Hakique Virani Says Yes
The clinical associate professor of medicine at U of A and former federal medical officer of health
The effective functioning of Public Health is a matter of life and death. The E. coli and Campylobacter outbreak in Walkerton, Ontario, in 2000, when people died, is a good example. In just over a week at least 2,300 people in a town of 5,000 fell ill. On May 17, people started presenting to their doctor with diarrhea. On May 20, 40 people went to hospital with worsening symptoms. The Medical Health Officer (MHO) inquired with the Public Utilities Commission (PUC) about water testing and was assured that results were fine. The MHO collected a new water sample anyhow and by May 23 had lab confirmation of E. coli in the town’s drinking water.
But the PUC had known about the presence of E. coli before anyone fell ill, because a routine specimen it sent to a private lab on May 15 had tested positive. The provincial Ministry of Environment had also been aware from lab tests since January 2000 that the town’s drinking water was compromised and at risk of fecal contamination. By the outbreak’s end, seven people had died. The economic impact was over a quarter of a billion dollars. All of this could have been prevented had the MHO had independent authority to obtain, share and use information to act swiftly in the interest of protecting human life.
When SARS hit Toronto in 2003 the transparency of public health information was again an issue. Government officials were suspected of hiding a second wave of SARS from the public to avoid international attention and a second global advisory against travel to Toronto. Every provincial and national post-SARS commission found that emergency public health action had been impeded by conflicts between political or bureaucratic objectives and public health goals.
COVID-19 again illustrated these conflicts. Like most public health threats, the virus affected marginalized populations first and disproportionately. But these groups are hardly a political priority. Of the first 5,000 COVID cases in Alberta, almost a quarter were at two meatpacking plants that the province had declared essential services. Despite fast-increasing cases among these workers, two ministers—with the Chief Medical Officer of Health (CMOH) at their side in a virtual town hall—assured workers at Cargill in High River that they were safe in their crowded plants. Yet Cargill became the single largest outbreak in North America at that stage of the pandemic, with 1,200 cases—largely temporary foreign workers and permanent residents. That outbreak spread to a First Nation and a retirement home. Indigenous populations and long-term-care residents were disproportionately affected by COVID-19 and, like TFWs, are marginalized from political participation.
These real-world examples underscore that transparency and independent decision-making are critical to effective public health action. When CMOHs lack the autonomy to safeguard public health, the damages are irreparable, especially to populations that are already vulnerable.
Patrick Fafard Says No
The Global Strategy Lab research director and social sciences professor at University of Ottawa
Chief Medical Officers of Health play vital roles in both the public health system and government. They advise the Minister of Health and cabinet on matters of public policy. They regulate the behaviour of citizens, businesses and groups under the Public Health Act. In times of crisis they serve as government spokespeople, explaining complex situations, supplying information and clarifying guidelines and rules. And they serve as the lead of the province’s entire public health system, which includes regional medical officers of health.
These functions are interconnected. To be an effective regulator, spokesperson or leader, for example, the CMOH must have a close connection to cabinet. The case for a more independent CMOH becomes increasingly complex when changes to one function diminish the capacity to complete the others. For example, big public health decisions often demand a whole-of-government approach, necessitating coordination with different ministries. This is especially true with chronic disease prevention (e.g., cardiovascular disease). It’s essential that the person in charge be a senior leader inside government, not one or two steps removed from the policymaking process.
Another example: Issuing public health orders or guidance is a core authority of a CMOH, but if these orders aren’t backed up by the resources and support of cabinet, problems ensue—particularly in a crisis. At best, directives go unfulfilled. At worst, different parts of the government send different, potentially contradictory messages, sowing uncertainty among citizens. Enhancing CMOH independence would disrupt coordination, hindering effective public health responses.
In public health, accountability is crucial. If a more independent CMOH retains a regulatory role (i.e., the power to issue public health orders), how will citizens hold this CMOH accountable, particularly when their decisions have substantial implications for a whole province? A sobering example comes from Sweden. In the early stages of COVID-19, a highly autonomous public health official used his authority to make controversial decisions that were eventually deemed to have led to preventable death and suffering. Though our system of representative democracy has many flaws, its strength is that the public ultimately holds elected decision-makers accountable.
