Despite major breakthroughs in antibiotics and vaccinations, infectious disease threats continue to emerge in Canada.
Lyme disease, West Nile virus and measles pose ongoing challenges. An increasing proportion of tuberculosis cases are extensively drug-resistant. Earlier this year there were 473 travel-related cases and three sexually transmitted cases of the Zika virus reported in Canada. And new global pandemics — exacerbated by factors such as conflict and the impact of climate change on cities — are an ever-present possibility.
At the same time, injuries and chronic health conditions like heart disease and diabetes continue to take lives and inflate our health-care costs. And while the health-care system seems to be our natural safeguard against these problems, there is only so much doctors and hospitals can do to maintain the health of Canadians. So who exactly is responsible for the well-being of the entire Canadian population?
As a PhD student of population health sciences at the University of Saskatchewan, I am researching the system delegated to this monumental task, one that is often taken for granted the world over: The public health system.
So what is the public health system? Who is involved and what do they do?
Preventing health disasters
The average Canadian will likely not even hear about the public health system unless something goes awry. This is because the public health system in Canada largely works to prevent health disasters from occurring, while maintaining existing initiatives — such as public health inspections programs, water-quality testing and disease surveillance programs — to ensure our health.
The public health system in Canada operates at three levels of jurisdiction: Nationally, provincially/territorially and at the city level.
At the federal level, the Public Health Agency of Canada provides national guidance to the provinces and cities regarding the state of infectious diseases, chronic diseases and injuries in Canada. It conducts research, provides policy recommendations and supports public health programs.
As with most health services in Canada, the provinces are in charge of setting regulations and targets for local public health professionals. They do this by collecting and synthesizing the provincial public health data to stay ahead of disease trends and by producing province-specific public health policies and regulations.
In local regions, epidemiologists, nurses, doctors and inspectors — along with groups of interdisciplinary health promotion professionals — work together to investigate outbreaks, maintain local food safety and promote day-to-day healthy behaviour and public policy. The exact organizational arrangements differ between provinces.
Turning data into action
The Public Health Agency of Canada (PHAC) lays out seven core competencies required of public health professionals. They include science, assessment and analysis, policy evaluation, collaboration and advocacy, diversity and inclusiveness, communication and leadership.
All seven describe the most effective traits for those working in public health to fulfil their mandates. These skills are similar to those defined by the United States Centres for Disease Control (CDC) three fundamental purposes of public health: Assessment, policy development and assurance.
“Assessment” involves monitoring the health status of populations and diagnosing population-based health issues. For example, it is public health officials who first detect a virus outbreak or announce increasing rates of chronic diseases based on data they receive from the health system or from their own independent investigations.
“Policy development” turns the data into action. This involves sharing information regarding public health issues, working with community organizations and the private sector to address emerging concerns and developing policies and programs to enable a healthy society. This work ensures that solutions are developed and deployed by public health agencies, and that they’re supported over the long-term by those living in affected communities.
“Assurance” involves a multi-partner effort to enforce public health laws and regulations. It involves interfacing with the health system to connect patients with services and improving the science of public health. This involves leadership, accountability and clear communication on behalf of public health officials.
Social determinants too large to handle?
In Canada, the social determinants of health include income, education, employment and housing. These are factors that influence people’s health status but do not necessarily involve the traditional health-care system. The Canadian Medical Association proposes that the social determinants of health are at least 50 per cent responsible for any given population’s health status.
Because the social determinants of health generally involve social and public policy factors outside of the traditional public health mandate, questions regarding what public health should and can do complicate action.
The National Collaborating Centre for Determinants of Health reviewed the research and found that social determinants of health are often seen as too large in scope for public health to handle, especially with limited resources.
As our understanding about the large impact of the social determinants of health increases, it is becoming clear that public health can only be achieved through the collaboration of all social and public policy spheres of influences — across economic, environmental, business and health care institutions — to move a healthy agenda forward.
Increasing public health investment
The rise and persistence of chronic diseases, and the re-emergence of global infectious diseases, threaten Canadians and the world alike. It is vitally important that all public health agencies work together, across jurisdictions, to maintain population health.
In 2014, only 5.6 per cent of total health care spending was allocated to public health. As most of the public health service providers in the country exist within the larger health-care system, funding is often tied to priorities that are not associated with long-term public health gains.
To make gains we must reorient our understanding of health, away from sickness-care and towards prevention. This involves increasing public health investment. This should also involve a Health in All Policies approach to governing. This calls for institutions responsible for the social determinants of health — such as government ministries in charge of finance, housing, social services and the environment — to consider the health of the population in their mandates. This will involve public health professionals working across silos to make health a societal priority.
There is also a general lack of detailed information about the public health work force, best practices and organizational arrangements in Canada. Promising developments in the field of public health systems and service research south of the border must be replicated in a Canadian context to better understand our public health landscape.
The more that is known about our current system, the better equipped we will be to mobilize effective practices nationally and to improve population health moving forward.