November 28, 2004
Moving Forward With Public Health in Canada
In recent years, SARS, BSE, and other communicable disease outbreaks have highlighted Canada's neglect of public health. The 2003 federal SARS report chaired by Dr. David Naylor noted that experts have advised governments for years of public health's problems but their warnings were disregarded. As a result, Dr. Naylor wrote, "there is much to learn from the outbreak of SARS in Canada - in large part because too many earlier lessons were ignored."1
In this issue of the CJPH, Dr. Kumanan Wilson of the University of Toronto raises important questions about the governance of public health in Canada. Since Dr. Wilson submitted his article, the government of Canada has established the Public Health Agency of Canada and appointed its first chief public health officer. This commentary reviews the events of the past six months and discusses what we need to move forward.A new public health agency for Canada
Ottawa's March 2004 budget allocated significant new funding for a Canadian Public Health Agency. The finance minister promised more funding in the future. In September 2004, the agency was officially launched. It is based in Winnipeg but will also have offices in Ottawa. The new agency will be connected to the rest of the country's public health services through six national collaborating centres and a to-be-established Pan-Canadian Public Health Network. At present, the public health agency's website advises that the Network could "complement and - if it proves effective - eventually subsume, certain of the existing mechanisms and arrangements for intergovernmental collabotation on public health matters."2 It is further suggested that the Network could serve as a forum for:
* Promoting dialogue on public health issues;
* Coordinating responses to public health emergencies;
* Developing national public health strategies;
* Facilitating the development of national standards and agreements on issues such as resource and data sharing, accreditation of health professionals; and
* Encouraging the development of centres of public health expertise across the country.
The Prime Minister announced the appointment of Dr. David Butler- Jones of Saskatchewan as the country's first chief public health officer on September 24, 2004. As recommended by Naylor's report, the new agency is at arm's length from Health Canada. Dr. Butler- Jones will report directly to the federal Minister of Health, the honourable Ujjal Dosanjh. This model allows the agency to contract directly with provincial and local public health agencies. It also permits the agency to have a flexible, private sector-like human resource policy which is needed to recruit and maintain staff.
The Liberals now have a minority government and will have to follow through on their promises. The economy has grown beyond the budget's projections, so money shouldn't be a problem.3 When combined with public health reform in Ontario and some other provinces, these circumstances open a large policy window for public health in Canada. Howevet, as the ink dries on the federal legislation and regulations, politics will be as important as governance for the success of the new agency.
Who has jurisdiction for public health in Canada?
As Dr. Wilson comments, public health is a matter of joint federal and provincial jurisdiction. Unfortunately, up until recently, the federal government has been remarkably silent in asserting its claims to the area.
The constitution gives the federal government authority over quarantine, criminal law, and interprovincial and international commerce. The constitution also gives the federal government authority to pass laws to ensure "peace, order, and good government". It is true, as Dr. Wilson notes, that the actual extent of these powers is ambiguous. But, like any powers, they atrophy with disuse.
The federal government also has its spending powers. The courts have reasserted the federal authority to spend its money as it wishes, even in areas of provincial jurisdiction like health care or social services. Without the spending power, there would be no medicare.
Finally, the federal government derives considerable authority from its international treaties and agreements. During the SARS outbreak, the World Health Organization (WHO) dealt with the federal government, not directly with the provinces or local public health agencies. The WHO travel advisory posted for Toronto had major economic implications for the whole country. It appears that even if our country somehow tolerates a confusion of mandates, international agencies will not. These events finally forced Canada's policy- makers to deal with the country's dysfunctional public health system.
What do we need to move forward?
The first steps towards reform are encouraging, but public health advocates will have to keep up the pressure to ensure effective implementation. The first priority must be more federal resources. While, in theory, the federal government has ample constitutional justification for a muscular public health role, in practice it must work with and through the provinces.
The federal government solved its deficit problems partly through cutbacks to provincial transfer payments. Twenty years of federal government cutbacks, through three administrations, has cultivated an environment of distrust between Ottawa and the provinces. One current reality of Canadian political life is that the provinces require the federal government to accompany any policy request with long-term cash. The $700 million in new operating money recommended by the Naylor report was a bare minimum requirement. This represents only about 15% of the new short-term health care money announced by the first ministers in September 2004 and about 0.5% of the country's overall health spending. So far, the federal government has promised a little over $400 million. Another billion dollars would be nice.
