Hakique Virani is a public health and preventive medicine and addiction medicine specialist, and a clinical assistant professor in the Faculty of Medicine at the University of Alberta
The Globe and Mail series A Killer High brilliantly describes the factors that led to the present crisis of opioid addiction and overdose death. Among the several subplots in the article, particularly in relation to Alberta, was the story of a public-health authority failing to perform its fundamental duty – to act rationally, decisively, and quickly in the face of an urgent and growing threat to human health.
Although broad media coverage of the fentanyl crisis began early in 2015, experts urged Alberta's Office of the Chief Medical Officer of Health (OCMOH) for action on the growing impact of opioid drugs on population health long before then. In 2011, OCMOH published its report, in preparation since 2009, Prescription Drug Misuse in Alberta: Everyone's Problem. The report's first recommendation was that OCMOH, the highest public-health authority in the province, "provide leadership and co-ordination to advance the discussion and initiate action that will address prescription-drug misuse in Alberta." Sadly, little leadership or co-ordination was provided and, as the families of hundreds of Albertans now dead from opioid overdoses since 2011 will tell you, no action was initiated for years.
Having consulted with experts from the province's multi-sectoral Coalition on Prescription Drug Misuse, OCMOH was aware that any distinction between prescription- and illicit-opioid abuse is artificial. Without urgent public-health intervention, the demand for opioids would predictably be met with whatever pill, powder or patch was available. And we met bootleg fentanyl.
Were Alberta's public-health officers as unprepared for opioid fatalities – our present No. 1 public-health crisis – as they were for SARS in 2003?
The reality appears to be that, no matter the skills, expertise, and commitment of our top public-health professionals in managing the opioid crisis, action remains impeded by the same "numerous systemic deficiencies" described by the commissions chaired by Dr. David Naylor and Senator Michael Kirby, respectively, after we failed in our management of SARS 13 years ago.
One substantial reason we are failing to address the opioid epidemic – a non-communicable public-health crisis – is that we have ignored the spirit of those commissions' findings. The Kirby report called for public-health independence from government to "allow greater timeliness and flexibility in responding to emergencies … in a way that is more difficult to achieve from inside a ministry." In Ontario, the 2004 SARS commission led by Hon. Justice Archie Campbell echoed Naylor and Kirby in its principles for provincial public-health reform. Campbell's commission found it fundamental that, in public-health emergencies, "the operational powers of the Minister of Health (under public-health legislation) should be removed and assigned to the Chief Medical Officer of Health," and that "the Chief Medical Officer of Health should have operational independence from government in respect of public-health decisions."
Federally, the creation of the Public Health Agency of Canada (PHAC) may have reflected an attempt, albeit a lukewarm one, to achieve the recommendations of post-SARS commissions a decade ago. But now, when a journalist contacts PHAC with inquiries in the public's health interest, the inquiry is directed to the federal health ministry's communication department. So much for independence. We are fortunate that the present federal Minister of Health, Dr. Jane Philpott, happens to be a public-health expert making generally solid decisions, but this happy coincidence rarely occurs with cabinet appointments, and even ministers who are experts must still be politicians.
Instead of working in the truly autonomous, nimble, and responsive public-health authorities that post-SARS Commissions envisioned, our top public-health officers remain beholden to their employers in rigid bureaucracies. So, ministerial crisis response teams are preoccupied with approval ratings rather than evidence, committees rather than commitments, and spin-doctoring rather than medical-doctoring. Of course, when they finally get around to solutions, they are not supported by scientific evidence. With the fentanyl crisis in Alberta, we have even seen government undertake "solutions" (such as expanding abstinence-based detox) that make for good media lines, while considerable scientific evidence shows these interventions can be harmful.
Alberta's former Chief Medical Officer of Health, Dr. Nicholas Bayliss, used to say that in public-health medicine, your patient is the population. Assess with precision, intervene with best evidence, and respond with urgency and compassion. But when an army of bureaucrats stand between the doctor and the bedside, science and empathy are stymied. And public health fails.