By Marian Orhierhor, Tasha-Aliya Kara, and Nicole Spence
Public health reimagined
As COVID-19 centered in many lives for the past 16 months, ‘public health’ became a household term. Through the media and elevated profiles of many health organizations, mainstream society is now more attuned to the only element of the health care system dedicated to preventing injury, illness and premature death, as well as to the underlying factors that lead to inequitable outcomes (Brisolara and Smith, 2020; Brownson et al., 2020). Whether this increased awareness will lead to increased societal value – and therefore increased support for the under-resourced field – is an uncertainty for many health professionals.
Historically, public health emergencies of international concern, such as HIV/AIDS, SARS, H1N1, Ebola and Zika, have been catalysts for change. After the Canadian SARS crisis in 2003, there was a resolve to strengthen public health, which led to the creation of the Public Health Agency of Canada (PHABC, 2019). Lessons learned from H1N1, Ebola, and Zika also spurred discourse on the need to invest in vaccine and biotech companies to stimulate the development of investigational vaccine technology that can be adapted to new and emerging pathogens (Lurie et al., 2020). The 2014-2016 Ebola epidemic in West Africa further highlighted the importance of research and fast funding in outbreak response. This led to the development of the WHO Research and Development Blueprint and the WHO Contingency Fund for Emergencies to allow for the rapid activation of research and development activities during epidemics.
While these events spurred positive change, particularly in increasing emergency response capacity, public health in Canada has not witnessed the same post-pandemic boom; rather, the enthusiasm seems to fade. Currently, the percentage of the national health care budget allocated to public health is at 5.7%, while hospitals, physicians, and prescriptions account for 54.3% (CPHA, 2014; PHABC, 2019; CIHI, 2021). In fact, the small portion of funding has suffered consistent cutbacks, despite clear evidence that increased investments in health promotion and disease prevention reduces health care spending overall by reducing the burden of disease (PHAC, 2010; PHABC, 2019). With public health solely responsible for keeping people healthy and preventing disease, injury and death, this depleting expenditure on public health has been explicitly linked to the lack of preparedness in responding to the first major pandemic of the 21st century.
Public Health expenditures include disease prevention and health promotion activities, community mental health and addictions services, and occupational health services to promote and enhance health and safety in the workplace. A broad definition of public health is consistent with the definition of preventive care used by the OECD for international comparative reporting of health expenditure (CIHI, 2021).
Like other disasters, immediate recovery efforts have focused on the areas that were highlighted as the biggest gaps: reforming long-term care, pivoting to greater virtual-based care, and revisiting methods and deliveries of care. However, this was the first pandemic to highlight the sociocultural dimensions of public health events on a global scale; it exacerbated existing inequities and further emphasized the importance of applying an intersectional lens to the population, as many marginalized groups shouldered the brunt of the pandemic (Paremoer, 2021). For example, individuals belonging to these groups worked in essential occupations and health care to prevent further economic, social, and health care system failure (UN Women, 2020; Paroemoer, 2021). Ultimately, the pandemic took a devastating toll on all aspects of society. Many hope that the silver lining of this impact is a level of awareness that has the potential to disrupt the status quo of an under-valued and under-resourced field.
Intersectionality is an analytical lens that examines how different identity markers (such as gender, class, race, education, ethnicity, age, geographic location, religion, migration status, ability, disability, sexuality, etc.) interact to create different experiences of privilege, vulnerability and/or marginalization (Crenshaw, 1990; Larson et al., 2016).
A new dawn
Despite devastating effects on a global level, the pandemic has rewarded the field of public health with a wide range of commendable developments, creative innovations, and has highlighted areas of strength. To understand the significance of this transformation and opportunity in the context of British Columbia, we interviewed Dr. Michael Schwandt, a specialist in Public Health and Preventive Medicine, who serves as a Medical Health Officer with Vancouver Coastal Health and Clinical Assistant Professor in the UBC School of Population and Public Health. Dr. Schwandt has been actively engaged at the front lines of British Columbia’s response to the COVID-19 pandemic, working to prevent transmission in high-risk contexts such as long-term care home and impacted workplace settings. Beyond his direct management of the COVID-19 pandemic, he is a specialist physician in Public Health and Preventive Medicine, with a focus on environmental public health and health equity. Through public health practice and research, Dr. Schwandt aims to explore and act on the health impacts of environments such as housing and urban form, in the context of climate change and persistent but modifiable disparities.
Q: How has the definition and perception of public health changed? Can you tell us how your role evolved as the pandemic evolved?
Dr. Schwandt: Most textbook definitions will highlight that public health is interdisciplinary and sectoral, but that can be lost in practice with specialty programs, such as food safety, disease prevention, and immunization, which are very focused by nature in order to effectively offer services.