The public has very little influence over who fills the CMOH role. Technocracy sounds OK in theory until you realize you don’t get to pick the technocrat. Indeed, increasing CMOH independence would mean first questioning the appointment process, qualifications and potential for partisan appointments.
The road to greater CMOH independence is fraught. Put another way, while the current institutional arrangement for the CMOH is flawed, proponents of a more independent CMOH must address the fact that the same person cannot issue a statement criticizing the government in the morning and provide advice to the Minister of Health in the afternoon.
Elaine Hyshka responds to Patrick Fafard
Hyshka is an associate professor in the School of Public Health at the University of Alberta.
Some argue that governments are held accountable by the electorate for their public health decisions. But casting a ballot against the governing party is cold comfort if you have been disabled by those decisions—and impossible if you’re dead. We also know that those Albertans most likely to suffer negative outcomes during the pandemic were those least able to vote (e.g., the unstably housed or homeless; newcomers).
The public’s ability to hold government accountable is also predicated on transparency. Here Alberta falls consistently short. Decisions about the release of critical data and information, whether concerning COVID-19, drug poisoning or other public health threats, require political approval. While the legislation may grant CMOHs the authority to address the public independently, this autonomy isn’t exercised consistently.
In the lead-up to Alberta’s 2023 election, the regular release of drug poisoning statistics was inexplicably delayed. At the same time the premier and cabinet were campaigning on what they claimed was North America’s most effective overdose response. Only after the election was the public informed of a surge in drug poisoning deaths. 2023 is set to be Alberta’s worst year for drug deaths yet.
The lack of transparency is further exemplified by the confidential nature of CMOH recommendations to the cabinet. These recommendations are exempt from freedom of information requests and media inquiries. Even when the court requested information on CMOH recommendations during ongoing legal proceedings, the government refused to disclose them.
When CMOHs can’t disclose their recommendations, it erodes the public’s trust and understanding of public health measures. The responsibility of informing the public about health threats instead falls on political decision-makers. This leads to a situation where political considerations take precedence over providing accurate and timely information about health threats. Such was the case in 2022, when the government banned mask mandates in schools. It was only after litigation that the public learned about Alberta Health’s analysis clearly demonstrating that school boards without mask mandates had three times as many COVID-19 outbreaks than those with mandates.
Casting a ballot against the governing party is cold comfort if you’re disabled—and impossible if you’re dead.
It’s ironic that our counterparts suggest that greater independence for CMOHs would further politicize the office. In reality, the office is already deeply entangled in politics. The previous CMOH was dismissed by the premier for not endorsing an ineffective COVID-19 treatment, as well as for her support for other public health countermeasures. Furthermore, when she was rehired by Alberta Health Services, an ostensibly independent public agency, the premier’s office apparently intervened to prevent her appointment.
And public health extends well beyond infectious disease control. Public health officials receive training in socio-behavioural sciences, risk communication and health promotion. They have the expertise needed to persuade the public and provide credible and stable guidance during crises. Their considerations extend beyond the collective to encompass the needs of vulnerable groups. They strive to strike a balance in their recommendations, taking into account health, economic and social factors as part of a comprehensive approach to promoting overall population health and well-being.
The status quo is unacceptable, and it won’t improve until we restore trust in public health institutions. To do that, we must first have access to basic information about public health systems and accurate, comparable data on population health. This data belongs to us, the people of Alberta, and its release should not depend on whether it’s politically favorable at the time nor should it be reliant on whistleblowers. We should have easy access to this information—we create it and it’s ours.
Albertans should have the option to turn to an independent, credible voice for public health guidance during crises. Ideally, this includes a CMOH who can openly discuss what is best for protecting health and preventing death. If that’s not possible, as we seem to agree, we need some kind of expert body that provides unfiltered information without political framing.
