Public health agencies should prioritize infectious diseases

The Editorial: The seriousness of the Ebola outbreak should motivate public health agencies to focus on fighting infectious disease

Francois Lenoir/Reuters

Francois Lenoir/Reuters

More than 4,500 Africans have died of Ebola to date. The number of new infections is doubling every month. Health facilities in hot-zone countries Guinea, Liberia and Sierra Leone are overwhelmed and understaffed. And while Canada has so far been lucky in avoiding infection, on Sunday, U.S. President Barack Obama mustered the Pentagon into the fight after the botched response by civilian authorities left the American public nervous. Meanwhile, the head of the World Health Organization (WHO)—the UN body meant to provide leadership during international health emergencies—has bigger things on her mind.

Last week, as the Ebola crisis deepened, the director-general of the WHO, Margaret Chan, was in Moscow hosting a conference on tobacco control. “Yes, Ebola is truly an issue of international concern,” she told the Wall Street Journal. “But tobacco—if we put the evidence on the table—tobacco control is still the most cost-effective and efficient way of reducing unnecessary diseases and deaths arising from using such harmful products.” The conference concluded with an agreement on the necessity for ever-higher tobacco taxes. (Canada and the U.S. boycotted the assembly because of sanctions against Russia.)

Ebola may be scary, but cigarettes are scarier.

As our cover story last week revealed (“ ‘It is hell on Earth,’ ” International, Oct. 27), the WHO has failed to provide effective global leadership in the fight against West Africa’s Ebola outbreak. As a result, it has fallen to the international charity Médecins Sans Frontières to deliver the main boots-on-the-ground response, and Western countries such as Canada and the U.S. have been left to cobble together their own ad hoc aid packages. This abdication of responsibility by the WHO is largely by design. While the WHO’s greatest accomplishment was its leadership role in the eradication of smallpox in Africa and Asia during the 1960s and ’70s, under Chan, the organization has shifted its focus from infectious disease control to lifestyle ailments and affectations more prevalent in rich countries, such as smoking, sugar consumption and corporate control. “It’s not just Big Tobacco anymore,” Chan said in a speech last year. “Public health must also contend with Big Food, Big Soda and Big Alcohol.”

Unfortunately, this sort of bizarre mission drift is not unique to the WHO. Public health officials around the world have succumbed to a similar preference for tackling issues of personal choice, the free market and political causes apparently inspired by the Occupy movement. The predominant public health fixation in developed countries these days is the so-called obesity epidemic and the alleged need for food taxes, along with other intrusive measures, such as New York’s failed Big Gulp soda ban, to correct this situation. Keep in mind, however, that the familiar public health jeremiad that we’ll be the first generation whose children live shorter lives than their parents due to body weight is entirely unsupported by facts. A Canadian born today can expect to live longer than ever.

It has also become fashionable for Canadian public health departments to declare income inequality to be a grave threat to public health. Despite an absence of convincing evidence proving such a contention, municipal offices in Montreal, as well as Guelph and the region of Waterloo in southwestern Ontario, have all published reports recently on this topic, arguing that higher taxes are necessary to fix the problem. Waterloo region’s public health department has also weighed in on the alleged public health dangers of free trade and corporate agriculture. Last year, Toronto’s activist public health office chastised ABC TV for adding actress Jenny McCarthy, a vaccination critic, to the cast of its talk show The View.

It is apparently necessary to remind public health officials that their mandate (and competency) does not include individual food choices, income disparity, trade, agricultural policy or network programming decisions. The original purpose of municipal public health departments in Canada was to guard against the spread of communicable diseases such as smallpox and influenza. They can properly take credit for such advances as modern sanitary standards, the eradication of polio and our tremendous gains in food safety. But while that primary duty against new threats such as SARS or Ebola remains, today public health administrators appear to have wandered far afield in search of new things to do, or perhaps to indulge their own political views. It’s time to get back to basics.

The seriousness of the current Ebola outbreak should provide ample motivation for public health agencies around the world to abandon their pet political crusades and efforts to control private personal choices and instead focus their energies on fighting infectious disease, wherever it may occur.


