Public Health Redux

 

It was a cold winter in Toronto in early 2003 when a foreign killer came to town. Hundreds sickened, coughing, fevered and breathless and 44 people died as their lungs filled up and failed. It was unclear what was causing this illness and initial attempts to identify it failed. In the meantime, even in this most sophisticated of health systems, society relied on the age-old mechanism of quarantine to control the spread of this novel disease – while the World Health Organization issued a travel advisory to avoid Ontario!

The events of that time were frightening and raised many, many questions. How did a new bug get here without our noticing? How did it spread? Where did it come from? Why did Toronto seem to bear the brunt of it, rather than another world city? Were we adequately prepared and if not, why not.

As SARS was brought under control, the then Minister of Health and Long-Term Care, Tony Clement, in the Conservative Government of Ernie Eves, appointed me to chair an Expert Panel on SARS and Infectious Disease Control to review how SARS was handled in Ontario, what lessons were learned, and to make recommendations for the future.

The panel consulted widely, held many public focus groups, and produced both an initial and final report which gained much attention at the time. Those interested may find the report on the Government website (with difficulty). It resides under a banner that says it was “released by a previous government”.

In a nutshell the report identified that our Public Health system had been allowed to deteriorate significantly and required substantial restructuring, investment and accountability – both to Government and to the Public. The panel was surprised to find that our Public Health labs had minimal capacity to identify the SARS agent, their professional resource having been allowed to languish over the years. Some health units had no medical officers of health and few graduating doctors were choosing the discipline as it was significantly underpaid and under recognized. Municipalities were responsible for a significant proportion of public health funding resulting in wealthier communities benefitting far more than poorer, often rural communities. At budget time at City Hall, Medical Officers of Health would be competing for funding with hockey rink and soccer field requests. International collaboration and information sharing was imperfect, surveillance mechanisms were outdated and, critically in Ontario, the ability to communicate important information to the public in a time of crisis was impaired by political considerations.The analogy, often used, was that given the prior success of fire prevention strategies, it would be quite justifiable to close many fire stations since there were so few fires! And that is what had happened with Public Health.

The panel’s recommendations bore fruit. A full Public Health capacity review followed, and subsequent change was executed following legislation, strengthening that most fundamental public policy, health promotion and disease prevention.

The simplicity of the premise of public health and its invisibility when fully operative form its Achilles heel. Crowded hospitals and wait lists for Long Term Care result in quite proper attention, but we forget at our peril that many solutions to those very acute problems reside in the community – for example improved home care, housing, addictions and mental health programs, based on a platform accountable for the health of the population. Furthermore, public health is cheap. Its impact is huge. And it is easier to cut spending for public health than it is for pacemakers or knee replacements.

Those of us who became preoccupied with identifying a blueprint for the renovation and rebuilding of our Public Health system note with interest another Conservative government’s plans. Some, such as reducing the number of health units, were suggested by the Expert panel. But combining such a plan with requiring increased municipal funding ratios may well be quite problematic- many towns may choose to pass the buck to their neighbour; and there are still those hockey rink priorities. And any reduction in public health spending will surely have significant ramifications.

Ancient societies recognized the critical importance of public health; clean water, sanitation, and control of infectious diseases. The invisibility of public health program success should not lead us to ignore its critical importance. As with public security measures, we can’t and don’t celebrate the terrorist attack that was aborted; we take it for granted. The same is true for public health. We are not celebrating the pandemic that did not happen, the surveillance that keeps us safer, the whooping cough that did not infect our children. We do know that one day the son of SARS, or a novel influenza, will appear. It has always been thus. Will we be ready? Or will we form another Expert Panel. We drop our defences at our peril.


DMC Walker MD, FRCPC
Stauffer-Dunning Chair and Executive Director, School of Policy Studies
Professor, Emergency Medicine, Family Medicine and Policy Studies
Queen’s University

Chair, Expert Panel on SARS and Infectious Disease Control, 2003-2004 and Inaugural Board Chair, Ontario Agency for Health Protection and Promotion

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