It’s essential to remember that this isn’t an abstract matter; public health governance has real human costs. Thousands of Albertans are mourning the loss of loved ones to COVID-19 or drug poisoning. Many others have life-altering disabilities from these conditions. We need stronger, more transparent and more independent public health institutions. Health is the foundation for all individual and collective aspirations, and reducing health disparities is a necessary condition for equitable political participation and a stronger democracy.
Jared Wesley responds to Hakique Virani
Wesley is a professor of political science at the University of Alberta.
We aren’t advocating for the current situation. Nor do we favour removing authority from public health officials. Though it’s too early to tell, recent moves by our government to hand even more powers over to cabinet may disrupt the balance between expert and political decision-making. In Alberta we’ve witnessed poor decisions. However, these may be more a reflection of the people involved rather than the institutional structure itself. Our argument centres on keeping the CMOH within the Ministry of Health’s senior leadership team. This ensures that the CMOH maintains access to the minister, directly or via the deputy. Crucially, this promotes coordination of actions, which is vital, because public health encompasses far more than infectious diseases.
To be certain: Alberta’s government failed in many aspects of pandemic response. One of its biggest mistakes was to make the CMOH the public face of government decisions. Ideally the CMOH should communicate the science and provide information, while a government representative, such as the minister or premier, explains government decisions. This would ensure clarity about decision-making authority. In this sense, the system itself wasn’t flawed. The individual actors just didn’t live up to their assigned roles.
In this vein, there is a notable gap between the perceived and actual level of independence for CMOHs. While some may believe CMOHs wield extensive authority to craft policy and dictate the terms of public health, the reality is more nuanced. And this is a good thing from a democratic perspective.
To summarize the core assumptions in the argument for giving CMOHs greater independence:
1: Public health is a unique field of public policy that should be treated differently. In public health, standard rules of accountability and responsible government might need to be set aside.
2: Scientific evidence should be the primary source of decision-making in public health. Other factors, like the economy or societal concerns, should take a back seat.
3: Experts, not elected politicians, should determine what’s in the public interest and what’s right for the people.
Implementing policy isn’t just about facts, logic or credentials; it often involves classic political persuasion.
Considering these assumptions, it’s easy to understand why some Albertans resisted public health measures during the pandemic. A vocal and influential minority undermined trust and compliance during the COVID-19 pandemic. And while no one is suggesting that public policy, especially public health policy, should cater to fringe elements of society, the challenge is that defining what’s “fringe” is a political judgment, not a scientific one.
To effectively implement public health policy, decision-makers like CMOHs must build “civic licence.” They need to foster broad support, compliance and buy-in for government intervention. While some people follow expert advice, many require persuasion. It’s not just about facts, logic or credentials; it often involves classic political persuasion. To establish civic licence, CMOHs should work closely with government and politicians. The current system, despite its flaws, ensures this collaboration.
This isn’t a matter of delegating decision-making authority to politicians. It’s about coordinating decisions, some of which involve matters of life and death. These decisions require significant government resources and a whole-of-government approach. They also demand public leadership to secure widespread compliance.
Imagine a crisis in which the CMOH and the government convey different messages. This would lead to confusion and pose risks to public health and democratic processes. For this reason, sharing recommendations to cabinet publicly isn’t allowed without approval. This is how our system of responsible government operates, and it serves a purpose. Officials who know their recommendations will appear in newspapers are less likely to provide the fearless advice we expect from them.
Ultimately, the argument that CMOHs should have more independence from cabinet presumes that CMOHs should monopolize the definition, prioritization, scope and realization of public health outcomes. In small-scale infectious disease outbreaks, it makes sense to entrust the experts and their protocols without interference. But when we face large-scale public health crises, like a pandemic, or prolonged crises with intrusive interventions and significant economic burdens, such as vaccination mandates or school closures, it seems reasonable for elected politicians to make decisions. If we disagree with them, we shouldn’t just grant more power to an unelected official. We should express our disapproval through the democratic process by electing a different government.
The lessons from COVID-19 are clear: the public health establishment should enhance its coordination with the government, not reduce it. It should engage more actively and meaningfully in the realm of politics.
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