Public health: What is to be done? ================================== * Richard Schabas Two years ago in Walkerton, Ont., drinking water contaminated with bacteria made more than 2300 people ill and caused 7 deaths. The full consequences, from renal damage caused by *Escherichia coli* O157:H7, will not be felt for many years. Canada was shocked to find itself welcoming the 21st century with a problem that belonged in the 19th century. The Bruce-Grey-Owen Sound Health Unit played a critical role in controlling the outbreak. The local medical officer of health, Dr. Murray McQuigge, acted quickly and decisively.1 Furthermore, he established himself as a credible independent spokesman. Indeed, public health was virtually the only public service that emerged with some credit from this tragedy.2 But the key lesson learned from the Walkerton outbreak is that we cannot take public health for granted. The outbreak happened because institutions vital to the infrastructure of public health were neglected. The incompetence of the operators of the local waterworks and the policy negligence of the Ontario government are the most obvious and most important proximate causes.2 The problems, however, run much deeper than just one government in one province. They go back many years and can be found, to a greater or lesser degree, in every jurisdiction in the country. My commentary will focus on the public health system in Ontario — the system I know best — but I believe that it has application across Canada. Ontario's public health system is not broken. It is staffed by dedicated professionals and does many things well. But it is fragile, particularly in some of the small rural areas of the province. Public health could be much better. A strong public health system requires stable and adequate funding, a sophisticated staff trained in modern methods of surveillance and analysis of health and environmental data and in risk and media communication, and, above all, professional independence from politicians and government bureaucracies. The current system of funding public health in Ontario is unsupportable. It relies on the willingness of individual municipalities to pay their share. The resulting funding — a little over 1% of all health care expenditures — is inadequate. Per capita funding rates vary almost threefold between health units. Modern public health requires increasing specialized expertise. Small health units simply lack the resources to accommodate this. They are becoming as anachronistic as the cottage hospital. A population base of at least 200 000, and ideally considerably more, is necessary to support a truly up-to-date public health department. Public health officials must always be free to speak and act in the interests of public health. Unfortunately, public health in Ontario, and across Canada, is too enmeshed with politicians and bureaucrats to ensure this. Although the problem exists throughout the system, it is most acute at Ontario's most senior level. The chief medical officer of health and the staff of the Public Health Branch must serve 2 masters: the government and the public. It should surprise no one that, as career civil servants, they all too often give priority to the former over the latter. They follow when they should lead. Fixing these problems will require radical restructuring. The public health system must be given a firm funding base, be reorganized to enhance professionalism and be disentangled from politics and bureaucracy. The Ontario legislature should create a provincial board of health, an agency independent from government. The provincial government would fund the agency, just as it funds all other essential health services. The board of health would hire the chief medical officer of health, who would provide leadership and direction to the system. There would be a strong central office, with the expertise and resources to support work in the field. Local health units would be consolidated, from the current 37 units in Ontario to about 15 units. Every province in Canada would benefit from some of these reforms. Change is also required at a national level. Health Canada employs many excellent public health scientists and professionals. Too much of their time and efforts are consumed, however, by the Byzantine politics of the federal bureaucracy and the interminable jurisdictional squabbling with the provinces. An arm's-length agency, based on the model of the US Centers for Disease Control and Prevention, would be a step forward. Public health is, to a large degree, a victim of its own success. There are no testimonials for diseases prevented or outbreaks averted. In normal times, public health is all but ignored by the media and politicians alike. They assume that nothing can go wrong. Public health is neglected until a disaster such as Walkerton captures their attention. Then they wring their hands in dismay and pontificate about the need to strengthen the public health system, until of course the disaster fades from memory and public health again drops out of their radar screen. In June 2001 I testified before the Walkerton inquiry and drew specific attention to the fact that 7 Ontario health units did not have a medical officer of health, as the law requires. Huron County, immediately adjacent to Walkerton, had not had a medical officer of health for 6 years. These observations drew media attention and sparked questions in the provincial legislature.3 The then, and current, Ontario minister of health publicly reaffirmed his commitment to filling these positions. Mr. Justice O'Connor's first recommendation in his report of the Walkerton inquiry spoke to the need to appoint medical officers of health.2 As I write this commentary in April 2002, 10 months after my testimony at Walkerton, there are still 7 Ontario health units without a medical officer of health, including Huron County. Inaction speaks louder than words. ## Footnotes * *Competing interests:* None declared. ## References 1. 1. Leadership and fecal coliforms: Walkerton 2000 [editorial]. CMAJ 2000;163(11):1417. Available: [www.cmaj.ca/cgi/content/full/163/11/1417](http://www.cmaj.ca/cgi/content/full/163/11/1417) [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTYzLzExLzE0MTciO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTY2LzEwLzEyODIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 2. 2. O'Connor DR. *Report of the Walkerton inquiry: the events of May 2000 and related issues. Part one*. Toronto: Ontario Ministry of the Attorney General; 2002. p. 499. Available: [www.walkertoninquiry.com/report1/index.html#full](http://www.walkertoninquiry.com/report1/index.html#full) (accessed 2002 Apr 16). 3. 3. Ontario, Legislative Assembly; 2001 June 25. Available: [www.ontla.on.ca/hansard/house\_debates/37\_parl/Session2/L035A.htm#P330\_56587](http://www.ontla.on.ca/hansard/house_debates/37_parl/Session2/L035A.htm#P330_56587) (accessed 2002 Apr 16).