Stuck in the middle with you: The inherent tension faced by medical officers of health

Editor’s note: This article is written by a medical officer of health. The author’s name has been omitted to prevent acts of harassment and intimidation. We have closed the comments section to protect the author’s identity. 

Though it has become publicly apparent only recently, there is a long and winding road of tension between medical officers of health (particularly provincial Chiefs) and their employers, our governments.

Advice-sharing, fashion-setting public celebrities featured as subjects of T-shirts and art and household names during the first half of the pandemic, Chief MOHs can do no right in 2022. The past year has seen mounting public calls for their resignations. CMOHs are subject to attacks by opposition parties for their complicity, or abandoned by the governing party as scapegoats for policy decisions.

This editorial isn’t intended to garner sympathy for a difficult position, but rather to shed some light on the predicament we have put medical officers into and its long history before COVID.

Medical officers are not political appointments, yet career longevity is a constant threat for MOHs who are in essence employed by governments as bureaucrats. Among medical school graduating peers, except for the rare and concerning exception, termination risk is not something usually faced by clinical physician colleagues.

For medical officers, this threat is exacerbated by their limited in-field employment opportunities if they lose their jobs. The public health community in Canada is a small one, so fired somewhere may mean employable nowhere. While historically medical officers were often end-of-career clinicians, direct training and the need for specialized knowledge means clinical work is not a fallback option for most these days. Additionally, unlike clinical colleagues, university academic positions that might permit more outspokenness are few and far between in public health, and at far lower comparative compensation.

But is this threat of job loss real?

A non-comprehensive recent history of sacking includes examples from coast to coast. In most cases, it has not been a dramatic firing but rather a quiet contract non-renewal without cause, leaving the public confused as to what really happened.

It would be wonderful for governments to make clear which they want: an independent advocate or a quiet, expert adviser? 

In 2002, Southeastern Alberta local public health officer David Swann was sacked with what was later identified as political interference for advocating the importance of the Kyoto protocol to counter climate change. In 2015, New Brunswick CMOH Eilish Cleary was fired; common understanding is that it was because of a report she released on the health effects of shale gas fracking, to the displeasure of the frack-friendly, Irvine-fuelled New Brunswick government. The list of premature retirements or NDA-driven silent departures most likely is far longer than these examples and warrants formal assessment.

Why the firing of (usually) intelligent and highly trained experts? Helpful academic work in Canada has helped identify the conflictual role medical officers are put in – acting as independent public advocates but also as expert bureaucrats, including during the pandemic – that is no doubt at least in part to blame. It would be wonderful for governments to make clear which they want: an independent advocate or a quiet, expert adviser? In striving to fulfill both roles, conflict is inevitable and, in fact, is entrenched in the origins of the profession.

Public health has its roots in social-reform that collides constantly with governments’ economic-focused agenda. Commonly in Public Health and Preventive Medicine training, this tension is implicitly discussed. While learning policy advocacy, the question, “Is this the hill you’re willing to die on or do you wait for a more important issue in the future?” is frequently discussed.

A further dilemma discussed is whether it’s better to be “in the room influencing positively but carefully” than excluded altogether. Public health reforms have changed the autonomy and relevance of medical officers in all provinces save Ontario, and even there the looming threat of public health system “modernization” – the consolidation of independent public health organizations and reporting hierarchies, in part to reign in local autonomy/advocacy – was postponed only because of the pandemic. But it is clear it remains on the agenda.

So where does this leave our country’s medical officers, who suffer from the stress between being the faithful, submissive bureaucrats governments sometimes want and the rogue auditors general the public sometimes needs?

At this juncture in the pandemic, they are subject to increasing pressure from their employers to publicly support policies that are unsupported by the science but to still say it is so. In acquiescing, they leave more people marginalized, those whom public health usually seeks to protect. The marginalized and those at higher risk of severe COVID are no longer covered by public health protections, and the question is whether this moral injury is worth keeping the job over?

Of course, the tension in the role, instances of where it has gone well and where it has failed, should come to light in imminent commissions on the response to the pandemic, but only if we remember long enough to keep caring about it.

If not, the merry-go-round will come full circle and we’ll again act surprised next time a pandemic comes around and this tension mounts all over again.


*story updated April 8, 2022

The comments section is closed.

