Health and Social Policy through the eyes of the IHSP Community
''One Health” – Building a sustainable development approach to address emerging infectious diseases.
Zika virus is the latest in a sizeable list of new pathogens including the Middle East Respiratory Syndrome Coronavirus, Ebola, Chikungunya, H1N1 influenza, SARS, and West Nile viruses, which have emerged or re-emerged recently and spread rapidly through communities, either regionally or globally, exacting a significant toll in terms of human suffering and lives. In addition, they have led, in some cases, to billions of dollars in economic losses.
The media understandably focuses on the scale of the human suffering caused by these agents, and on the heroic actions of medical and nursing personnel, community workers and aid agencies. However little attention is usually paid to the root causes of these emerging infectious diseases (EIDs).
It is now well recognized that a majority of all new emerging pathogens arise from animals and the environment. Some of the well-recognized drivers and determinants of EIDs and their spread include: socioeconomic, environmental and ecological factors, such as population growth, density and movement, poverty, urbanization, environmental and land use changes, international trade and tourism, migration, climate change and changing human behavior. Some of these same factors contribute to the loss of agricultural land and this, coupled with disease outbreaks in food animals, including foot and mouth disease and “mad cow” disease, and highly pathogenic avian influenza, compromise food security especially in impoverished societies.
As Dr. Lonnie King, of Ohio State University, has pointed out, “We live in a world that is rapidly changing, complex, and progressively more interconnected. The convergence of people, animals and our environment has created a new dynamic-one in which the health of each group is now profoundly and inextricably linked and elaborately connected”. It is this convergence, at the human/animal/environment interface, which is leading to a new integrated approach, known as One Health, to prevent and control emerging infectious diseases.
The international public health community, led by the World Health Organization (WHO), has made significant effort in advancing the concept of One Health. This includes a collaborative framework of action between WHO, Food and Agriculture Organization (FAO), and the World Organization for Animal Health (OIE) and the implementation of the International Health Regulations (IHRs) that are an international legal instrument that is binding on 196 countries across the globe including all WHO Member States. Their aim is to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide. The several requirements of the IHRs include obligation to notify, report, consult and inform WHO and strengthen national surveillance and response capacity. At the national level the Public Health Agency of Canada (PHAC) works closely with the provinces in terms of surveillance and response to EID threats and the Government of Canada has strengthened inter-sectoral collaboration by moving the Canadian Food Inspection Agency from the trade sector to the health department.
Collaborative efforts in surveillance and response capacity are vital in the fight against EIDs but do little to address their root causes or set in place a sustainable approach for their prevention. However the development of the Sustainable Development Goals by WHO has now provided a framework for the upstream prevention of EIDs within a One Health context. WHO’s “Health 2015: from Millenium Development Goals to Sustainable Development Goals (SDGs) states “The spread of infectious diseases is affected by multiple socioeconomic, environmental and ecological factors as well as rapidly increasing antimicrobial resistance. The SDGs provide a new platform for an integrated approach across the economic, social and environmental pillars of development, which should be used to address all infectious diseases”.
The concepts underlying One Health have been appreciated since Hippocratic times. Their recent re-discovery emphasizes the urgency for their implementation to sustainably prevent EIDs. One of the early champions of this concept in the 19th century was Sir William Osler who held joint faculty appointments at McGill University and the Universite de Montreal School of Veterinary Medicine. Veterinarians have been among the strongest proponents of the One Health concept in recent years although the incorporation of this concept in the medical curriculum and undergraduate education has been slow. Given that current and future efforts to contain EIDs will require strong collaboration between physicians, veterinarians, environmentalists, epidemiologists, social scientists, economists, and several other disciplines, it is highly desirable that such cross-disciplinary issues take root in our institutes for higher learning.
The last few months have witnessed dramatic changes in the legal status of physician-assisted dying (PAD) in Canada. First, the National Assembly of Quebec passed legislation that contains a comprehensive set of measures to address the medical needs of persons at the end of life. These measures include the requirement that all health-care establishments in Quebec draw up palliative care plans. They also provide Quebeckers with a very narrowly defined right to request the aid of their physicians in dying when they are in the grips of irremediable suffering caused incurable diseases in their terminal phases. That legislation will enter into effect in December of this year.
Quebec’s move might have triggered a constitutional confrontation with Ottawa. After all, PAD is illegal in Canada in virtue of articles in the Criminal Code, a jurisdiction of the federal government. Quebec was claiming its right to legislate on end of life care, including PAD, as an integral part of its health-care policy.
