Public health is most often understood as “...the science and art of preventing disease, prolonging life, and promoting health through the organized efforts of society”. Its scope is broad and encompasses both physical and mental health. We are often attuned to the ways these efforts are not meeting the needs of our patients, and to the public-health crises that continue to plague us (pun, intended). Fifty-six long-term drinking water advisories remain on public systems on First Nations Reserves in Canada as of September 3rd, 2019. Although a significant reduction from previous years, this indicates that many Indigenous Canadians still lack access to clean drinking water. In Thunder Bay, an HIV outbreak affecting predominantly the homeless population was declared in June 2019 within the context of an ongoing tuberculosis outbreak. News coverage regularly includes threats to public-health programs and funding, and concerns from within the field about changes to public-health organization and infrastructure. During my Public Health and Preventive Medicine elective at the Interior Health Authority in Kelowna, B.C., I discovered that no matter how distant that fifth-floor board room might seem from the exam table in my future, public health is changing the lives of individuals for the better every day.
Population-health initiatives aim to facilitate and normalize healthy behaviours and maximize the upstream potential of social determinants of health instead of solely optimizing health services. The Penticton Baby Friendly Initiative (BFI) Pilot Project aims to establish breastfeeding policies and practices to support breastfeeding in all stages of pregnancy and lactation. By following best practices, all people have access to information on the benefits of breastfeeding; skin-to-skin time after delivery becomes the norm when possible; and informed consent regarding labour analgesics includes information on their possible impact on lactation. After delivery, mothers feel comfortable and empowered to breastfeed. Advocacy for a population-health perspective is a critical role of local Medical Health Officers (MHOs). I was inspired by an MHO emphasizing at a city council meeting the potential of city planning that takes into account not only health services but the social determinants of health. The presence of a medical professional advocating for their most vulnerable patients can and likely will influence local-government decisions.
Harm reduction, which aims to prevent the negative consequences associated with risky behaviours, is an increasingly common approach to substance use. Provision of harm-reduction supplies has obvious impacts – injection-drug users using clean equipment are at a lower risk of contracting communicable illnesses like HIV and Hep C. Targeted outreach also creates an entry-point into health and support services. When these services are designed from a harm-reduction perspective, individuals can feel more comfortable being open with providers, facilitating effective acute and preventive care and planning for future needs. The Outreach Urban Health Clinic in downtown Kelowna is one such example. It provides accessible, non-judgmental, full-service primary care in a convenient location to patients with or without a health card. Importantly, the clinic offers someone to advocate for its patients’ needs within the health care system and beyond. It is an important resource for the homeless population, immigrants and migrant workers, and other marginalized groups.
The direction provided by public-health bodies and provincial and territorial health authorities directly impacts the services available to Indigenous people. Staff of the Aboriginal Health team at Interior Health note there has been a perspective shift across the province that emphasizes the responsibility for ensuring the health needs of Indigenous and non-indigenous residents of B.C. are met, rather than focusing on which jurisdiction is responsible for meeting them. This shift has led to a tangible increase in services for Indigenous people living on reserves. Immunizations for school-age children, traditionally viewed as a responsibility of the federal government on-reserve, are now offered by provincial public-health nurses in schools on reserve just as they are everywhere else in B.C., improving equitable access to vaccines and therefore disease prevention. By acting as a liaison between Indigenous communities, Interior Health, and the First Nations Health Authority, the Aboriginal Health team aims to ensure that programs and services are designed with the needs of Indigenous communities in mind. They also educate staff on how to provide culturally safe care and create culturally safe policy that takes into account Canada’s history of colonialism and residential schools. Ideally, the most vulnerable individuals who face the most barriers to care are relieved of the burden of systemic racism that hinders their ability to access timely and effective care from providers who are sensitive to their needs.
Epidemiologists make up an important part of the public-health infrastructure. They ensure various areas of government, other organizations, and the public have access to reliable health data (and a reliable interpretation of that data) that informs important decisions about the distribution of health care resources. It was epidemiological data that illustrated rising numbers of opioid overdose deaths in British Columbia, triggering the declaration of a public-health emergency under the Public Health Act in 2016, and leading to the substantial dedication of resources that followed. Epidemiologists are also critical in communicable disease surveillance, ensuring that potential outbreaks are identified, investigated promptly and possible sources identified as quickly as possible before others become sick. During my time at Interior Health, a winery was closed after a number of people at an event became ill. An investigation revealed a number of environmental health infractions and identified a likely culprit: E. coli contamination of a food source. The winery was able to reopen after completing appropriate remediation and mitigation.
A colleague at Interior Health said that while family physicians can have a large impact on a relatively small number of people, public-health physicians have a small impact on a large number of people. It’s time we realize that the impacts of public health aren’t small at all - they are large and life-changing. My experience was a call to action for ongoing support and engagement in the field no matter what clinical role I hold in the future. Will you join me?