Public health agencies should prioritize infectious diseases

  1. Mostly what we’re dealing with is Big Bullshit.

    A lot of this stuff isn’t science….it’s fund-raising with FEAR as a goad.

  2. I found it difficult to take in this editorial. At first I thought it was some tongue-in-cheek criticism of the WHO’s mishandling of the Ebola crisis. Certainly the situation in West Africa was mishandled but not in the sense that the WHO was wholly responsible and failed in its duties. What has happened was a collective failure of many organizations and countries and their leadership — in particular both their inability to learn quickly about the situation on the ground and their inability to act innovatively and in concert to evolving circumstances. This I get. And if Macleans would explore in future the collaborative challenge in such a complex global problem I would welcome it.

    But the editorial was not about this. It was about “public health agencies” in general (ie government) and their “efforts to control private personal choices”. This is about as ideological as it gets and had little to do with actual public health needs in Canada. Clearly, the author was focusing on Canada and West Africa was simply a ‘bait and switch’ distraction.

    I thought how could an editor from Macleans be so uninformed? He or she must be aware that 2/3 of all deaths in Canada are caused by cancer, heart disease, lung disease and diabetes – the major cause of which results from either a) smoking, or b) other lifestyle choices such as diet and exercise. And while those 150,000 deaths are each tragic, the people involved don’t just get sick and die right away, they linger on for months and years, draining the public treasury, currently amounting to 40-50% of public sector expenditures. An actuarial analysis conducted last year on the Canadian health care system concluded that, at current growth rates, a staggering 97% of total revenues available to provinces and territories will be spent on health care by 2037, compared to 44% in 2012. On the other hand, the editor of course would also be aware that the percentage of Canadians that die from bird flu, malaria, SARS, cholera, ebola and other serious hemorrhagic fevers approximates zero. The evidence suggests that public health agencies are indeed focusing on real threats.

    In my own interviews with senior public health officials, the sustainability challenge is now being framed not as a question of ‘cost containment’ but one of ‘cost avoidance’. How do we keep people healthy in the first place? “Keeping Canadians healthy” is not simply a “pet political crusade” but the very raison d’etre of Canadian public health agencies. Therefore, I found it troubling that the editor of a reputable Canadian magazine chose to set aside evidence in favour of such a narrow, ideological view.

    Given the escalating costs, what the editor’s comments suggest is a high level of entitlement that I find quite unpalatable. In essence he or she is suggesting that their personal choice is paramount and that he or she has not only the right to a lifestyle choice, but also the right to pass off the cost of their personal choice to me. In a society with privately funded health care, I would whole heartedly agree — you make the choice and you live with the consequences. But Canada is not such a place. We as a society made another choice long ago to support a public system of health care. In a publicly funded system, especially one with increasingly limited resources, your choice can have a negative impact on me, either in terms of new taxation or reduced services in other areas. Our system was initially designed not so that people could become free of the consequences of their actions but to reduce the burden on those who through no fault of their own became ill or infirm. It was designed out of compassion not to encourage people to behave stupidly in light of obvious evidence. The editor seems in favour of stupid.

    Lastly, the editor should know, but apparently pretends not to know, that much of the focus of public health agencies in this area is not on adults but on children. And they are not alone in this. They partner extensively with community organizations, parent groups, schools, teachers, doctors, employers and many others in order to cultivate within children a healthy pattern of lifestyle choices they can take with them throughout their lives. They do this against an onslaught of corporate advertising and media messaging that attempts to manipulate choice among those most vulnerable in our society. Public health agencies spend hundreds of millions in this area, although it is clearly not enough given the dramatic rise in diabetes, obesity, and mental health issues among our children. Let me underscore this – this epidemic is among children, not fully matured, independent adults but children. Those children then grow up to have a lifetime of disease — not just an end of life experience of it. This also incurs a lifetime of demand on our publicly funded health care system.

    So what am to think of the editor’s comments? He /she is uninformed, ideological, has a strong sense of entitlement, favours stupidity and is lacking in understanding or compassion with respect to Canada’s children. Didn’t seem like Macleans.

