Monday, July 17, 2023

The Role of Public Health under Neoliberalism

The air quality is bad again today, but public health hasn't issued any warnings, and it's not on the Weather Network website. A few people were commenting on their eyes burning and asthma being triggered. Sure enough, the air particulate numbers are up. So, it looks like we're on our own to track which way the wind is blowing and if we're downwind from any fires and should close the windows. Good to know.

Dr. Christopher Leighton, radiation oncologist and medical educator in Windsor, wrote in Post yesterday that public health "went rogue in 2022." He asks, "If public health isn't there to protect the vulnerable, then why bother?" He made an FOI request last fall after so many protections were dismantled, and got documents in late March, which he shared with MPPs and the Chief Ontario Human Rights Commissioner. Here's his synopsis:

"During a time of increasing contagiousness and immune evasion of the circulating Omicron variants, and when less than 37% of children had completed a primary series of vaccinations, the Ontario government ignored calls to strengthen public health measures. Instead, they gradually withdrew them in overt opposition to expert guidance. . . . Dr. Jessica Hopkins, Chief Health Protection and Preparedness Officer, PHO in a March 4, 2022, communication to the CMOH and Associate CMOHs, shared a technical briefing on the removal of mask mandates and stated: 

'Mask mandates are associated with reductions in population-level SARS-CoV-2 transmission. The benefits of masking likely remain in the Ontario risk context which includes possible early resurgence, introduction of Omicron sub-variant BA.2, low uptake of booster doses among eligible populations, low vaccine effectiveness of three vaccines doses against omicron infection, low levels of immunity among children under 12, negligible immunity among children under 5, and large numbers of immunocompromised individuals. Mask mandates are less restrictive than other measures used during the pandemic.'

The risks could not have been stated more clearly, yet just a few weeks later, the Ford government ignored seemingly every aspect of that evidence briefing and removed nearly all mask mandates in Ontario, also in opposition to Science Table Members and three Medical Officers of Health who publicly pleaded for a resumption of mask mandates. 

The government withdrew measures without regard to the potential risks and harms to vulnerable populations including those hit especially hard by the pandemic, seniors, persons with disabilities, pregnant persons, visible minorities, and those living in high-density housing. It was a violation of the precautionary principle so lauded by the Honourable Mr. Justice Archie Campbell of the SARS Commission. 

Most notably, Anne Hayes, the Ministry of Health Director of Research, Analysis and Evaluation, Strategic Management and Policy Evaluation Branch, shared an evidence brief with the CMOH and the Science Table Members on January 17, 2022. Her division had recommended respirators (N95/KN95 masks) for use in community settings 'whenever possible' as providing the best protection against contracting COVID-19. The CMOH and the VP of Public Health Ontario expressed concerns about the messaging (i.e. it was a more stringent recommendation than prior messaging by the government). 'Staying on message' appeared to supersede new evidence. Her recommendations didn’t reach Ontario’s most COVID-19 vulnerable. Respirators were never endorsed for use by this government. Why? The airborne nature of transmission was well described in briefs by Public Health Ontario. Yet as the summer came to a close, there was apparently more focus on droplet transmission i.e. 'source control'. It beggared belief. Had politics usurped the role of the CMOH?

In July 2022, Emily Karas, Deputy Chief, Health Protection, Public Health Ontario, described that re-implementing public health measures such as wearing high-quality N95/KN95 masks or the equivalent, improving ventilation, and updating vaccination boosters were likely to make a significant impact by dampening community transmission, especially in schools and on public transit. She was explicit in her language: 

'The evidence that SARS-CoV-2 can cause immune dysregulation is increasing. Reducing the risk of SARS-CoV-2 infection and reinfection could reduce the overall burden of death and disease in Ontario during the pandemic and longer-term.' 