The next challenge will be to develop the on-the-ground contacts necessary for an effective public health system. Nearly a quarter of the US Centers for Disease Control's 8,600 employees are based outside the head office of Atlanta, Georgia. Most work in state and local public health offices. The Epidemic Intelligence Service provides training for field epidemiology and gives the US an expert "flying squad" of disease control specialists. The CDC also assists with the development and evaluation of public health programs at the state and local level.
In the past, efforts to develop such relationships in Canada have been compromised by the intergovernmental affairs process. But will the new institutional structure of the agency allow it more flexible relationships with other public health organizations? Let us hope that such relationships and programs will not get bogged down by major intergovernmental negotiations.
A mandate as broad as public health itself
Another challenge to the agency is timeless for public health, "How broad the mandate?" It was concerns about communicable disease that led to the agency's establishment. Often decision-makers seemed confused about public health's other mandates, especially health promotion. The Naylor report recommended a broad role and the agency is subsuming a variety of health promotion programs, including the Community Action Program for Children and the Canadian Prenatal Nutrition Program. However, the agency will be continually challenged to advance these programs within a political environment which too often displays little understanding of a population health approach.
Nineteenth-century public health pioneer Rudolf Virchow claimed that diseases were caused by defects in society. He further argued that governments should prevent disease through economic and social policies.4
Public health advocates have historically linked public health with social change and made alliances with social reformers. But, by definition, political and economic elites draw their privileged positions from the status quo. They tend to be disquieted by calls for change, especially if it will cost money.
Public health has used two major approaches to promote social change. The first is to speak out. This is now part of the platform offered to a chief public health officer. A hundred years ago, Toronto medical officer of health, Dr. Charles Hastings, toured reporters through slum housing to prod the politicians to make housing reforms.Mr. Martin assured reporters that he would support Dr. Butler-Jones' independence. However, the whole public health community will have to practice eternal vigilance to preserve this liberty.
Public health's second approach to social change has been to partner with citizens and their organizations. The Toronto public health department partnered with the South Riverdale Community Health Centre to clean up a major lead pollution problem. This partnership also led to new policies at national and international levels.
Unfortunately, the weakening of the public health infrastructure has compromised public health's abilities to work with communities. At the same time, community health centres have developed an approach which combines primary health care with public health services. In addition, almost all regional health authorities are looking at new primary health care mo\dels which integrate direct service (often to vulnerable groups) with prevention. While some projects are mainly focussed on medical care, others (e.g. in Saskatoon5) have an explicit public health focus.
New policies in Quebec have removed the 147 CLSCs from direct community control, but the centres continue to provide a community infrastructure for public health work. They are an important component of Quebec's population health assessment process and its response to public health emergencies. The new public health agency would find its work easier in other provinces if there were similar networks.
The federal government has a major opportunity to reform public health in Canada. With enabling legislation, it has established a new Public Health Agency of Canada and appointed its first chief public health officer. Current circumstances are more favourable for public health than for many years. However, governance and legislation is only one aspect of reform. Public health advocates will need to continue the pressure to ensure adequate funding, new cooperative federal-provincial decisionmaking, and a broad focus for public health work.
1. Naylor CD. Learning from SARS - Renewal of Public Health in Canada. October 2003. A report prepared for the federal Minister of Health. See: http://www.hc-sc.gc.ca/english/protection/warnings/ sars/learning.html (Accessed October 7, 2003).
2. Public Health Agency of Canada website: http://www.phac- aspc.gc.ca/about_apropos/federal_strategy_e.html#pillar3 (Accessed October 3, 2004).
3. Federal Department of Finance Fiscal Monitor July 2004. http:/ /www.fin.gc.ca/FISCMON/2004-07e.html (Accessed October 4, 2004).
4. Taylor R, Rieger A. Medicine as social science: Rudolf Virchow on the typhus epidemic in Upper Silesia. Int J Health Serv 1985;15:547-59.
5. See Saskatoon Health Region website: http:// www.saskatoonhealthregion.ca/your_ heal th/ps_primary__health.htm (Accessed October 4, 2004).
Michael M. Rachlis, MD, MSc, FRCPC
Associate Professor, Department of Health Policy Management and Evaluation, University of Toronto, 13 Langley Avenue, Toronto, ON M4K 1 B4, Tel: 41 6-466-0093, E-mail: [email protected]
Copyright Canadian Public Health Association Nov/Dec 2004