Public health on the ropes

Ever since Chadwick and Snow demonstrated what public health is all about, society has tried to tend the commons of health by monitoring risks, promoting safer living and working conditions and sounding the alarm when danger threatens.¹ In today's world these public health functions require an increasingly specialized and well-trained workforce, sophisticated surveillance, monitoring and information systems, adequate and continuously available laboratory support and the ability to communicate results and health advice rapidly.

As we report in this issue, we have a public health system that is on the ropes.² Human and technical resources are insufficient, surveillance is wobbly, laboratory backup is inadequate, especially in emergencies, and the multitude of health units within the federal government and across the provinces are woefully disconnected.

Despite numerous task force reports and commissions, things are getting worse, not better. In 1997 Justice Horace Krever reported that “Public health departments in many parts of Canada do not have sufficient resources to carry out their duties.”³ In 1999, the Auditor General found Health Canada unprepared to fulfill its responsibilities in public health: communication between multiple agencies was poor and “weaknesses in the key surveillance systems” impeded the effective monitoring of communicable disease, chronic illness and injuries.⁴ And then there was Walkerton, an entirely preventable catastrophe that resulted from underfunding, a confused overlapping of jurisdictions, inadequate surveillance and a complete disregard of the need for a well-trained workforce.⁵

In June 2001 the federal, provincial and territorial deputy ministers of health met in St. John's, Nfld., to discuss, among other things, a commissioned report on public health capacity in Canada.⁶ This unpublished report documents serious deficiencies in public health manpower: critical vacancies in this aging workforce are difficult to fill because of a lack of experienced mid-career personnel with a full complement of skills (see News, page 1319). Also noted were “[w]eaknesses in data quality, quantity and accessibility [and] a lack of skills and knowledge to analyze data,” along with deficiencies in telecommunications and a “need for integrated … systems and resources to ensure collection of quality, comprehensive, health-based data.”

Moreover, there are serious regional disparities in our public health capacity. The Western and Atlantic provinces and the North are particularly fragile. However, as Richard Schabas points out in this issue⁷ (see page 1282), even wealthy Ontario is unable to maintain adequate public health protection for its citizens.

It is hard to grasp, then, how this report fell off the agenda at the meeting in St. John's, unless it is because ministries of health are not interested in problems that require commitments for follow-up that extend beyond a political term. At any rate, it was not considered or discussed, nor — as far as we can tell — has anything been done about it since.

The globalization of travel, disease, the food supply and armed conflict means that we need a robust public health capacity, not one that is down for the count. We need a politically independent national task force to investigate this serious problem and make strong recommendations to put it right and get public health functioning in this country. — CMAJ