When public health became sexy again: How the pandemic influenced that change
'COVID-19 has turned public health doctors into rock stars'
If you've ever walked around Trinity or even just navigated the loop behind the Health Sciences Centre in St. John's, you've been closer to the birth of modern public health than you might know.
In 1796, Dr. Edward Jenner of England injected fluid from a cowpox lesion into a child to see if it would protect the child from closely related smallpox.
The technique was based on the much older process of variolation, whereby body fluid from an affected individual was introduced into a healthy individual to help them mount a defence. Because Jenner had crossed the viral species line, his technique warranted a new name. "Cow," in Latin, is "vacca," so the new procedure, quite radical at the time, was called "vaccination."
Jenner wanted to share his successes around the world, so two years later he recruited his old classmate and friend Dr. John Clinch, now a medical missionary in Trinity, Trinity Bay, to help. Clinch injected his wife's nephew, Joseph Hart, who likely became the first person in the New World to be vaccinated against smallpox.
Today, we have Clinch Crescent as a small reminder.
Once upon a time, the most common form of smallpox killed around 30 per cent of those it infected; two-thirds or more of survivors were disfigured. Jenner's discovery led to the first (and only) vaccine eradication of a human disease from the wild.
It was accomplished through "ring vaccination," meaning that when a new case of smallpox was identified, anyone who might have come in contact with that person was tracked down and vaccinated as quickly as possible (a strategy we're all hoping will one day help us coexist safely with COVID-19).
The last known case of smallpox occurred in 1977, almost 200 years after a small English boy offered his arm to the good doctor. The suffering smallpox caused — or might have caused — if a vaccine had not been discovered is incalculable.
Quarantining since the Middle Ages
The idea of preventing illness was nothing new.
Quarantining dates back to the late Middle Ages, when travellers potentially exposed to the Black Death were held in isolation for a period of time to ensure they couldn't infect others. In 1754, Scottish naval surgeon Dr. James Lind was thought to have conducted the world's first clinical trial on sailors with scurvy and learned about the power of citrus fruit to prevent the devastating connective tissue disease.
A century after that, Dr. John Snow of London used dogged sleuthing to trace the 1854 Broad Street cholera outbreak to contaminated water from a particular hand pump, disproving that the disease was airborne, as previously believed.
If the contribution to human health and dignity of the smallpox vaccine is incalculable, then what about all of these small moments in the history of medicine combined? It gives me vertigo. Yet somewhere along the line, public health became that stodgy distant uncle you avoid at family dinners for fear of his boring stories.
Team approach to health care
When I was in medical school, one question routinely made my head pop off: "Are you going to specialize, or are you just going to be a family doctor?" Emphasis on just.
I understand where the question comes from. The specialties require longer training, and there is sometimes the perception that specialists are, well, smarter. Truth is it takes a whole team of people to give someone the best medical care possible: a family doctor who hopefully knows when someone's health is slipping and how that intersects with the rest of his life, and consultants for the rare or complicated things, things requiring procedures. Not to mention all the allied health workers.
We do pretty well, healthwise, in Canada.
Globally, according to the World Health Organization, females can expect to live 74 years from birth and males 72 years. In Canada, on average, we can add about 11 years to that for women, and five years for men. (Except for First Nations folks, whose life expectancy remains lower than the global average, and changing this has to be a goal of reconciliation.)
We have greater access to doctors and hospitals and operating rooms and medicine, so it just goes to show, right? More medicine, better outcomes? Not necessarily.
But the work of preventing suffering in the first place? That's the work of the usually unsung folks in public health.
The truthier truth is that we who respond to injury and illness, even in this day of advanced medicine, do not do the heavy lifting when it comes to the health of whole communities. In 2019, two Stanford University researchers asked how many premature deaths in the United States could be attributed to restricted access to medical care. Their answer: around 10 per cent. Genetics accounted for some portion. But the social determinants of health — things like income, education, job security, food security, gender, race — and health behaviours, accounted for most of the other 90 per cent.
In other words, a rising tide floats (nearly) all boats.
On my bathroom wall hangs a vintage public health poster that may or may not have been stolen from a health-care institution in Newfoundland: "For the good of your health, wash your hands!" It's funny, of course, and it helps me keep my work in perspective.
My "downstream" medicine is not a waste. When I've needed an operation or a bone put back together or a baby delivered, I've had clean, well-equipped hospitals and smart, compassionate doctors and nurses. But the work of preventing suffering in the first place? That's the work of the usually unsung folks in public health.
I say usually unsung because COVID-19 has turned public health doctors into rock stars. Dr. Deena Hinshaw, Alberta's chief medical officer of health (a family doctor, I might add), wore a dress stamped with the periodic table of elements in one of her early new conferences; within days, the dress, which was made in Victoria,sold out.
T-shirts have been made with her image and captioned "What would Dr. Hinshaw do?" As a worker bee in this pandemic, I have been endlessly impressed by her steadiness and candour and decency. When a reporter asks her about an unconfirmed story of something or other, she shares what she knows and says she'll look into the rest; she calls people touching their masks a form of "inadvertent contamination," rather than stupidity.
Many unanswered questions
I watched a webinar a couple of weeks ago featuring doctors Hinshaw and Jeff Kwong (of Toronto), and mulled over the many still-unanswered questions. How soon will we have widespread immunity testing? When will there be a vaccine? There are more than 100 candidates, eight of which have entered trials, and you can watch the horse race here if you like.
Will the country that succeeds in making the first vaccine keep it all to itself? How effective will it be? Might we have widespread population immunity before we have an effective vaccine? How long will that take? What will we have to give up until then? Family doctors participating online wanted to know whether public health should be taught in grade school.
As I write this, we're into our seventh week of COVID-19 restrictions. If you're anything like me, you're irritable, anxious, and tired of being contained and redeployed and surprised. But I'm quite enjoying the new profile of public health. I can recall big public health campaigns around exercise, smoking, cervical cancer, breastfeeding, SARS, Ebola virus and opioids. But was there ever a time in your life when a public health news story led the hourly newscast for months on end?
Dr. Clinch must have a big old smile on his face.