Consultant in Public Health Medicine and member of the IMO public and community health committee Dr Ina Kelly outlines the importance of public health medicine in combating the spread of the new coronavirus
he recent international reporting of a novel coronavirus (Covid-19) in Wuhan, Hubei province, China, has heightened awareness of the global risks of new serious infectious diseases, for which no human immunity exists. It has also highlighted the work of an under-appreciated specialty within our public health service, namely that of public health medicine.
Public health medicine reaches beyond the usual boundaries of the healthcare system. Doctors in this specialty work in national government agencies, local community and voluntary organisations, as well as within the health service. Public health medicine works to improve and protect the health of the population, rather than treating individual patients. Public health physicians have specialist knowledge of health protection, health service development, and health improvement.
One of the largest domains of public health medicine is health protection. The International Health Regulations 2005 aim is to “prevent, protect against, control, and provide a public health response to the international spread of disease”, and each country’s obligation is mainly carried out by their public health medical service. In short, public health medicine carries statutory responsibility for the health security of the State.
While the global response requires co-ordinated efforts from all, including governments and frontline healthcare services, as in other UN member states, the public health medicine services in Ireland lead on biological emergencies, anticipate emerging pathogens (and all other hazards), and prepare to protect health when new risks occur. Most of this preparedness involves considerable unseen expertise and workload so that in an emergency the response is as effective as possible. To maximise protection we in public health medicine use our legislation to facilitate timely and effective investigation, surveillance, and control actions for our population. The ultimate goal is to prevent any avoidable case of such infection within Ireland and to contribute to global efforts to control the new infection.
The health protection services in Ireland are mainly led by the Health Protection Surveillance Centre (HPSC) and the eight Departments of Public Health, each of which has public health responsibility for a defined geographic region.
The HPSC is the national focal point for information from the World Health Organisation (WHO) and European Centre for Disease Prevention and Control to Ireland, and vice versa. It disseminates epidemiological information, expert advice and monitors global developments, including international preparedness efforts to inform Irish policy and practice. A recent report by the Global Preparedness Monitoring Board was clear in its analysis that “the world is not prepared for the next global pandemic”. Preparedness needs significant investment, in capacity and capabilities. The cost from being unprepared may vastly outweigh the cost of prevention. The size of the SARS outbreak in Canada in 2003 with 44 deaths was associated with reduced public health capacity. Tourism costs alone were cited as 1.5 billion Canadian dollars. This is not just a health issue, but a financial issue. The World Bank Working Group on Financial Preparedness makes detailed recommendations in its report From Panic and Neglect to Investing in Health Security, including to prioritise health security in budgets. In Ireland, while we take preparedness seriously, significantly more investment is needed to ensure that systems are robust and tested during the interpandemic phases of the emergency response cycle. We are in a world where preparedness investment is a necessity, not a luxury. In fact, after the devastation of the 2014 Ebola outbreak in West Africa, the WHO set up the WHO Emergency Programme to:
• Address the gap in preparedness investment;
• To ensure readiness to diminish public health risks in countries with high vulnerability; and
• To provide life-saving health services to affected populations in countries with ongoing emergencies.
Part of preparedness is the ongoing risk assessment. When suspected cases of disease appear in Ireland, the investigation and control actions are carried out by specialists in public health medicine/medical officers of health in Departments of Public Health that cover the eight regions. The public health medicine service works with the existing emergency management structures, providing the necessary risk assessments, contact tracing, and medical advice to all who need it.
Since the first notifications of 2019 novel coronavirus in early January 2020, public health medicine working groups have been developing algorithms to assist streamlined, evidence-based and efficient care and risk assessment. These algorithms are modified in response to new risk information, which occurs generally every few days. As of 30 January, when the WHO declared a Public Health Emergency of International Concern (PHEIC), the service has been gearing up to provide surge capacity as needed.
The Crowe Horwath final report on the Role, Training, and Career Structures of Public Health Physicians in Ireland recognised the challenges and unsustainability facing the current public health medicine service and recommended it be strengthened in many ways including the need for consultant contracts. Industrial action was deferred in late 2018 because the IMO is now in negotiations with the Department of Health to strengthen the public health medicine service through provision of consultant contracts and significant reform of the service. Many of our newly trained consultant level doctors are depending on a satisfactory resolution of negotiations to continue their careers here in Ireland. The status quo has been acknowledged at all levels as unsustainable.
Despite the challenges of lack of investment in health security, the public health medicine service is stepping up to provide extended frontline hours, additional weekend services and doubling of on-call cover, despite already stretched rosters.
Our goal as always is to protect people, so that while we may not be able to prevent a case entering Ireland, we will do all in our power to prevent secondary cases from occurring. We will also deal with calls from anxious members of the public and provide advice to health professionals, hospitals and other healthcare facilities, communications and media proactively and reactively. There is a need to balance sufficient communication and information with the need to manage uncertainty among both healthcare professionals and the general public. We hope to be able to maintain capacity throughout this PHEIC [Public Health Emergency of International Concern], although the specialty has been much reduced and underfunded in recent years.
We have great faith that Ireland will see the value in investing in health security into the future, towards a strengthened public health medicine service to protect us all. The coronavirus is an unfortunate reminder of the need to have a strong and robust public health medicine service with appropriate structures and governance to ensure adequate health protection measures and capability are in place for such events.
Health protection is just one aspect of public health medicine with health service improvement, health service development and population health initiatives also being essential elements of the public health medicine specialty. Now more than ever we need to invest in the specialty to ensure that future generations can enjoy better health systems, public health initiatives, and public health security.