The pandemic has revealed the essential role of public health in the management of a health crisis. Some are concerned about the consistency of public health decisions and recommendations and the possibility of political interference. Others question the Quebec model of public health and the central role of the national director within the Ministry of Health and Social Services and the government. To appreciate the work of public health, it is necessary to understand the nature of this discipline and the objectives of the model implemented in Quebec.
Posted at 9:00 a.m.
Public health is a complex discipline. Unlike other medical disciplines, it must consider a health problem not in a sick individual, but in the entire population. It must examine a problem by locating it among all the health issues affecting the population. For example, although the compulsory wearing of bicycle helmets is effective in reducing head injuries and accidental mortality, this measure also results in a significant reduction in the practice of cycling as a physical activity. The excess cardiovascular mortality induced is even greater than the reduction in deaths from bicycle accidents. An apparently effective measure is thus inappropriate for the analysis of public health.
The other issue to consider in public health is the practicability of a recommendation. A proven measure can only be supported if it can be applied, given the availability of staff, equipment and funding. Social acceptability is also to be taken into account, because the support of the target population is essential to ensure the effectiveness of a public health measure. Fluoridation of drinking water is a glaring illustration of this component. This measure, although well documented in terms of its effectiveness in reducing tooth decay in children, and easily implemented in many places in Canada, the United States and Europe, has been the subject of fierce resistance. in Quebec. It is therefore no longer supported here by public health, given its low social acceptability.
While the efficacy of an individual treatment is often supported by methodologically sound clinical studies, this is not always the case when looking at a public health measure and its population impact.
With the exception of vaccines, a population-wide experimental protocol can rarely be used. It is in fact impossible to assign subjects randomly to an experimental group that receives the intervention and a control group. We must fall back on less robust methods whose results are more questionable. The environment and the population of the experimental context is therefore an important limit to the applicability of the study to our situation in Quebec.
The current pandemic provides several examples of the complexity of public health decisions. Wearing a mask was not recommended by public health at the start of the pandemic. On the one hand, the scientific evidence for its usefulness was not, at the time, well documented. It could still have been recommended on the basis of the precautionary principle, but the applicability was difficult given the stocks available. We therefore had to insist on other barrier measures such as distancing and hand washing. During the pandemic, scientific evidence for the effectiveness of the intervention mask became convincing and stocks were more available, hence the recommendation to use them.
Another example: rapid screening tests. These tests have significant limitations in their sensitivity to detecting the virus. In a context of absence of symptoms and low community transmission, the value of a negative test is highly questionable, which limits their usefulness. There are too many false negatives, which can create false security. In contrast, in symptomatic people or during an outbreak or community outbreak as is the case with the Omicron variant, they become more useful. The number of false negatives becomes negligible compared to the positive cases identified. The public health recommendation therefore changed, as the context changed, which influenced the performance of the test.
Public health is therefore a complex discipline due to this mixture of medical and social sciences. Public health, although based on science, must also take into account political considerations which sometimes become preponderant.
And I’m not talking about partisan politics here, but the social context and power relations in society. This sometimes explains the divergence of points of view with experts specializing in infectious diseases, the environment or epidemiology, who often only consider a more limited aspect of the problem.
Quebec has been at the forefront of the development of public health in Canada and around the world. Under the impetus of Dr Jean Rochon, Quebec has a National Institute of Public Health which concentrates expertise in this field, well before the creation of the Public Health Agency of Canada. Quebec also has an executive public health organization in the form of a national directorate and regional directorates. The national director of public health is a deputy minister in government, which gives him an important role in the decision-making process. The Public health law grants it very important powers which even go beyond the usual powers of a minister or the government: compulsory treatment or vaccination, evacuation or confinement of a population at risk, stopping the use of a water supply network, etc.
In managing the pandemic in Quebec, Dr Horacio Arruda has played a leading role in being at the heart of government decisions.
His role was not limited to giving an opinion, but took part in the decision-making process by having all the data as to the feasibility of a measure and its eventual social acceptability.
This is an important advantage which gives public health a crucial role in the management of health crises. Its counterparts in other provinces and countries would no doubt like to have such power, but they are often relegated to the role of experts without real control over decisions. This situation can be extremely uncomfortable when political decisions diverge from recommendations, as was the case with Dr.r Anthony Fauci in the United States and for certain chief physicians in other Canadian provinces. The Dr Arruda, he took part in the decisions having all the levers to assess the underlying political considerations. He supported them and explained them from the same platform as the government authorities. What could be interpreted as reversals or hesitations were in fact linked to the rapid evolution of scientific knowledge and the context.
We have entrusted public health in Quebec with an important active role in the state’s decision-making process. This is a definite advantage for public health and a crucial achievement for the population.