1 Comment
  • Vanessa Acheson says:

    I thank the author for the time and effort to write this article. However, there is little acknowledgment of the responsibility of officers of health who stood by destructive COVID containment measures that did not honor the numerous, and equally vital pillars of public health.
    At the onset of this crisis, Canadian officials adopted never been done before, hardline, Communist Chinese government-grade, infection suppression measures. Due to fear of the unknown and based upon unreliable data they implemented lockdowns of the healthy and shuttered “non-essential” businesses. They chose this measure over less aggressive infection mitigation strategies which would have seen isolation efforts geared only to high-risk populations while our economy carried on with a heightened awareness around infection control measures to protect the vulnerable. 
    The choice to adopt suppression measures was largely spurred on by a mathematical model constructed by the Imperial College of London, which since has been found to have significantly overestimated mortality. However, the Imperial College model’s authors’ clearly disclosed: “Suppression carries with it enormous social and economic costs which may themselves have a significant impact on health and well-being in the short and longer term. ”

    Without question, impacts on local health care systems from COVID-19 is of extreme importance. Yet, officers of health are equally aware that Public Health measures do not take place in a vacuum and that our nation’s health is about more than fighting COVID-19.
    These militant actions were disproportionate to the threat and did not reflect local and global data. According to data from the best-studied countries and regions, the lethality of Covid19  averaged about 0.2%, which is in the range of severe influenza and about twenty times lower than originally assumed by the WHO to qualify lockdowns. Asymptomatic or mild cases were not calculated into the initial death rate and have reduced the mortality rate substantially. Even early WHO reports stated that 80% of all Covid-19 cases were mild and evidence indicates that 80% of the population has little to fear from COVID-19.
    Younger or healthy people have an extremely low risk of death and serious outcomes.  Less than one percent of deaths at any age is in the absence of underlying conditions. Knowing this, an achievable goal is to target isolation policy to high-risk groups, including strictly monitoring those who interact with them. Rather, officers of health implemented total isolation policies which have interfered with vital population immunity..and all to wait for a vaccine for a never before done virus (with an alarming history of failed past vaccine attempts), using a never before approved for human use platform for a mutating virus.
    In addition,  experimental social distancing, based upon “limited” evidence that saw public playgrounds and beaches closed and an economy forever scarred did not work as promised. Throughout this crisis, our hospitals remained under capacity in most instances, and you fully knew that past influenza seasons have seen equal demands without implementing draconian measures.
     Long-term care homes were in bad shape thanks to privatization and government underfunding long before COVID-19. This is even more concerning considering the previously mentioned Imperial College mathematical model warned that 2/3 of the estimated deaths from COVID-19  were those who were going to die within months regardless of COVID-19. So, rather than fortified long-term care facilities, well equipped to reduce impacts upon hospitals and protect those at the end of their lives, we saw chaos, hysteria and understaffing that led to dreadful outcomes for these highly vulnerable populations. Had our infrastructure in long-term care institutions been sufficient to identify and manage these care needs, nursing home residents could have been treated with the dignity and respect they deserved. In addition,  we may have averted significant harms associated with lockdowns.
    Officers of health were fully aware there are well-established harms incurred as a result of COVID-19 suppression measures. You knew suicide risk among youth skyrocketed, calls to crisis hotlines and domestic violence saw dramatic increases. As have, alcohol and recreational drug use. You were aware teachers are the first line of defense for abused children and that UN report sited numerous escalating impacts on children from school closures.
    Officers of health were also aware that prior to the shutdown of our economy, 3.2 million Canadians, were living directly on the poverty line and that the average person is $500 dollars away from going into debt. You knew an at last an additional 1.55 million are now unemployed across Canada. It is well established that poverty, unemployment, and despair are public health plagues of the first order. A 2011 meta-analysis on the relationship between unemployment and all-cause mortality found that unemployment increased the risk of dying by 63%.
    Officers of Health also know the consequences on medical care were been profound. We will never know the implications of fear that keeps citizens from going to an ER, canceled surgeries, diagnostics, and delays in medical treatments such as chemotherapy. Depression, mental distress, and suicide have seen further escalation under COVID-19 lockdowns. Impacts on women’s health alone stand to be considerable. This does not even touch upon consequences such as starvation in developing nations as a result of first world lockdowns.
    Yet, officers of health remain committed to all things COVID-19 by resisting efforts to ease unscientific masking, future threats of more lockdowns, and continue to fiddle while Rome is burning. The time has come for citizens to demand officers of health and the politicians from whom they take their orders, and take accountability for their actions. For be assured, orders of prolonged draconian COVID-19 control measures and endless calls for mask and vaccine mandates will cause far more harm than good.

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