Her worries about immune dysregulation were soon realized in Ontario when pediatric critical care centres were overwhelmed by children with severe RSV, influenza, and COVID-19 infections. It posed the greatest paediatric critical care crisis since the polio pandemic. Immune dysregulation is accepted by many experts as a cause of this phenomenon. I firmly believe had public health measures remained in place, this impact could have been greatly diminished. FOI documents confirmed the Ministry of Health Schools Work Group had recommended high-quality masks for students who could not afford them in the fall 2022 semester. Discussions about a PPE Tender occurred at the highest level in the Office of the CMOH (OCMOH). Nothing materialized. . . . The changes in isolation requirements described on August 31, 2022, were not based on experience or science. Gross assumptions were made from the pre-Omicron era and careless liberties were taken, such as not requiring respirators for those infectious and in the community. It was a reckless approach in my opinion. 

It’s unclear whether equity measures were ever seriously considered for the tens of thousands of highly vulnerable Ontarians. Many could not afford high-quality masks, and others were at increased risk of infection because of socioeconomic factors (low income, living in high-density housing, visible minorities etc.). This failure was apparently contrary to public health ethics, equity, the precautionary principle, and the Ontario Human Rights Code policy on COVID-19 recovery planning. Use of public transit, for example, requires close contact amid a poorly ventilated location. Without the ability to purchase an N95 mask, vulnerable persons were and are at higher risks of infection/re-infection. The Ford government failed to demonstrate a duty of care. I believe they were obliged to at least notify those groups at greatest risk of infection, identify the environments they should avoid, and provide free N95/KN95 masks if they could not afford them. That’s what responsible government does. It's time to minimize the risks of COVID-19, and Long COVID-19, and prepare for the next pandemic. We have the tools. We need willing leadership."

At the same time, The John Snow Project explained the nefarious use of the public health goal of "flattening the curve" instead of minimizing ill health: 

"Attitudes have been changed to accept that healthcare exists in order to provide a workforce with sufficient capacity to keep the economy functioning. Instead of optimizing the pandemic response for the best health outcomes, which also helps the economy long-term, the default position adopted by most government established a new principle that the total amount of human suffering caused by disease is not important, only the immediate stress on healthcare systems. . . . The pernicious idea behind it was that 'slowing the spread of the infection is nearly as important as stopping it.' The disturbing reality behind this strategy should be obvious - there was never any intention to stop the spread of the virus, and stated policy from the outset was to hope for herd immunity or, failing that, make it endemic - always circulating at a constant level. . . . The number of people who got infected was unimportant as long as healthcare systems did not succumb to a state of complete collapse. While the ostensible goal was to reduce overall casualties, it was not to prevent a huge number of deaths and serious long-term disability, only to stretch it out in time to make it more acceptable to society. . . . 'Flattening the curve' meant postponing death and disability, and reducing it somewhat, but not really preventing it. . . . 

Few seem to appreciate what a monumental shift in public health philosophy these events represent. The traditional goal of public health has been to promote public health  by eliminating the disease burden that plagued humanity for much of its existence. No longer. It has now been firmly established that human lives and health are not the priority as long as there is 'capacity' in the healthcare systems, and we are not yet at the point where refrigeration trucks are needed. . . . 

We live in the third decade of the 21st century and have advance technology that is capable of fully solving the problem . . . through respirator-style masks, clean air and mass testing, which can be effectively combined with the traditional practices of quarantine and isolation of the infected. We're not even using technology to try to stem transmission in settings that are either known to play a disproportionate role in spreading the virus, such as schools, nor are we attempting to do so in settings where disproportionate harm can be caused, such as hospitals and care homes. . . . It is the transition over the last few decades of healthcare and medicine from being a higher calling, aimed at improving the well-being of all of humanity, to a purely transactional business, the primary concern of which is profit generation. . . . Unfortunately, we can only expect even worse in the future, unless drastic course correction occurs soon."

Yup, neoliberal capitalism. 

