The goal of the public health system in Canada is to improve the health of communities, whether that is locally, provincially, nationally, and/or globally. Historically, most significant improvements in health occurred in the realm of public health, including preventing infectious diseases and improving water quality. These areas are still vital – we don’t typically worry about our children dying from measles because of the ongoing work of public health – but those activities need to be situated in a context of what we have learned about the health of our communities.
We know that where we live, how much we earn, what job we do, what we eat, what our early childhood was like, and who we spend time with have significant impacts on our health. We also know that most differences in people’s long term health are due to factors we can change. For example, we can change what kind of housing people live in, how easily people can access healthy food, how we design our cities to promote active living. This is what is known as a determinants of health approach: dealing with the root causes of poor health. Public health needs to recognize this shift in knowledge and evolve in order to build upon strengths and increase the impact we can have on the health of the communities we work in.
A key figure in this shift is the Medical Officer of Health (MOH), a doctor whose specialty is in public health, who holds varying levels of responsibility depending on public health structures throughout the country. Irrespective of structure, the role of the MOH is to assess the health of the community s/he works for and work to improve its health. Many MOHs are embracing the evidence that indicates their work needs to address determinants of health, and even the systemic factors that shape these determinants. However, some are stifled by the acute care focused structures they are a part of, or by systems that do not recognize that a primary role of the MOH is to address health disparities. Some prefer to maintain historical roles and not move into the complex, and often controversial, world of addressing determinants.
The MOHs leading change throughout the country will hopefully create an impetus for others. Some examples of equity-focused initiatives include the creation of the Toronto Food Policy Council (TFPC) and the Peterborough Community Food Network. The TFPC advises the City of Toronto on food policy issues, and has been key in a number of areas, including the establishment of the Toronto Food Charter, creating links with agricultural bodies, and influencing city planning. The Sudbury District Health Unit had been a leader in embedding equity in all aspects of its work. Through an intensive multi-year process, they established equity as a foundation for staff members and interactions with community organizations, and contributed to the public health evidence base, most recently through the publishing of its “10 Promising Practices” fact sheets that give clear guidance to local public health units striving to address inequities. Outside of Ontario, the Saskatoon Regional Health Authority clearly demonstrated the glaring disparities in health between poor and wealthier neighbourhoods in its jurisdiction and suggested concrete policy steps needed to address these differences, many of which are being implemented through an intersectoral committee. These are just a few examples at the local level. Provincically, Ontario, BC, and Nova Scotia are including addressing inequities in their provincial standards for local public health. Nationally, one initiative involving public health and many others is the Coalitions Linking Action and Science for Prevention program, which focuses on the built environment.
This type of work is complicated and multi-faceted and requires long-term thinking with a goal to reduce structural inequities. Yet it is necessary if MOHs want public health to be truly relevant to the health of their communities. Aspects of traditional public health are still essential, but the new mandate of public health is (or should be) social justice focused. MOHs need to be part of that change. Public health, the healthcare system, community partners, and the public need to demand a focus on equity from their MOHs.
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i was looking for the roles done in point form not this long fairy tale youve written
Nice Information, it was really knowledgeable for me
Politics? Ignoring the living conditions that cause disease is not politics? Politics is about power and influence in society: “Who gets what, when, how.” Medical officers of health get secure jobs, high salaries and prestige. The vulnerable get admonitions about not smoking, exercising, and eating fruits and vegetables. As Sylvia Tesh says: “Given that there is no science uninfluenced by politics, the plea is not to get the politics out of science, but to get the politics out of hiding.”
Learn more! http://ped.sagepub.com/content/19/3/54.abstract
“Educating the Canadian public about the social determinants of health: the time for local public health action is now!”
Hi Adam,
I don’t know that we’ll resolve our contrasting opinion since it seems we have fundamental differences in the way we view health in general and the role of government, and ideally all people, in the promotion of health. But I’ll add a few points to try to address some of your concerns.
1. There is a clear accountability process for MOHs. Structures differ in different provinces, but MOHs always report somehow through a system which typically ends up reporting to a Board of Health, which can be made up of a mix of politicians and provincial/local representatives. There are also different methods of accountability to the provincial government. The “community” I serve is the population covered by the Health Authority that I work for.
2. Although I do think funding is a concern (currently public health receives about 1.5%-5% of the healthcare budget depending on the province), I was not making the argument for increased funding (at least not in this piece!). It is more a change in practice that is needed, which is based on evidence. There is a whole body of population health research that is increasingly showing evidence of community/provincial policies and programs that improve peoples’ health.