The COVID-19 pandemic has required an all-of-society response to an all-of-society problem, driving home the idea that public health is an intersectoral field. To effectively manage the pandemic, we have supported areas like housing, transportation, education, income supports – but it has also highlighted opportunities to help manage the pandemic. There has been a general evolution in public understanding, which has been reflected in our health partners – for example, housing services now recognize they are a major part of a pandemic response and are part of an all-of-society approach.
Q: COVID-19 became the first pandemic in history to benefit from the Information Age, supporting connection and collaboration around the world. Yet, the technology used by health experts to mobilize interventions, programs, responses, and recovery, also provided means for an infodemic. How has public health dealt with this in the past and what are the plans to tackle this in the future?
Infodemics are an overabundant and rapid spread of information regarding a specific topic, often triggered by a major incident, making it difficult to find credible and accurate information (WHO, 2020a; PAHO, 2020). During the COVID-19 pandemic, misinformation showed up in various narratives: how the virus originated, treatment options, mechanism of transmission, and government intentions. Data from a BC Centre for Disease Control (BCCDC) survey of 400,000 BC residents during the first wave demonstrates that increases in engaging online was not always healthy, nor did it help provide clarity (BCCDC, 2020).
Dr. Schwandt: As a trainee at the time, I witnessed how the 2003 SARS event was the first epidemic to take place under a 24 hour news cycle; the health authorities that thrived were those that kept up with the cycle, producing daily reports and clear information, ensuring public confidence and dispelling misinformation in advance. Now, the COVID-19 pandemic has witnessed a new level of social media engagement. We see not only rapid communication with new findings and new discourse, often with global experts and politicians, but a live public debate on practice, policy, and guidance.
To deal with misinformation, health organizations have had to adjust not only how they broadcast but also how they understand what the conversation is, as the public can now drive the news cycle. For example, there was a lot of pessimism and alarmism about the immunization campaign, which has proven to be safe and effective. Early on, it became clear that we needed to notice and quickly address trends in discussions, adjusting the message for each audience.
Q: Knowing there is often fast economic growth and people tend to demand more of politicians in a post-pandemic world, how can we capitalize on this opportunity? Do you think the focus of public health will change? Is this shift due to scientific learnings or new public priorities?
Dr. Schwandt: I really hope it will. Many public health practitioners adopt approaches in ‘One Health’, ‘EcoHealth’, and ‘Health-in-all-policies’ that acknowledge solutions to complex problems won’t come from the health system, but rather from organizations that have their hands on the ecological and social determinants of health. For example, municipal governments and provincial ministries are turning to public health to solve their issues, but we need to ask, “How can they help with ongoing health issues?” Public health needs to further influence policy outside of health, and we could be in a better place to do this following COVID-19 – that would be a silver lining.
One area that has received a lot of attention throughout the pandemic is the nature of livelihoods. For example, policies have developed around mandatory paid sick leave, as unpaid sick leave is a known barrier for staying home when sick. Other risks that have been made clear include managing healthy practices around crowding, shift work, and the ability to take time off. If these types of healthy public policies could stick, they would have positive impacts.
Q: We’ve learned that it takes an interdisciplinary approach to solve global crises like COVID-19. Knowing this, who are the critical partners for public health going forward?
Dr. Schwandt: As a field, public health increasingly understands that complex issues are not solvable by the government alone – ‘health-in-all-policies’ means including all partners. Large institutions, such as a health authority, benefit and need guidance from those who are closest to the front lines. Therefore, the biggest opportunity lies within the non-government sector, with those who provide direct services to diverse populations. This is where we learn about cultural safety and anti-racism – in immunization programs, overdose emergencies, or the effects of climate change. And it can’t just be a matter of collaboration, the work has to be driven by community-based organizations.
Q: Throughout history, as the human population spread across the globe, infectious diseases have typically followed. Pandemics are not new to our species, they are just new to this generation. What research is needed now for creative and innovative solutions to this problem?
Dr. Schwandt: Community-based and driven research is what is needed; hopefully with the support of formal researchers and public health institutions. There is greater impact when research questions are driven by lived experience rather than from the office of a health organization. Health problems we identify may not be the greatest concern at the community level, which is why we need to turn to the advice and input from communities. There is a disconnect when health organizations define their own metrics; there needs to be space for research structures that are more directly informed by the community. That goes for funding research as well: understanding what constitutes rigorous research, what research helps inform policy decisions, and gaps in research. This drives innovation and creativity, and allows us to ask the right questions but also make sure there are actionable outcomes.