So does it even matter if we can prove that Ford didn't do what's best for the people? We're operating in two different systems: the elites are perfectly following the neoliberal goals, and people like Leighton and the John Snow Project (and I) are stuck back in the New Deal days in which government took care of people. It's like jumping up and down trying to impose the rules of Go Fish in the middle of a high stakes poker game. Ford and his peeps are saying, "Look, I get that you want to play a different game, but the big kids are playing this game, and we're not going to start playing your game any time soon."

Earlier this month, an article in Forbes discussed a recent study finding that Covid damages the vagus nerve, which runs from the midbrain to the gut, extending into every major organ. It's also responsible for countering any fight/flight response with a mend and befriend counter response. If that's damaged in people, it can affect our entire social system. 

"In 20% of those reporting Long Covid symptoms, they observed significant thickening throughout parts of the vagus nerve that extend out from the neck and into the chest. Nerve thickening often results from inflammatory damage. Lldados et. al, therefore, speculate that these structural changes in the vagus nerve were likely a consequence of direct viral infection, as well as indirect damage from robust activation of the immune system. . . . 40% of those with Long Covid also had observable flattening of the diaphragm, a muscle at the base of the lungs that contracts to control breathing. . . . normal imaging in the rest of the lungs, suggesting that respiratory symptoms related to Long Covid may not be a result of direct injury to the lungs. Instead, injury to the vagus nerve likely disrupts signalling to the diaphragm."

We don't know how to fix damage to the vagus nerve. We really need to reduce transmission. It's entirely on the masses to take care of themselves and each other. Please spread the word!


Lorne said...

As Rick Salutin said in one of his columns years ago, Marie, "The economy is doing fine - the people, not so much." Sounds like it is still true, eh?

Marie Snyder said...

Absolutely. I can't see a way out of this mess short of Tommy Douglas rising from the dead.

Cap said...

There's no question the Ford government gave up on Covid following the Freedom Convoy. But the blame doesn't end there.

After the SARS fiasco, Justice Campbell's post-mortem criticized Ontario’s chief medical officer of health for being too close to government and failing to lead effectively. Following Campbell's recommendations, McGuinty changed the legislation to give the CMOH independence and central authority during times of potential health emergencies, free to act on his/her own initiative.

This means it shouldn't matter what Doug Ford thinks. The CMOH is in charge of public health, not Ford. But both Dr. Williams and his successor Dr. Moore failed to stand up to the premier and implement effective health policy. As a result, despite changes to the law, we're still bungling public health by ignoring the science in favour of what's politically expedient.

Marie Snyder said...

I believe the CMOH role isn't as independent as it once was. I thought things changed in 2018, but can't find it. S/he reports to the Deputy Minister though, and is in the middle of the flow chart of info, not separate from it. In 2020 there was a private members Bill 227 to, in part, "make the Chief Medical Officer of Health an independent officer of the Legislative Assembly" suggesting it's not currently the case. It failed to pass. I remember when Kieran Moore was first appointed, and people were excited that now things would improve, and then it just got worse. If it's not because of the official chain of command, then there's definitely an unofficial one in play.

Marie Snyder said...

Here's the catch that I discovered when trying to file an unsafe work report when we were made to be in class and forced to stay in a room to all have morning nutrition break together (back in Sept. 2020), that since public health says it's safe, then it's safe and you can't claim it's not safe even if you have tons of research on your side! They are the authority here, missy!

So, with the precautionary principle, if their baseline of acceptable losses isn't affected by the pandemic, then no precautions are necessary, and they set the baseline. So, officially, the pandemic ended. Pay no attention to the overflow in hospitals.

I wrote, last November, when Moore claimed he doesn't have the authority to mandate masks in schools, about how it's all a big circle jerk of government levels saying "not it" so we can't pin down who actually has responsibility for anything. It's Hannah Arendt's bureaucratic "rule by nobody." It's crazy making, so now I'm focusing on ground-up community-building. But if anyone ever actually gets heat for anyone of this, I'd want Ford to be first in line.