“Be hard on the problem, not on the people.” – unnamed OMA Executive
When I was President of the Ontario Medical Association (OMA), I had the privilege of touring the province. The tour was during flu shot season, so I took the opportunity to meet many Public Health physicians and staff. They are all good, hard working people who are dedicated to their communities and doing their best to advocate for the health care needs of the population.
Unfortunately, the Public Health system in Ontario (and Canada) is fragmented and disjointed. This really impeded the ability of Public Health to act in a unified manor prior to the pandemic. But because Public Health wasn’t as “visible” at the time, the flaws in the system remained hidden.
To understand just how this fragmentation affected our health, one only looks at the situation around trans fats. I wrote about this previously, but in short:
– We’ve known since 1993 that trans fats are linked to increased heart disease
– We’ve known since 1995 that Canadians are one of the highest consumers of trans fats in the world
– Denmark, led by their strong public health system, essentially banned trans fats in 2004 and within 2 years had 4% less deaths from heart disease. There was also a reduction in childhood and adolescent obesity.
– The results were so good that many other European countries followed suit.
If we apply the Denmark results to Canada, we could prevent 600 heart attacks a year. Banning trans fats would seem to be a no-brainer, and clearly the type of thing Public Health should effectively advocate for.
But here in Ontario, outside of the City of Toronto trying to ban trans fats in restaurants in 2007 not much has been done about this. Part of this is because Ontario has 35 different Public Health units, who all function independently. They may not even have the same software when collecting data, and some still use paper charts. Because they all function independently, just because Toronto Public Health wants a ban, doesn’t mean all the other units would even know about it, much less share information on it, or advocate for it. And of course, every Province and Territory has their own autonomous Public Health System.
So essentially, the Public Health Units were unable to co-ordinate around this issue, and outside of trying to ban Trans Fats in school cafeterias, and a failed voluntary guideline by Health Canada, not much has happened.
It wasn’t even until 2017 that Health Canada got around to proposing a ban on trans fats, and 4 years later this still hasn’t happened. It’s worthwhile noting that over 10,000 heart attacks could have been prevented if we had acted at the same time as Denmark.
If in “normal”, non-pandemic times, the Public Health system was so fragmented, and disjointed, that something this straightforward couldn’t be accomplished, how would they perform in a once in century pandemic?
The answer, sadly, is not very well.
Just as the various Public Health Units couldn’t co-ordinate on the same message for Trans Fats, it appears the various units can’t co-ordinate on the same messaging around COVID. Case in point, on Nov 4, 2020, Health Canada finally (!) announced that yes, indeed, the coronavirus has airborne spread, and all facilities should take airborne precautions.
Yet a look at the website for my Public Health unit (Simcoe Muskoka) on Jan 10, 2021 (2.5 months later!) still shows the same guidelines that’s before the announcement. Namely, that the virus is spread through droplets and so cleaning surfaces is more important.
So here we have two different messages coming from public health authorities.
By comparison, take a look at Japan. Japan decided back in February 2020 that the virus was aerosolized. They too have many regional public health offices, however, the regional branches send the information to the national office, and the national office makes decisions. Those decisions are clearly communicated to the public, so the same message goes through the country.
They very quickly focused on things such as air purifiers with HEPA filters in rooms, improving ventilation by leaving windows open (even in the crowded community trains) mask wearing, and improved HVAC systems.
As a result, on a per capita basis, Japan has only 1/8th the number of infections, and 1/14th the number of deaths from COVID19 as we’ve had in Canada so far.
But it’s not just messaging that’s the problem. Public Health Units are hampered by their archaic systems from adequately preforming the test/trace/isolate process so important to controlling the spread of COVID19.
My practice is close to the border of the Simcoe Muskoka District Health and the Grey Bruce Health Unit. If one of my patients comes down with a reportable illness, I have to figure out which health unit to report to. But they use separate forms. Additionally because they use separate data systems, they can’t share information between the two.
Supposing one of my patients were test to positive for COVID-19. What if they live in Grey Bruce, but work in Simcoe Muskoka. Who should I report this to? And more importantly who is responsible for the contact tracing considering they work in one area and live in another? Especially since they can’t share data.
The result? Effective test/trace/isolate does not occur in Canada.
Compare this to South Korea. South Korea has multiple regional offices for public health, but they’re integrated by the Korean Ministry of Health and Welfare (KMHW). They share software, and so can share data and information.
By having all of Public Health integrated, South Korea was able to have one source for information. So not only did they have a consistent message (the KMHW gave two press conferences a day), but they were able to effectively test/trace/isolate.
On a per capita basis, South Korea has only had 1/13th the number of COVID cases as Canada, and 1/20th the number of deaths.
Canada’s response to the COVID pandemic is among the worst in the world. Only the fact that we are next door to a country that has had arguably the worst response in the world seems to prevent Canadians from recognizing this fact. If there is one learning that me must take forward from this, it is that lack of an integrated, seamless and co-ordinated Public Health system has cost us many lives.
As a country, we need to support the people working in Public Health by improving the systems they have, so they can protect us in the future.
Note: This blog is based on the first part of a presentation I gave to the Public Health Youth Association of Canada (my thanks to them for asking me to speak). If you are suffering from insomnia, or if you are generally good person and want to support young people who are keen to improve the world, feel free to watch the presentation here:
justanoldcountrydoctor 
So true Sohail. Public Health suffers from the classic Canadian problems: Politicization of health care causing infighting about who is in charge and using health care as an election issue to be ignored between elections, and a suffocating overabundance of bureaucrats bent on their own advancement and job security.
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Thank you, Dr. Gandhi, for helping to shed light on this situation. I’ve become more painfully aware of this problem in recent weeks while trying to create a guide to support notifiable disease reporting (for clinically diagnosed cases of Lyme, specifically) province by province. In many cases local public health units are operating independently, using different forms (if any form at all), and in too many regions it is difficult or impossible to find someone in public health who even knows the correct reporting process doctors are supposed to follow. Meanwhile doctors are blamed for under-reporting. Reporting is mandated by law, yet the system is too fragmented and dysfunctional to reliably support it.
Serology is unreliable in the early stages of disease. Diagnosis of Lyme is *primarily* clinical. Yet the most common answer I receive from public health authorities when I ask the correct procedure for reporting clinical cases of Lyme has been: “Well, the lab does that.”
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