But that confrontation has been put on hold, because in February of this year, the Supreme Court of Canada ruled that the provisions of the Criminal Code that make PAD illegal were unconstitutional. In doing so, the Court essentially overruled a decision that it had reached in 1992 in the case of Sue Rodriguez, a BC woman suffering from ALS. In effect, the Court held that times had changed since the Rodriguez decision. There are now several jurisdictions around the world that allow PAD under certain conditions, and the evidence suggests that a regime can be put in place that protects vulnerable persons from being adversely affected by the practice. To prohibit the practice for all persons is now considered by the Court an overbroad restriction of Canadians’ rights under Section 7 of the Charter.
The government of Canada has been given a year to comply with the Supreme Court Judgment. It can do one of three things. It can invoke the “Notwithstanding Clause” of the Canadian Constitution that would allow the impugned provisions of the Criminal to remain in force despite the ruling. It could allow the provisions to lapse, and refer the matter to the provinces and to their medical associations (which is what happened in the case of abortion after the Morgentaler decision). Or it could craft an exception to the criminal prohibition against aiding and abetting suicide, which would allow PAD in a limited range of cases. It might very well then turn to Quebec’s legislation as a model of how to move forward.
Many interesting issues surrounding the way in which PAD will ultimately be dealt with in Canada remain undetermined at present. The most important unresolved issue has to do with the kind of medical condition that could qualify a person as a recipient of PAD. In order to secure cross-partisan support, the drafters of Quebec’s legislation added a clause at the last minute that restricted it to patients “at the end of life”. But the Supreme Court decision was taken in the case of a woman, Gloria Taylor, who, like Sue Rodriguez, suffered from ALS, and was requesting aid in dying not at the very end of this slow degenerative condition, but rather at the point that she would have determined as unacceptable in the progress of the illness. This point may very well have been months, perhaps even years before the “end of life”. Quebec’s legislation will arguably have to be amended in order to broaden the range of cases that PAD can be applied to, else it too be subject to a Charter challenge. Thus, there will likely be movement on both the provincial and federal fronts in the months and years to come.
It’s heating up to be a season of big changes in the Quebec heath care system. In Montreal, the MUHC begins is historic move to the new Glen Campus. Across the province two new pieces of legislation are poised to move the system itself in a new direction.
The legislation in question was introduced by the Quebec Liberal government as a one-two punch of health reform: Bill 10, An Act to modify the organization and governance of the health and social services network; and Bill 20, An Act to promote access to family medicine and specialized medicine services and to amend various legislative provisions relating to assisted procreation. As health minister Gaëtan Barrette himself put it, Bill 10 serves to re-organize the delivery of health care service establishments; while Bill 20 serves to increase the quantity of these services to patients.
It may seem difficult to criticize improvements to access to health care services, but the opposition to both bills has been fierce. Bill 10, which came into effect on April 1st, abolishes an entire layer of administration – the regional agencies that have been in place for a decade – and rationalizes the remaining administrative structures into “super-agencies” that are now under the direct supervision of the ministry, and its minister. Questions have been raised about the centralization of power this entails, the crowding out of local knowledge and room for regional differentiation, and the ensuing dilution of participatory engagement in governance, the hallmark of Quebec’s global health approach.
Bill 20 is still in legislative play, but physicians, both general practitioners and specialists, are forcefully opposed to its measures. General practitioners, who have been absorbing a decade-long primary care reform that led to the establishment of Family Medicine Groups, will now be obliged to roster a specific number of patients, in addition to retaining a certain number of hours per week in health care establishments. They will also be held accountable for a minimum number of visits by their patients and be penalized should their patients seek care elsewhere. Specialists, meanwhile, will be obliged to make themselves more available for hospital-based consultations, and will be held accountable for reducing wait times for surgical procedures.
The rationale behind Bill 20, according to Dr. Barrette is simple: we are licensing more and more doctors in Quebec, and they are working fewer and fewer hours. His tough-love approach does not sit well with physicians, who challenge these claims and chafe at the imposition of hefty punitive incentives that may reach as high a 30 % of a physician’s income. But the broader question raised by the legislation is the extent to which it infringes on professional autonomy in a way never before seen in Quebec – or anywhere in Canada, for that matter.
As professional organizations (Federation des médécins omnipraticiens, Fédération des médécins specialists du Québec, l’Association médicale du Québec, etc.) gear up in opposition, the season is poised to get hotter still.