Putting the public back into health

It is time the government did something about health care. No, not that. It should attend to the real field of public health. Canada finally does have a minister of public health, Dr. Carolyn Bennett. Regrettably, she just told this newspaper: "I think, as governments, it is our moral responsibility to do whatever we can to help people stay healthy." I do not know what political philosophy would justify such a dangerously open-ended statement. But even on the charitable assumption that it was mere bombast, it suggests a troubling lack of focus.

The proper concern of public health, a clear core responsibility of government, is diseases and conditions that pose health risks bystanders cannot control. I don't want to get sidetracked here by the arguments about second-hand smoke that underlay her remarks; all that shouting about consensus, questioning of motives and proposals to meddle in the lives of vulgar persons is too characteristic of politics not science.

Nor do I want Dr. Bennett to get sidetracked. And in the face of SARS, flu and "mad cow," I worry as much about what such rhetoric might distract her from doing as what it might excuse her doing. It's an old rule that "he who guards everything guards nothing" and she must prioritize. Start with Bovine Spongiform Encephalopathy (BSE) and its horrifying human equivalent Creutzfeldt-Jakob Disease (CJD).

Safety experts are right that the public often misjudges risk. For instance, pigs kill more people a year than sharks. And they are right that a rational person should estimate both how likely a pig is to assail you and how bad it will be if one does. But for that reason they should not mock the strong popular aversion to unknown risks. If you know something is bad but not whether it is likely, or that it is likely but not whether it is bad, you can't do the math. Which is truly scary.

It is not rational as a general rule to test every bite of food before consuming it. But when we know we face a risk whose dimensions we do not know, it makes sense to undertake a meticulous inspection of our beef supply to understand not just the incidence but also the epidemiology of BSE and CJD. Andrew Nikiforuk just warned of a few small-scale studies that found some "Alzheimers" patients actually died of CJD, so just possibly BSE is far more widespread than we think. I doubt it, and I'm not in the business of peddling panic. But I certainly want to check it out. Later, less exhaustive sampling will suffice once the problem's outlines are understood.

Next, Dr. Bennett could usefully concentrate on influenza. Here we know a few things including that another pandemic is overdue and that most flu pandemics are not like the dreaded Spanish flu, with its puzzling tendency to kill healthy young adults. Unfortunately we also know this year's vaccine targeted the wrong strain and it's too late to fix it now. So it's troubling to read in Tuesday's Citizen that "Health Canada is working with the provinces and territories on a national influenza response plan" but can't get suitable vaccine in time and isn't stockpiling antiviral drugs. There may be little we can do, but at least let's have drugs, and whatever useful vaccine can be manufactured quickly, available to key emergency response workers before the next big one hits.

Third, "iatrogenics," that is, the ways in which health care inadvertently causes illness. A recent spate of disquieting stories about improper hospital sterilization processes may be just the tip of the probe here. So as with BSE, the first priority should be getting a grasp on how widespread such problems are, including the breeding of "superbugs" in hospitals.

Fourth, indeed, is the proliferation of drug-resistant diseases. It's partly bad medical practices, from overprescribing antibiotics (to patients who then don't follow the regimen properly) to poor hospital sterilization. But as evolution is not our friend here, our options may again be limited. Since we already know part of the answer must be a return to old-fashioned barrier medicine, let's do it.

Fifth, emergent diseases. Some environmentalists claim things like Ebola are Mother Nature's revenge for our messing up ecosystems and unless we stop, the Red Death will come for us. Perhaps. Or we may have poked our noses into almost every swamp by now so few such surprises await us. Either way, jet travel favours viruses, so be as ready as we can to track and contain them, especially those we cannot cure.

Dr. Bennett, forget doing "whatever we can to help people stay healthy." Identify key health risks we can't mitigate for ourselves, study their scope, and make what plans you can to deal with them, ideally before they hit page one.

It is a logical requirement of political philosophy. It is your legal duty. And it is very much your moral duty.

[First published in the Ottawa Citizen]

ColumnsJohn Robson