Ministry Reports

Building the Foundation of a Strong Public Health System
for Ontarians

2005 Annual Report of the Chief Medical Officer of Health
to the Ontario Legislative Assembly

Summary Highlights

These events have focused attention on public health's critical role in the prevention, detection, investigation and management of outbreaks of infectious diseases

SARS was the tipping point for public health "system renewal" in this province and across the country. Years of decline resulted in what Justice Campbell has assessed as a "broken system." In 2005, we have had major outbreaks of rubella and Legionnaire's disease, contaminated water in Kashechewan, and increasing concerns over our readiness for an influenza pandemic. These events have focused attention on public health's critical role in the prevention, detection, investigation and management of outbreaks of infectious diseases.

As part of the government's action plan to strengthen the public health system post-SARS, significant new powers have been given to Ontario's Chief Medical Officer of Health (CMOH). Among these is the independence and responsibility to report on the state of public health to the Legislative Assembly of Ontario. In my first independent report to the Legislature, I will focus on the status of system renewal following the 2003 SARS outbreak. This focus on health protection in no way diminishes the importance of the system's other functions. We need to build the foundation for a strong and effective public health system that will allow us to address health protection issues and also strengthen our ability to address the entire spectrum of public health issues. Public health's mandate involves not just the immediate threat of infectious diseases, but also the longer term requirements of chronic disease and injury prevention, healthy child development, family and community health, and environmental health - all with a focus on the underlying determinants of health and illness. The ability to fulfill these responsibilities is dependent on the strength and capacity of the public health system.

This report can be thought of as a "check-up" for the province's public health system. Overall, my assessment is one of "guarded optimism." Much progress has been made over the past two years, but there is much more that must be done.

In this report, I will highlight where progress is being made and identify areas of continuing concern.

In June 2004, the Ministry of Health and Long-Term Care (MOHLTC) released Operation Health Protection : An Action Plan to Prevent Threats to our Health and to Promote a Healthy Ontario. Of the many components of this action plan that are being actively implemented, a critically important item is the creation of a provincial Public Health Agency. This centre of excellence will ensure that Ontario has a credible, reliable and objective source of public health knowledge, information and data to support effective practices and policies.

The design of the Agency is being informed by the experiences with public health agencies successfully implemented elsewhere in Canada and around the world. An expert group provided its interim design recommendations in October 2005 and its final report is expected early in 2006.

A key component of the proposed Agency is the provincial public health laboratory. It is to this laboratory that we would turn to identify the unknown agent causing an outbreak (e.g., SARS, Legionnaire's disease), as well as perform tests in massive volumes to support patient treatment and outbreak management decisions. Yet, the current public health laboratory is faced with numerous and fundamental challenges. The current situation must be turned around if the public health laboratory is to serve the public health interest during future infectious disease outbreaks. Until the laboratory is appropriately staffed, resourced, and fully integrated with the rest of the public health system, Ontario will be vulnerable.

Ontario's 36 local public health units are the front line of the province's health protection system. There are a number of important questions regarding how they are structured and whether they have sufficient capacity to protect and promote the health of all Ontarians. Many public health units have longstanding vacancies in their Medical Officer of Health positions, as well as difficulties recruiting other types of public health professionals. A Capacity Review Committee was set up to review these and other issues and the final report is expected early in 2006. I anticipate that recommendations will call for substantial changes including consolidations of some existing public health units to achieve a critical mass of expertise and resources.

SARS exposed several gaps in our ability to control infectious diseases in Ontario. While comprehensive system renewal was initiated post-SARS, major outbreaks of rubella and Legionnaire's disease in 2005 tested the extent of our progress to-date. The rubella outbreak occurred in a small public health unit that had been without a full-time, qualified MOH for many years. While the system responded favourably with substantial assistance from other public health units to help control the outbreak, it illustrated the insufficient critical mass of expertise and resources in some smaller public health units. The Legionnaire's disease outbreak highlighted the need for further work to improve coordination and communication within the health care system. Both of these incidents contain lessons about Ontario's ability to manage major infectious disease incidents in the future.

Many other initiatives have been implemented to exist with outbreak management. For example, a Provincial Infectious Diseases Advisory Committee has been created to provide expert scientific advice to public health and health care workers. Regional Infection Control Networks are being implemented to improve local coordination and communication. Increased infection control training for health care workers is also being developed.

There is increasing professional and public concern about our readiness to handle an influenza pandemic. Ontario developed its first influenza pandemic plan in 2004 and updated it in 2005. While we are in a better position now than two years ago, much work remains to be done. Further planning and resourcing are required to ensure that stockpiles of supplies and pharmaceuticals are in place and that plans for their distribution are established. Of particular concern are the roles and responsibilities for local, provincial and federal public health officials in emergency planning and response involving First Nations communities. Discussions on a formal protocol relating to public health emergencies affecting First Nations communities have been occurring, but much more work is required.

My assessment of "guarded optimism" is due to the significant progress that has been made over the past two years to strengthen Ontario's public health system while recognizing that more remains to be done.

In rebuilding our public health system, we must avoid "patching cracks without fixing the foundation" as Dr. David Butler-Jones, the country's Chief Public Health Officer, has described previous efforts at system renewal. The challenge is that renewing the province's public health system will take several years of committed effort. We are close to the three-year point post-SARS and are entering a critical time period that will define whether the momentum for system renewal will be maintained or will dissipate.

Creation of the provincial Public Health Agency, including a revitalized public health laboratory system, and strengthened capacity of local public health units are critical action steps for 2006. The ability to protect and promote the health of Ontarians against future threats depends, at minimum, on the full implementation of these initiatives.

In doing so, we will be establishing the foundation for a strong and effective public health system in which Ontarians can have confidence. In future reports, I will highlight the progress that is being made and areas of continuing concern.

Dr. Sheela V. Basrur, Chief Medical Officer of Health

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Building the Foundation of a Strong Public Health System for Ontarians
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January 2006

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