    • What an extraordinarily dumb editorial. Insulting, as well. Would the author criticize the latest surgical techniques because he or she thought that surgeons should confine their work to one type of surgery which only afflicted a small proportion of their patients? Or perhaps family doctors should stick to coughs and colds and forget about depression and anxiety in their patients. Public health practice is based on scientific evidence, just like the other branches of medicine. The reason “modern” public health has turned its attention to healthy policy, health inequities, the importance of early childhood development, how our neighbourhood environment affects health, and any number of other pressing problems is very simple. These are the things that determine whether we will be healthy or ill.

      No one is suggesting that we abandon the prevention and control of infectious disease. That will always be a key role for public health, but preventing the things that are killing us the most needs action on the determinants of health. This editorial was written out of profound ignorance, warped libertarianism, or, more likely, a lazy combination of both.

  3. Its interesting that the editorial uses the term “choices”. Under the Influence, a great CBC program, shows how ‘choices’ are manipulated and controlled by vested interests. The book “Scarcity” also demonstrates that poverty affects decision making.
    Age (both very young and very old), abuse, mental health like PTSD, also affect decision making. So this idea that we all have equal ability to make choices is just an idea.

  4. I am shocked at this editorial! Other commenters have phrased the concern well, so I will not repeat, but perhaps the author needs to do his/her research to fully understand the work of public health and the mandates that they work under.

    Simply put, the business of public health includes both communicable and non-communicable diseases. Non-communicable being heart disease, cancer, obesity etc. etc. To ignore these maladies would be remiss.

    I suggest whomever wrote this piece, get busy writing a retraction or continue to face increasing embarrassment about their lack of knowledge and awareness.

  5. What a disappointment this editorial is.

    Before running an article telling public health professionals what their job is supposed to be, Maclean’s editorial staff should have done just a little research. Although there is no single definition of public health, I have never seen one that explicitly limits public health functions to the prevention and control of communicable diseases. Rather, most accepted definitions could be summarized by something along the lines of “the science of preventing disease and improving population health”.

    Nevertheless, say we follow Maclean’s lead and decide to restore public health to its original goals. We should then ask public health agencies to focus exclusively on sanitation and hygiene, as those constituted the main goals of the American Public Health Association when it was founded in 1872. The fact is, as our understanding of the determinants of health has evolved, so has the scope of our efforts to improve health. It is true that when most public health agencies were originally established their focus was on communicable diseases, but that is only because at the time these diseases represented the most important threat to population health.

    Today, largely because of those early public health efforts, the health toll of many communicable diseases has been significantly reduced. On the other hand, chronic physical and mental illnesses now account for most of the loss in years and health-related quality of life in high-income countries. These illnesses cannot be prevented with antibiotics, by washing hands, or thru quarantine; they have deep roots in social and cultural factors. When public health officials focus on “big food, big soda, and big alcohol”, they are simply doing their job: preventing disease and improving population health.

    Ebola and many other old and emerging infectious diseases are scary and public health agencies have an obligation to respond to them promptly and efficiently. In no way does this imply that we should look the other way when it comes to the many other major factors negatively affecting health across the world. Partially quoting the blog post that led me here: “public health agencies should prioritize public health.”

  6. I substantially agree with the preceding comments and avoid repetition. In a a nutshell, commenting the Ebola crisis was a pretext for Maclean’s editorial staff to pass mainly ideological messages about public health services in Canada. Macleans clearly missed the mark in this issue and in my book, it’s credibility just dropped severaly points.

  7. “their mandate (and competency) does not include individual food choices, income disparity, trade, agricultural policy or network programming decisions”
    I beg to differ. As the program director for the largest training program for training public health physicians in Canada, I can tell you that both our mandate and competency includes, but is not restricted to both of the above. In 5 years of post-MD training, only 3 months are devoted to communicable diseases – the rest to income disparity and equity, policy (including trade), chornic diseases (including food choices), program planning and much more. The mandate of public health authorities – local, provincial and federal – include, and emphasize non-communicable diseases, and the physicians and other public health professionals are highly trained to address this mandate. The writer of this editorial is mistaking the 21st century for the 19th. The times have changed and so has public health.

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