A Canadian agency for public health: If not now, when?

The National Advisory Committee on SARS and Public Health, headed by Dr. David Naylor, has issued a thorough, blunt and eminently rational report.¹ Commissioned by Health Minister Anne McLellan between the 2 waves of the SARS outbreak in Canada, the report draws on interviews with front-line health care providers and officials, submissions from stakeholders, and the committee's own background research. The committee's findings confirm what has been apparent but ignored for far too long: a dismal lack of public health capacity to ensure even the “minimal expectations” of health protection and disease prevention, ranging from a safe water supply to comprehensive vaccine coverage to the containment of infectious disease.

This lack of capacity is amply demonstrated in accounts collected from those who formed the SARS “bucket brigade” in Toronto. Ontario's disease tracking and information management software was described as “an archaic DOS platform … that could not be adapted for SARS,” and protocols for handling data as “unclear or non-existent.” Information exchange was impeded by misunderstanding, turf wars and the muddy waters of patient confidentiality, thus frustrating attempts to construct an accurate epidemiology of the unfolding outbreak. Toronto's Public Health Department “was overwhelmed early … even though the city has 1800 public health employees.” Reporting structures were unclear, and “no one knew who was in charge.” If this is the impact of a disease outbreak in possibly the best-resourced city in Canada, it is hard to avoid one respondent's conclusion that “The system is sick. It is broken.”

The Advisory Committee has resisted any temptation to blame individuals. Their etiology of the blundering response to the Toronto outbreak is unambivalent: the long-standing neglect of public health over decades and inadequate leadership in Ontario and Ottawa. The lack of “operational credibility” within the Population and Public Health Branch of Health Canada makes a poor contrast with the authority of the US Centers for Disease Control and Prevention, who are “‘invited early and often’ to become involved with any serious outbreak” and whose “credibility mitigates jurisdictional tensions.” During the SARS outbreak, a SWAT team took shape in the form of the Scientific Advisory Committee, “a human-cellphone conglomerate” of infectious disease experts and administrators, some of whom became sidelined by SARS or quarantine. The CDC, by contrast, has the capacity to mobilize both a front-line response and a “B team” to provide “scientific backup and sober second thoughts in the midst of … a crisis atmosphere.” How is it that in Canada a national team was not already in place, ready to respond to such an emergency?

Over the last 2 decades, commissions and expert groups have warned us of the folly of neglecting public health preparedness in Canada. The Naylor report is the most lucid proposal yet for the creation of a new Canadian Agency for Public Health, to be led by a chief public health officer of Canada, a health professional accountable to the health minister but unfettered by government. This is not just another high-sounding recommendation: the committee lays out a legislative roadmap to create such a body within the existing provincial–federal jurisdictional minefield. Only minimal (and feasible) legislative changes will be needed.

To propel structural reform and repair the damage done to public health capacity by decades of cutbacks and neglect, the committee proposes federal funding increases over the next 5 years to provide, per annum, $200 million for core functions of the new national agency, $300 million to strengthen provincial and local public health programs, $100 million to realize a National Immunization Strategy, and $100 million for infectious disease control. Specific recommendations include giving priority to infectious disease surveillance, renewing the infrastructure of public health laboratories, building capacity in research and addressing the deplorable shortage of human resources in public health.

Health Minister Anne McLellan has already endorsed the idea of a Canadian Agency for Public Health. But even with legislative amendments and a real boost in funding, we still face the difficult and critical task of changing the culture of public health in this country. For far too long public health professionals and medical officers of health, impeded by bureaucracy and political agendas, have struggled to make unencumbered decisions in the public interest. Like other physicians, medical officers of health diagnose and treat, but their patients are populations and their treatments — public education and mass communication, quarantine, school and workplace closures, boil-water orders, travel advisories, bans on the sale of hazardous goods — readily become politicized by their social and economic consequences. Nowhere will courage and leadership be more important than in the office of the first chief public health officer of Canada. — CMAJ