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Federal Politics
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Fixing the Crisis in Public Health

It’s another brutal winter in health care. Here’s what we need to do to set things right.

Crawford Kilian 1 Feb

Tyee contributing editor Crawford Kilian blogs about the pandemic at H5N1.

After three years of pandemic and the turmoil it’s generated, Canada is looking a little the worse for wear. We may want to think it’s over, but 50,344 Canadians have died of COVID — 18,920 of them in 2022. As well, the winter of 2022-23 has put a brutal strain on health-care workers and their patients.

Meanwhile, Ottawa and the provinces have been growling at one another about health-care funding. Given the mess in the health-care system, they seem likely to come up with some kind of cost-sharing formula on Feb. 7, which may improve the situation.

Dr. Theresa Tam, Canada’s chief public health officer, has made some excellent suggestions for improving the health-care system in her annual reports for 2021 and 2022. But I expect the politicians will ignore her.

Health spending has been enormous since the pandemic began in 2020. According to the Canadian Institute for Health Information, total health spending in 2022 was expected to reach $331 billion, or $8,563 per capita. Hospitals got 24.6 per cent, physicians received 13.6 per cent, and 13.6 per cent of all health spending was for drugs.

Strikingly, only 5.3 per cent of that was for public health.

Clearly, the pandemic forced all governments to spend more than they wanted. Rising costs are unavoidable: Canadians who couldn’t get adequate care during the early pandemic years are seeking care now, and our aging population puts increasing demands on the system.

But at the same time, inflation is driving up the cost of food and other necessities, and economists warn of an impending recession. So this may not be the best time to boost federal and provincial health spending, even if people are still falling ill with COVID-19 and other diseases.

When nothing happens

The goal of public health is to prevent disease; failing that, public health tries at least to mitigate it. You know public health is working, the old saying goes, when nothing happens.

But we see “nothing” as normal, the natural state of affairs, and we don’t see the point of spending money so that nothing will continue to happen. It’s when epidemics break out and hospitals are overwhelmed that we jump into action and spend money to get as much curative power as we can summon.

Still, when Justin Trudeau and the premiers gather to work out a new cost-sharing formula, they might consider an observation by Tam in her 2021 report A Vision to Transform Canada’s Public Health System.

In it, she discusses the “return on investment” of public health interventions.

“The median ROI across all assessed interventions was 14.3, meaning that every dollar invested in public health generated more than $14 in cost savings. This is achieved by preventing additional downstream costs to the health and economic sector. Importantly, public health actions that can effectively target a large part of the population, such as legislative, health protective, or national-level interventions yield the largest ROIs (27.2 – 46.5).”

Tam goes on to say: “In contrast to typical health care or social service investments, it may take considerable time before the positive impacts of public health interventions are noticeable. Therefore, long-term commitment and planning, rather than short-term political and economic considerations, are essential.”

“Considerable time” is more time than most politicians are willing to spare. They are looking ahead only to the next provincial or federal election, preferably just after some major accomplishment like a new federal-provincial health agreement.

If Canadian life expectancy rises in 2028, or fewer Canadians develop dementia in 2030, the government of the day may not be the government that paved the way to those achievements.

We’re not all in this together

Tam has consistently pointed out the public health problems resulting from the social determinants of health. COVID-19 has simply provided more evidence that as far as disease goes, we are not all in this together. Relatively poor and marginalized Canadians have suffered in the pandemic much more than affluent Canadians.

So it would be a major advance in public health equity to implement some kind of guaranteed basic income. When it was tried in Dauphin, Manitoba, in 1974, it worked. Fewer people needed to be hospitalized, fewer had accidents, fewer suffered mental health problems and more stayed in school, or returned to it.

To an extent, the Trudeau government scaled up the Dauphin experiment in 2020 with support for out-of-work employees and distressed small businesses. A lot of the money was misdirected, but people could at least stay in their homes and buy groceries.

For almost 60 years, medicare has helped narrow the Canadian income gap, ensuring that poorer Canadians could enjoy pretty good access to health care without the stress and costs endured by their American counterparts.

But the pandemic has overloaded the hospitals and aggravated the growing lack of primary care. Ontario is planning to outsource some procedures to for-profit clinics rather than provide more funding for medicare. That will further widen the gap between rich and poor.

So the emphasis in Canadian health care will remain curative rather than preventive, and costs will go up. We will have more cases to deal with, not only of COVID-19 but long COVID as well. The anti-vax movement is spreading; some parents are reluctant to vaccinate their kids for anything, which means we may soon see serious outbreaks of diseases like measles and mumps.

Meanwhile, public health itself is in trouble. Chief medical officers sometimes seem like mere mouthpieces for their premiers. As in the U.S., public health officials have been the targets of anti-vaxers. And last year’s demonstrations in Ottawa and at the Coutts, Alberta border crossing were supposedly triggered by resentment of public health measures.

Regaining trust and authority

So it’s going to be very difficult for public health agencies to regain trust and authority if a new outbreak threatens Canada. Routine public health procedures like surveillance, looking for possible outbreaks of new diseases, are likely to be seen as invasions of privacy. Development of new vaccines is now amazingly swift, but uptake will be far too slow. Don’t even think about mask mandates.

Clear, science-based messaging will continue to be drowned out by fake news. A recent report by the Council of Canadian Academies estimates we have already a paid a high price for lies.

Misinformation about COVID-19 is estimated to have cost the Canadian health-care system at least $300 million in hospital and ICU visits between March 1 and Nov. 30, 2021. This doesn’t include the cost of outpatient medication, physician compensation, or long COVID. Model outcomes also do not include broader societal costs, such as delayed elective surgeries, social unrest, moral injury to health-care workers, and the uneven distribution of harms borne by communities.

'Tell the truth'

A basic principle of crisis communications says we should “Tell the truth, tell it often and tell it well.” We might have a chance at rebuilding public health if our chief medical officers, and their health ministers, did just that.

They would admit, and apologize for, their mistakes in the pandemic. They would boost public health spending well beyond a mere five per cent of the health budget, and present careful estimates of the lives saved and illnesses prevented by public health spending.

Chief medical officers and premiers (and the prime minister) would also tell the truth about the ongoing public health disasters caused by our unequal society. They would advocate for higher taxes on the rich and better health care for everyone — including pharmacare, dental care, taxes on sugary foods and drinks, and a host of programs that would prevent or reduce the incidence of diabetes, heart disease, dementia and cancer.

And they would point out how public health would save money as well as lives. A dollar invested in a hiking program for teenagers, or hearing aids for seniors, would save $14 in treating future heart attacks and dementia.

What’s more, a robustly healthy population would be that much more resistant to the next virus. The health-care system could then focus on the most vulnerable and those at most risk from climate-related diseases and conditions.

Somehow, though, it seems far more likely that Trudeau and the premiers will make a deal that puts our money into trying to cure diseases we could have prevented altogether. It might be bad medicine, but it’s good politics.  [Tyee]

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