Dr. Michael Schwandt at a Vancouver Coastal Health office in Vancouver, BC
An obscurity when things go as planned; a silver-lined cloud after a storm
As Dr. Schwandt illustrates throughout his answers, one of the perennial problems in communicating public health’s value is that when it works most effectively, the outcomes are not necessarily clear; they are marked by the absence of disease, injury, and premature death. This phenomenon is all too familiar for emergency managers – when the practice functions as intended, there is minimal impact. For example, when zoning properly mitigates structural damage during an earthquake, business goes on as usual. Unfortunately this means that when things go as planned, these fields are shrouded in obscurity and demonstrating the preventive value is significantly challenged (Richardson, 2012). But thanks to the pandemic, people are taking note – highlighting that there is no better time to capitalize on the silver linings to support preventive measures in public health:
- Work against traditional silos and integrate health in all policies. It is commonly understood amongst public health professionals that action taken outside the health sector can have health effects much greater than actions taken within it. Now, people are generally more aware that everything impacts health, resulting in a greater all-of-society response. For example, community supports for homelessness increased during the pandemic.
- Continue to advance public health technology. Public health took on a responsive and preventive role, enabling innovative solutions in areas that had previously struggled to progress. Digital technologies have been utilized in every area of the COVID-19 response, from epidemiological surveillance, rapid case identification, and contact tracing, and the delivery of clinical care through telehealth services (Budd et al., 2020). Telehealth and virtual health services have eliminated some barriers in access to care, especially for rural and remote communities.
- Listen to the community. There is a greater impact when research, practice, and structures are driven by the community. Diverse communities outside of the health authorities facilitated knowledge translation and supported health literacy initiatives. For example, an online resource called the C19 Response Coalition used their platform to make resources accessible for the multilingual population. Their goal is to empower Chinese-, Vietnamese-, and Filipino-Canadian citizens to take the proper precautions and make informed decisions for themselves and the broader community during the COVID-19 health emergency.
- Continue to dedicate funding and resources to public health. There has been an increase in the funding allocated for public health, research, surveillance and data management, and for strengthening public health institutions. The Canadian Government has also provided $803 million over two years to support the Public Health Agency of Canada and Health Canada in the ongoing pandemic response and almost $1 billion to support mental health care (Government of Canada, 2020; Government of Canada 2021).
- Use social media to effectively engage with the public in real-time. More than ever, health organizations, health authorities, government agencies, and health professionals have utilized social media platforms to share hard facts about COVID-19, preventive and control measures, and also engage members of the public. Using these platforms helps health officials reach large audiences and provides a direct mechanism to combat misinformation.
Looking over the horizon
Despite the hardships of COVID-19, it is clear that public health is undertaking an important transformation. There is consensus among the global public health community that the lessons learned and meaningful progress made during the COVID-19 pandemic cannot and will not go to waste. The foundations have long been built for meaningful action to improve not only domestic preparedness, but more notably, global health security.
The silver linings of COVID-19 need to be utilized to combat the most pressing public health concerns of our time. Global collaboration and technological innovation to support public health research have proved to be powerful tools for the field. Looking beyond COVID-19, how could these creative solutions be applied to more complex and chronic diseases such as diabetes, the opioid crisis, and obesity?
Marian Orhierhor is a graduate scholar from Nigeria and currently studying a Master of Public Health at UBC. She holds a Bachelor of Science degree in Animal and Environmental Biology with a specialization in parasitology. Before her graduate studies, Marian worked with non-governmental organizations in Nigeria in community health, health promotion, and health education. She is currently undertaking qualitative research for her practicum at the Vaccine Evaluation Centre of the BC Children’s Hospital Research Institute.
Tasha-Aliya Kara is an MPH student at the Dalla Lana School of Public Health at the University of Toronto. Her area of study focuses on social, behavioural, and global health. She obtained her BA from McGill University, and has previously worked with the BC provincial health authority (PHSA) in emergency management.
Since 2019, she has been the community of practice coordinator for the Canadian Association of Global Health (CAGH) and this year she was appointed to the Board of Directors of Free Periods Canada, a grassroots organization dedicated to achieving menstrual equity across the country. In her spare time, Tasha enjoys playing her piano and watching Seinfeld.
Nicole Spence is a projects and initiatives manager at Health Emergency Management BC (HEMBC), a program of the Provincial Health Services Authority. She holds a Graduate Diploma in Public Health and Social Policy, and is currently studying a Master of Science in Disaster Healthcare at the University of South Wales, with a research focus on how climate change exacerbates existing risks and inequities, while introducing new challenges to emergency preparedness. While not dealing with disasters, you can find her in the mountains resisting the urge to yodel.
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