We Elected This Pandemic

Two and a half years into the COVID-19 pandemic, it’s clear that most of us are not really interested in public health. After the first scary months, our collective attitude changed to “Let her rip,” while we sat back to watch the consequences as a kind of entertainment.

The effect on health-care workers and other social service workers like teachers has been demoralizing: burnout, early retirement, resignations. And while U.S. President Joe Biden may say the pandemic is over, we know it’s not. In September alone, the U.S. reported 1,634,091 COVID-19 cases and 11,827 deaths. For Canada, the September numbers were 71,355 cases and 1,061 deaths.

Public health can be defined as “preventive” care: keeping people from getting sick in the first place by providing clean water, food inspection, quarantines, vaccinations, and so on. A recent report by the Public Health Agency of Canada estimates that without restrictions and vaccinations, we would have suffered 34 million cases, 2 million hospitalizations and 800,000 deaths. Instead, we’ve seen 3.3 million cases, 150,000 hospitalizations and 38,000 deaths. That’s a pretty impressive achievement.

But most health care is “curative” — treating the sick through the use of physicians, hospitals and pharmaceuticals. According to the Canadian Institute for Health Information, in 2021 Canada spent 25 per cent of its $308 billion health budget on hospitals, 14 per cent on drugs and 13 per cent on physicians. Various other categories absorbed most of the rest, with COVID-19 response taking seven per cent.

We spent just five per cent of the budget on public health — and many Canadians attacked both public health measures and the people trying to save us from getting sick. Now we’ve abandoned public health itself for “personal responsibility,” ensuring that the virus will continue to spread and mutate and reinfect us.

Why public health is a low priority

Why so little public support for public health? At the University of Montreal, researchers led by Olivier Jacques may have found an answer. Jacques is an assistant professor in the university’s department of health policy management and evaluation. He and his colleagues at UdeM, the University of Toronto and Carleton University have studied the politics of public health funding both around the world and here in Canada.

In “The Politics of Public Health Investments,” Jacques and his colleague Alain Noël look at health funding in 25 of the most prosperous nations in the Organisation for Economic Co-operation and Development.

In such countries, the authors argue, “Preventive care is particularly unlikely to be prioritized by governments since it is a public good that requires the allocation of scarce resources in the present to generate diffuse benefits that unfold only in the long term. As such, public health is a ‘quiet’ policy that is not supported by interest groups or public opinion.”

When a disease breaks out, however, we are happy to spend money on the “loud” policy of curative care and its short-term results. We know who needs care, and who’s giving it, and we can easily imagine ourselves falling ill.

Jacques and Noël argue that “Individuals and governments have fewer incentives to pay for public health investments and public health has no obvious constituency to support it.” And when an economy gets into trouble and politicians impose austerity, it’s politically easier to cut back on public health than on curative health.

By looking at data from 25 countries in the OECD, Jacques and Noël found that most of those countries spent a fraction of their health budgets on preventive care compared to curative care. Canada’s preventive care spending is relatively high, at 0.6 per cent of GDP and about 20 per cent of curative spending. Sweden spends much less of its GDP on prevention, and spends only about five per cent on curative care.

Left and right spend alike on curative care

Jacques, Noël and colleagues at U of T and Carleton have also studied spending on public health within Canada. In a paper currently under review, they studied provinces’ health spending from 1975 to 2018. They find that “left” governments (the NDP and Parti Québécois), “centre” governments (the Liberals) and “right” governments (the Conservative party, Saskatchewan Party and BC Liberals) all spend about the same on curative health care. The left parties tend to spend more on preventive care. And when governments must cut spending, preventive care is crowded out and more funding goes to curative care.

Unsurprisingly, the researchers also find that all health spending goes up before elections, and that federal transfers lead to slight improvements in curative spending but not to public health.

Jacques, Noël and their colleagues conclude that “even though they have low salience, public health expenditures remain driven by partisanship and electoral concerns. However, despite their widely acknowledged importance, public health programs develop in the shadow of curative care programs.”

Assuming that the studies are generally accurate, they suggest that we have exactly the health care we voted for — and we voted to let the pandemic rip. And we rewarded politicians who held elections during the pandemic with re-election while the death tolls kept rising.

However many lives public health has saved in the pandemic, the long-term goals of preventive care deprive it of a constituency. Even in the early months of the pandemic, isolation and wearing masks were urged as policies to save curative care by “flattening the curve” and reducing pressure on hospitals and health-care workers. With our curative system now on the brink of collapse, that approach hasn’t worked out.

Public health is political

The pandemic has certainly created new constituencies to lobby for more curative care, especially the growing numbers of Canadians dealing with long COVID. But it may have created a powerful new lobby for preventive care.

For example, COVID-19 rampaged through Canadian nursing homes and long-term care facilities. The friends and families of those lost elders have every reason to put pressure on their governments to improve preventive care: when the middle-aged reach retirement, preventive care will improve their chances of a longer and healthier old age.

Those most at risk from COVID-19 — the immunocompromised, those with disabilities, Indigenous peoples and persons of colour, the poor — should be strident supporters of great public health spending.

Similarly, teachers and parents should demand a return to complete vaccination for children and those who work with them. Such protections were routine and gratefully accepted by earlier generations; they should now be considered necessities of life that parents are obliged to provide for their children. The curriculum itself should include far more on preventive care, with plenty of horrible examples from the COVID-19 pandemic.

Unions and professional associations should also insist on improved public health measures and messaging. Their memberships have suffered from inadequate prevention and garbled messaging; it’s in their own interest to protect themselves, their colleagues and their clients.

If nothing else, the pandemic should have taught us that the “long term” is getting shorter and shorter, and that we all have an intense personal interest in the health of everyone else.

We’d better start voting for that interest.