A modest proposal: Chief Medical Officers of Health should report to their legislature

“The counsel of the CMOH [Chief Medical Officer of Health] is presented as unbiased medical advice, but it is almost inevitably tainted by politics,” said Dr. Jillian Horton in the Globe and Mail this week. Exactly. Here’s why.

Provincial and federal public health officers in Canada are public servants. Like deputy ministers in other, arguably less life-and-death roles, they express their views to the government of the day. The government makes its own decision, and the dutiful public servant must support that decision, even if they privately and professionally disagree. That’s how it works.

Several times I have shaken my head while hearing Dr. Deena Hinshaw, CMOH of Alberta, answer the media’s questions about whether she agrees with Jason Kenney’s latest decision. She doesn’t answer directly. Rather, she describes the process. She gives the government advice; they make decisions; she supports their decisions. Does she agree? Read between the lines.

Should public health decisions be political ones? Hint: the question is rhetorical.

Here’s my proposal to divorce public health from politics: make CMOHs answerable to the legislature rather than the government. They should be autonomous and free to provide evidence-based advice. They could release reports saying, essentially, “Here’s what our projections show if you take the most stringent public health measures, if you keep some measures and relax others, and if you drop all measures. We would recommend such-and-such a course of action.”

The government could say, “Thank you very much, but we’ve decided to go in a different direction from your recommendation and take the flak.” Everyone would know what the projections show and whether the government has followed the scientific advice. Citizens could hold their governments to account in full knowledge of the evidence.

CMOHs could be selected, evaluated and, if necessary, fired through a process similar to processes for other parliamentary officers or, for example, judges.

I would actually prefer it if CMOHs had some superpower to overrule governments, but my democratic ethics tell me final decisions have to be made by elected governments. So the report-to-legislature solution would at least allow them to speak freely and expose the discrepancies between scientific guidance and political decisions to the full light of day.

Why diseases matter

I was 25 when I got very, very sick. After six weeks of illness, four doctors who had no idea what was wrong, and two weeks in hospital, I was finally treated for giardia diarrhea I had caught in the countryside two months earlier. It took months to feel back to my old self, and I had post-traumatic stress symptoms for years.

Once I got back to something like everyday life, I began to notice that our society’s views of illness did not match the reality in many ways. As I started to work at the Canadian Medical Association Journal and learned much more about illness, this view was reinforced.

The reality is that most illness – in Canada and certainly elsewhere – is a matter of bad luck. You are in the wrong place at the wrong time and you catch something. Or something in your body misfires. Or a remote relative had a bad gene.

On a public-health level, society can make changes to prevent disease: vaccinations, good sanitation and water treatment, advisories to wash your hands, and surveillance and screening programs. But at the moment that those systems break down and a person gets a disease, there’s really not much that can be done.

At the same time, health classes in schools do not teach much about disease causation or medical care. Many Canadians come from cultures (and I’m talking about my own here) that see illness as a failing, either of morals or self-care or stoicism. Others see illness as someone’s – either the patient’s or the doctor’s — “fault.” Still others see illness in superstitious terms, even in this day and age. Many Canadians still think little of medical science and still say “I’ve never taken a day off work sick.” Well, either they were very lucky or they were going to work with viruses and infecting their colleagues.

Sometimes I prefer the views of those from other countries where diseases are more prevalent and acknowledged as a fundamental part of human existence. I believe from my own experience and my work that disease, disability and death are part of what makes us human.

Back in Canada, there’s an inaccurate view among people who have not had serious diseases that they happen only to people with poor lifestyles or people in other countries. That is manifestly not true. If you think about it, either you or your friends and family members have been profoundly affected by diseases: heart disease, cancer, rheumatoid arthritis, multiple sclerosis, ALS, SLE, diabetes, etc., etc.

There are a lot of things said in the street, in the media and even in medical literature about what causes these diseases, but biomedical researchers working on them are much more circumspect. In many cases, we do not really understand how these diseases start, or the things we have been saying are turning out to be incomplete — or even completely incorrect.

My feeling is that we are at the beginning of a coming explosion of knowledge on diseases, which will transform prevention and treatment. Because how can you prevent or treat a disease until you understand what is causing it?