrayed; you just finish the job and go home to your private life.

Spousal betrayal

When a spouse has an emotional affair while you change their bandages, modern psychology calls it “betrayal trauma.” Montaigne might consider it a hideous whim of nature. Look at the offending spouse as if they were a broken machine or a storm. By expecting them to be “better” or “fairer,” you are giving them the power to hurt you.

Resentment lives in the gap between reality and expectation. If you lower your expectation of them to zero—if you accept that they are, at this moment, a flawed and selfish creature—the resentment has no fuel. You aren’t “forgiving” them; you are simply refusing to let their character rot your peace. If they are looking elsewhere for intimacy, you should look elsewhere for humanity. Not necessarily an affair, but a deep friendship, a demanding hobby, or a secret intellectual life.

Lack of cooperation

If a patient refuses PT or meds while expecting you to pick up the slack, Montaigne would suggest a form of strategic detachment. We feel obligated to offer help and support. We must act according to our own integrity. We are not, and cannot be, responsible for their behavior or their fate.

Montaigne’s ultimate tool was the shrug. He realized that people are often “monstrous” in their selfishness.

He would tell you that by begging for intimacy or cooperation from someone who refuses to give it, you are making yourself a beggar: “We are each of us richer than we think, but we are trained to go about begging.” If you stop asking, stop hoping, and stop “fixing” their willful choices, you reclaim your wealth. You do the minimum required by law and custom. Save the rest of your energy for yourself.

Their choices are theirs. My peace is mine.