What COVID has taught us about public health capacity

Guest blog by Dr. Cory Neudorf

Dr. Neudorf is a professor in the Department of Community Health and Epidemiology at the USask College of Medicine, and a former chief medical health officer for Saskatoon

The first half of 2020 has proven to be one of huge challenge for the health system and society at large. However, it may yet prove to be a year of huge opportunity born out of tragedy and resiliency. As I write this, COVID-19 has stretched health system capacity in many jurisdictions. Interventions to slow the virus have disrupted the economy, while disproportionately impacting the most vulnerable in society and those working in health care and other sectors deemed essential.

Global pandemics have been overcome in the past, but both the scale of COVID’s impact and the response to date have been unprecedented in most peoples’ lifetimes. However, part of the health system was established and specifically trained to do outbreak prevention and management in the wake of pandemics of cholera and influenza in past centuries. The public health system was expanded and entrusted with learning what causes these outbreaks. Public health was funded to train and hire the staff to deal with outbreaks, and given legislative authority to act in the best interests of public safety, well-being and security through broad measures such as quarantine, mass testing, immunization and contact tracing and prevention. In short, public health is here to ensure we are not left vulnerable through delays in decision making in the critical early stages of a pandemic.

Between large outbreaks, these same approaches are used to manage smaller-scale outbreaks and prevent more common communicable diseases, which together improves population health. In the past 100 years, a legacy of improvements  through public health have followed, including routine childhood immunization, workplace safety laws, health inspection of our food, water, air and soil, family planning, and efforts to improve healthy behaviours and the social determinants of health (see History of Public Health – 12 Great Achievements).

One improvement was the creation of pandemic plans at all levels of government, with the mandate to update them continuously as they are tested over time. These reviews resulted in recommendations to invest in stockpiles of personal protective equipment (PPE), ongoing training of staff in the appropriate use of these supplies, and improvements to institutional infection prevention, control processes and infrastructure. As well, strategic improvements have included strengthening public health and primary care systems with adequate surge capacity, and making the pandemic response lead role of the medical health officer clear through legislation.

However, with pressures mounting to cut taxes and shrink budgets, public health and other community investments in prevention may be at risk. Ironically, neglect in funding prevention and the determinants of health can in turn add to the pressures on the acute care system and the need to respond to other health and social downstream effects. Recommendations to re-invest in public health and other evidence-informed upstream health and social programs have been strong and consistent in the wake of smaller crises like water-born outbreaks in Walkerton and North Battleford, SARS (2002/3) and H1N1 (2009/10), and have resulted in small gains in some cases. However, the most recent rounds of budget cuts and re-organization across the country have reversed these gains in many provinces, leaving us vulnerable once again. (See The Weakening of Public Health)

The net effect is Canada has experienced mixed results in our response to the COVID crisis so far. While some residual legacy products of past crises have stood us well, cutbacks and re-organizations have had unintended negative consequences on our ability to be as prepared as we may have hoped in parts of the country. The Public Health Agency of Canada and the Chief Public Health Officer position created in the wake of SARS have certainly helped us respond to COVID nationally. Investments in Saskatchewan in better information systems for communicable disease surveillance and more inspections and immunizations have been helpful.

Thanks to a good initial response to public health measures, the first wave of COVID-19 has been blunted, giving the system time to prepare for a possible second wave or future stressors. Now is the time to prioritize investment in a strong and unified public health system. In the near future, public health must plan for heightened surveillance for signs of setbacks as we gradually loosen early restrictions, and respond with aggressive testing and contact tracing to contain new clusters and outbreaks. Later, a mass immunization program may be needed on the heels of the seasonal flu immunization campaign, with the spectre of a possible second wave of COVID.

Meanwhile, other essential public health services cannot be put on hold indefinitely, as this leaves us vulnerable to other outbreaks caused by low routine immunization levels, an overburdened outbreak control team, or delayed health inspections. Other gains in health promotion and social determinants of health need to continue. Public health and community partners need to also respond to the unintended consequences of the pandemic, including rising overdoses, increases in family violence and homelessness, setbacks in healthy living strategies, and health inequalities.

Now is the time to invest in prevention and surge capacity. We have been given the gift of time. Let’s not waste it.

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