3. The issues that make the news are the legislative actions, which are just one aspect of public health work. Sometimes they are initiated and supported by public health. Sometimes they are not done/advocated for by public health – that is when politics can play a greater role, ie. when a politician who may not have the evidence-based background makes a decision. I’m not saying that’s the case with your examples – it would be a much longer discussion to go through the for and against of each item you’ve listed. Additionally, I’d agree, that there are times may advocate for something in inappropriate. Hopefully that changes as evidence does.
I do support the use of legislation in some cases, and I’m assuming we’d disagree on that. For example, taxation of cigarettes has been one of the most effective methods of decreasing smoking rates. You could argue that that infringes on individual rights or that there are harms to lower-income people who are more impacted because they continue to smoke when they can’t afford to.
4. You mentioned the need for politicians to be able to argue against the “experts”. Experts in the civil service are there to give advice to politicians. No decision is based solely on evidence, although it should ideally be a significant motivator. Decisions may be made by politicians that go against advice, and there are numerous examples of public health people speaking out or leaving their jobs when they feel the disagreement harms their professional credibility.
5. Collaboration definitely does not need to fail. There are examples I cited in my piece that show the ability of politicians, health, community organizations, others, to achieve outcomes that improve health.
Again, I don’t think we’ll agree because it seems we differ on the idea of a collective responsibility – I believe that if people are as healthy as possible (which means dealing with SDOH) then we are are healthier as a society, and that we all play a role in that. That philosophy goes far beyond me – it’s the basis of many of the benefits we have as a society, such as Medicare. I realize there are many other opinions, including yours. The discussion is valuable, particularly since, as you say, population health work will have an impact on you. Your views are important aspects of what needs to be considered in the ethics of public health.
Hi Adam,
A few thoughts about your post.
1. Public health is increasingly expected, by elected officials, to take a social justice perspective. This expectation evolves through a political process, so it is ultimately politicians who are creating/supporting this mandate for public health. For example, in Nova Scotia, the public health standards state that public health should be focusing on “upstream” factors (aka social determinants of health) and should use a social justice lens. Another example is in Ontario, where public health is required through standards to address the public health issues of “priority populations” – this means understanding why certain populations are at greater risk of illness and addressing those contributors. Again, the Ontario standards emerged from and with a political process.
So although MOHs are not elected officials, their work is greatly influenced by politicians who support a social determinants approach.
2. The nature of the powers given to an MOH under provincial legislation are specific and are typically used judiciously as actions taken in the name of legislation need to be reasonable and justifiable. It would be difficult the type of legislation you’re talking about to address social determinants of health. I think most MOHs and public health workers would say that SDOH work requires collaboration and there is no easy way to achieve outcomes. Legislation and regulation might play a role, but almost all SDOH work occurs using many other tools.
3. I don’t want to tell you how to live your life – although public health often does focus on the behaviour of the individual – that is slowly changing. What is increasingly common for public health is the desire to create an environment where people are able to be healthy. This might entail working with others to have recreational facilities available, or be able to easily access healthy, appropriate food, or to earn a living wage.
4. As a public health physician, the community is my “patient”. My medical training was based on learning about what makes communities healthy and unhealthy, and taking step to ensure that communities are as healthy as possible. I would not be fulfilling my role as a doctor if I did not look at the evidence regarding SDOH and apply that to my work, just as a surgeon wouldn’t be asked not to take evidence-based actions to help her/his patient. Additionally, just as physicians advocate for the health of their patients, public health physicians advocate for the health of their communities.
5. The focus of public health on SDOH is evolving throughout the country. Public health at the local and provincial levels may be taking different approaches to social justice and equity – this speaks to both the nature of our political system as well as the complexity of the issues being dealt with.
Monika,
Thanks for your reply.
1. About the “community” being your patient. As a taxpayer, this concerns me because it represents mission creep and it is amorphous: Who is the community to hold MOHs accountable, to argue against the experts?
This is a complaint I have with many in the health care system, and so this comment is not directed to you. For that reason I will not give a public health example to illustrate my point. When oncologists (but fill in many practitioners of your choice) say they need more funding to provide more services to their patients, they say that they are acting in the best interests of their patients, which (lo and behold!) happens to also be in their own interests (more money, more budgets, higher profile, more power). We must be aware that discussions about roles in the health care system, and new roles for health care practitioners, may be advocated benignly to benefit patients, but these new roles often benefit the providers and practitioners too.
My point is simply that there is a never ending demand on the public purse for more money to be spent on health care programs. Health care practitioners, who design and manage those programs, are often at the forefront of advocating for the expansion of those programs and are apparently the neutral experts in their field. This is often done in the best interests of the patient and yet that also happens to co-incide with the interests of the practitioner/provider. Who is to tell the difference and make that choice?
