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