Dr. David Butler-Jones was Canada’s first chief public health officer and deputy minister of the Public Health Agency of Canada
There are few things that focus the mind quite like the fear of contagion. With the emergence of a new coronavirus, the world is once again reminded of the outbreak of SARS in 2003.
Public-health officials and governments across the country are responding quickly and diligently to the current outbreak, applying lessons from SARS (severe acute respiratory syndrome) with better co-ordination and public information, so that appropriate action can be taken. Public-health experts involved in both SARS and the pandemic of H1N1 in 2009 are still around to reinforce the lessons. As this crisis eventually fades, we must remember the overarching lesson from SARS that seems to have been forgotten.
In spite of courageous efforts in 2003, the Canadian systems of health care and public health were not up to the challenge. These have been well documented in numerous inquiries, including the federal government review led by Dr. David Naylor, and the Ontario government review, led by Justice Archie Campbell.
The Naylor report was appropriately titled Learning from SARS, Renewing Public Health in Canada. Public health is a first order of public good for which governments are responsible, requiring co-operation and co-ordination across multiple levels, as public-health threats respect no jurisdiction, borders, socio-economic structures, religion or political perspective.
During the 1990s, as governments struggled with deficits and rapidly rising health-care costs, public-health budgets and capacity diminished in support of the short term, sacrificing long-term investments that would support greater health over all in the population and reduce risks. Recognizing this, deputy ministers across the country commissioned a review of public-health capacity.
In brief, the conclusions were that the health system was missing key opportunities to better understand what makes us healthy, promote health and well-being, reduce the burden of illness and injury, and protect against health threats, among others. And when it came to combatting major outbreaks, public health was coping, but barely. Then came SARS.
After the 2003 SARS epidemic, governments increased focus on public health, and new organizations dedicated to public-health issues and expertise, such as the Public Health Agency of Canada (PHAC) and Public Health Ontario, were formed. New capacities and investments were built upon. The agency and its development became recognized internationally for the PHAC’s expertise and organization, approach to collaboration and as a model for other national or multinational public-health organizations.
In positive contrast was the management of the H1N1 pandemic in 2009, a far more severe threat to health, with millions at risk. What few realize is that the 2009 virus was just as virulent as the flu strains from 1917-18 that killed an estimated 50 million people. It disproportionately attacked the young and healthy, with rapid progression in many to respiratory failure. Canada, with its new capacities and focus on public health, for the first time in history stopped a pandemic in the same year. Few, if any other countries could make the same claim as their ICUs continued to fill in the spring and the following winter.
Unfortunately, many governments seem to have forgotten those lessons as changes since 2014 have diminished the capacity of public health to prepare for and respond to new and inevitable threats, as well as to carry out their mandate to protect and promote health and prevent illness and injury.
There is good reason that medical specialists in public health and preventive medicine require five-plus years of postgraduate training after medical school. To understand and apply public health effectively requires expertise in everything from epidemiology and statistics, to prevention and control of disease and injury, to health policy. You also need proficiency from the management of organizations, to the complex interactions of animal and human health, the environment and economy, as well as knowledge of the biological, physical and social sciences.
Some jurisdictions have since divided public-health programs and expertise among different departments, reducing their ability to co-ordinate planning and responsiveness. Many have replaced public-health managers and analysts with generic public servants. Resources, expertise and capacity have been reduced, and expertise positioned further away from where organizational decisions are made on budget, policy, communications, programs and services and so forth.
We’ve seen this movie before. While many capacities in public health remain, and public health has always done remarkable things with little support, both the trend and our current state are worrying moving forward. It should not take another crisis and subsequent inquiries to remind us.
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