What this represents is mission creep as roles expand (rarely contracting, rarely becoming less important to the health system). As new interesting high-profile roles are taken on, there is a significant risk that the drudgery of the old work is given less priority.
While you say politicians can balance these demands, I am not so sure, especially when we live in a society where every change in our system is perceived as a threat by someone and every shift in resources is protrayed as a “cut” by the loser.
And do politicians really have the expertise to argue against the experts? In 2004, in Ontario, public health officials wanted to ban the use of raw fish (sushi) and to instead mandate using frozen fish because of the fear that some people could become ill from eating these products (e.g. pregant women, people with immune system issues). The proposal sailed through the political process and was announced, only to be repealed once there was a public outcry. And this came from the very well liked/respected and well meaning Dr. Sheela Basrur. Or, perhaps, one can look at the ludicrous situation in Ontario where it is illegal to sell unpasteurized milk or make raw milk cheese, but one can buy raw milk cheese imported from Quebec or France at any cheese store. These public health rules were introduced over a century ago, but they don’t go away because no public health official speaks up to say that perhaps today there are ways of dealing with this issue with acceptable risk.
2. About collaboration and individual freedom. Thank you for not wanting to control my life. I appreciate it. Unfortunately, I am skeptical about the slippery slope that begins with good intentions yet ends in using government legislation (i.e. force) all in the name of good health.
With tobacco, for example, public education was not enough. We went further and had to ban it in all public spaces, which (as a non-smoker) I can easily justify on the basis that someone else’s harm to themselves should not be a nuisance or harm to me. But we also banned smoking in separately ventilated spaces where smokers could merely burn their own lungs. And we ban advertizing, restrict where the product can be sold etc. Some public health officials (advocating of course for their communities) would like to ban the product altogether or ban smoking it in homes. Where do we stop in the name of protecting our communities?
What about the recent developments in New York City to ban the sale of large surgery drinks to combat obesity? Fortunately, I am spared the need for such beverages, but NYC’s public health department has been on the fore-front of pushing that initiative to combat obesity. Where will this stop? The flames of “something must be done” about this health crisis is turned into “anything must be done”. Should we have ration cards issued to everyone allowing one such drink a month? It would be a very courageous public health official to stand up and speak about the need for evidence on whether the proposed ban would actually achieve the intended result, or to speak about values that individual freedom should trump health care because we should focus on persuasion and education not the force of legislation.
So, yes, in neutral pleasant tones we can speak about the need for collaboration on these complex issues. But it won’t stop there. Once collaboration fails (because it’s just too hard, the results too hard to measure, the causes/effects too difficult to connect), there will be a demand for more powers, more intrusions on personal freedom, not merely to keep people from harming others (which I am quite prepared to admit is a legitimate tool for law), but also to keep them from harming themselves. And all of this will be done in the name of my health and my community’s health and seem oh so innocuous.
Sorry but arguing that public health should be about social justice means that you have entered the realm of politics. Since when did MOHs become publicly elected officials? You are bureaucrats, not elected officials, and should not be seeking a pulpit to expand your role. You have a conflict of interest.
I am also concerned that MOHs have in many jurisdictions significant legal powers, developed for the purpose of combatting communicable diseases in light of the historical role that you now wish to move away from. I do not want public health officials to start to use these powers to deal with social determinants of health. I do not want you to tell me how to live my life, what to eat, what to drink, how/when to exercise. As I said, you are not elected to socially engineer my life.
Hi Sandra,
Thanks for your comment. You’re right, networks are vital – as a fairly new MOH, I look often to the work of those I cited as well as others who are leaders in addressing equity. There are various networks that exist, such as through the advocacy committee with the Public Health Physicians of Canada, and within provinces, for example, Ontario has a strong group of MOHs and other public health agencies working together on equity issues. The Health Officers Council of BC is another good group. There are also groups like the Urban Public Health Network which involves MOHs from the 18 largest Canadian cities.
What’s helping motivate all MOHs, in addition to the ones with a special focus on equity, is the growing recognition that equity is both intrinsically required as well as legislatively required.
That being said, I’d welcome others’ thoughts on ways MOHs could be collaborating more effectively to address inequities. Your questions is making me think about where the gaps are.
This is a very good article.Please I need more health information from you so that I will be in tuned with the lattes Health Information from your country or any countries around the world.
Great article, Monika. I look to blogs like yours to build my knowledge about recent developments.
I am wondering if there would be any interest in a network of health equity focused MOHs. I recognize that all MOHs should have a focus on equity in their day to day work generally, however there are some MOH’s with a special focus on health equity activities, and gathering a critical mass of common minded may help to spread good ideas, rather than waiting to learn about them after the train has left the station.