It used to be the case in much of Canada that public health units were autonomous or semi-autonomous organizations at the local level, often aligned with and sometimes part of local government.
The medical officer of health was the chief executive and had a staff of public-health nurses, public-health inspectors, epidemiologists, dental hygienists, community nutritionists and others. While they worked to some extent in collaboration with the health-care system, especially family doctors, they were largely able to focus on the local community and work with a wide range of partners outside the health-care system.
But in recent years, in most of Canada, we have seen public health brought firmly within the health-care system. This has been a mistake, in my view, for one simple reason; most of what determines our health lies beyond the scope of that system.
As a result, much of the work of public health to protect and improve health has to focus on actions beyond health care. But health-care-system managers — who are constantly facing budgetary challenges — are understandably focused on trying to achieve what they can within the scope of their operations.
This has two negative consequences. First, these health-care-system managers — very few of whom have public health training — see much of what public health does or tries to do as beyond the scope of the sector. Second, when they see public-health staff engaged in work that, to them, is beyond scope, they are likely to try to redirect that work toward more “useful” clinical care.
This reduces the effectiveness of public health, which is a problem not only for the population as a whole, but for the health-care system itself. At a time when the system is struggling to meet the demands placed upon it, it is extremely short-sighted to reduce the effectiveness of the only part of the system that is fully dedicated to reducing the burden of disease in society.
In particular, we have seen senior health-care-system managers reduce the power of medical officers of health and break up public health units. It is now not uncommon to see medical officers — community-medicine specialists with years of extra training in public health — reduced more to an advisory role, marginalized and with few staff, while public-health nurses report through a separate part of the organization and public-health inspectors through yet another.
As a result, we have seen some frontline public-health nurses moved into being primary-care nurses and community nutritionists becoming more like dietitians, doing one-on-one care rather than community-based prevention.
This marginalization can also be seen at the provincial level. In B.C., most of the staff and budget for public-health programs are separate from the small Office of the Provincial Health Officer; this is seen in other provinces, too, and now at the federal level.
Moreover, the bureaucrats in charge increasingly do not have public-health training, and might have no health background at all.
The most extreme form of this approach is seen in New Brunswick, where the government recently announced a major reorganization of its system of public-health services. While the Office of the Chief Medical Officer of Health stays with the Ministry of Health and its “existing mandate and legislative responsibilities … will remain the same,” most of the staff have been dispersed to three other ministries. In essence, they are getting rid of public health as a cohesive whole.
I had the great good fortune to begin my public-health career working for Toronto’s department of public health. Having watched the growing challenges facing public health in B.C. and other provinces, I am convinced that Ontario — where public health still is municipally based — has it right; public health does not belong in the health-care system.
But I would go further; public health does not belong within the Ministry of Health. We need municipally based public-health units, with secure provincial funding, under a separate Ministry of Population and Public Health. Then public health could do its job without having to worry about being further harmed by the health-care system.
Dr. Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy.