Who Do You Want Making Your Health Decisions? Post No. 10

Prepare for an examination of a public health policy by someone hardly qualified to add insight to such a complex discussion. At best I am a member of the "public" to whom health policies apply. I am not an immunologist, an epidemiologist and certainly not a doctor. But I have been goaded into action by a decision by the Alberta government to impose a charge of something in excess of $100 on anyone wanting a vaccination against COVID-19 and, apparently, require attendance at a public health clinic rather than your neighbourhood pharmacy.

You might think the reason for discouraging a particular vaccination would be tied to the efficacy or risks of the vaccination. Or be part of a larger attack on vaccinations of any kind: measles, influenza, or other preventative vaccinations like shingles, pneumonia, hepatitis. Or be because of the staggering costs of health care services in our provincial budget, causing a general tightening of belts to reflect provincial budget constraints.

But you would be wrong if you guessed any of those causes. Somewhat embarrassingly for a government trying to cut health care costs, just a few days after this decision was announced this summer the Province of Alberta announced a budget surplus for the most recent year of $8.3 billion, even taking into account that health care expenditures for the year were $1 billion over budget. This was Alberta's fourth straight budget surplus.

The announced reason was because someone (I don't know who - it wasn't me) ordered too many doses of the vaccine last year, causing great waste. Why too many doses were ordered, why the general demand for vaccinations, including the COVID-19 vaccination, has declined, and how, exactly, imposing a fee of $110 on someone wanting the vaccination is supposed to address that mis-ordering, are not questions our government has answered, or intends to answer.

Perhaps the thinking is that if we impose a substantial fee and make it harder to get (there aren't many public health clinics in rural Alberta), NO ONE will get the vaccination, so we won't have to order any! A win! Costs cut, no waste. If you are at risk from the effects of COVID-19 because of your age or underlying health issues, unless you fall in one of the few groups exempted from the charge, you must pay. If you need or choose to have the vaccination and can't afford the fee, too bad. You are being sacrificed. Your government decided not to invest in the protection of your health, preferring instead to bear the costs of your care if you become ill enough to require hospitalization or emergency care. And (bonus!) it has found a way to generate revenue in the public health arena.

Last year our government created a task force to consider quality, use and flow of information that informed the government's decisions during the pandemic. It was called the COVID-19 Pandemic Response Task Force, and its report was issued in January. In forming the task force the government intentionally appointed people who hold what are politely called contrarian views. Of the 12 "contributors" or authors of the report, there were several who could be considered experts in infectious diseases, pandemic planning or public health policy. Three were doctors - two emergency doctors and an anesthesiologist. There was a lawyer, and too many PhDs to count. Two members of the panel had lost academic appointments because of their public statements regarding COVID response. The axe they carried with them to grind was too big for a person to carry alone.

The authors of the report began with a statement that I found shockingly callous in its disregard for the suffering caused by the pandemic. The report acknowledged that hindsight is a dangerous thing to use, and that the effects of the virus "were not uniform and were influenced geographically, temporally and demographically." This is a fancy way of saying that experiences in Italy and New York were different than Alberta, and experiences changed as time passed and were different for the old compared with the young.

But, the report said: "Despite this, the relatively few deaths that did occur in otherwise healthy people, were - as they would be under any circumstances - tragic and poignant."

I read this sentence over and over and I can't make sense of it. Does this mean that the many deaths of people who were not otherwise healthy were not tragic or poignant? And what does the word "relatively" mean here? Relatively few deaths when compared to the number of unhealthy people who also died? Relatively few deaths when compared to the number of healthy people that would have died anyway, pandemic or not? Aren't all deaths caused by an unknown and unmanageable pathogen tragic, whether the victim was healthy or not? Why make a point of saying that a (small) portion of those who died were healthy? So what? They're just as dead as those who weren't healthy. Was the task force trying to measure the relative magnitude of the tragedies affecting the healthy and the unhealthy?

The report is 269 pages long and contains hundreds of footnotes and references. I don't intend to summarize or interpret the report here - it is easy to find if you're interested. There are many conclusions or observations that are controversial, to put it mildly: that the Province was too focused on the recommendations of Health Canada, or the World Health Organization or the US Center for Disease Control, or even other provincial public health officers . That the government (and the Colleges of Physicians and Pharmacists) were too quick to prohibit the use of non-conventional therapies like ivermectin (the veterinary medicine), hydroxychloroquine (an anti-malarial drug) and others. The authors concluded that doctors should be left to decide for themselves whether to recommend these "off-label" uses to their patients, uses for which the drugs were not designed or tested or recommended, or subjected to normal clinical trials.

I mention this report not because I think it is self-serving nonsense, or wrong, or dangerous. I am not qualified to make those judgments. I mention it because I think the report gets us closer to the real reason we are being discouraged from being vaccinated. There can, of course, be differences of opinion about the effectiveness and harm of vaccinations or of the non-medical measures that were adopted during the pandemic: restrictions against gathering or travelling, school interruptions, masking, and social distancing, for example. But in exploring those differences of opinion it is important to remember that many people died and many more continue to suffer the effects of long COVID. That ventilators and ICU beds were dangerously scarce. Yes, the COVID vaccines may cause harm that isn't yet fully known. But the infection caused real harm and created real dangers to us and our health care system that we do know about, and any retrospective study of our pandemic response must start by acknowledging that difficult decisions were made in dynamic and unprecedented circumstances.

I have decided that if my health in the next pandemic must be the responsibility of anyone other than me, I want it to be someone who is trained in public health, epidemiology, and infectious diseases, who considers the science first but is empathetic, careful, thoughtful and precise. Someone like, say, Dr. Deena Hinshaw, who had the misfortune of being the Chief Medical Officer of Health during the first pandemic in more than a hundred years. Dr. Hinshaw was unceremoniously relieved of her position (read: dumped) once the pandemic was over by the very same people she advised, who clearly, and with perfect hindsight, didn't like her advice. This is their prerogative, but that doesn't mean I want future public health decisions affecting me to be made by politicians responding to a vocal and unhappy minority of their constituency. Are these the people you want in charge during the next health crisis? Like, perhaps, measles, a disease that had all but disappeared from public health discussions until a critical minority decided it wasn't a problem anymore, so why vaccinate for it?

The whole point of public health policy is to prevent disease, or at least to reduce the impact of preventable diseases. This has two consequences: people live longer, healthier lives, and the costs of caring for the unnecessarily ill are reduced. There will always be a tension between personal freedoms, including the freedom to harm oneself through lifestyle choices, and public good. Sometimes public good wins (seatbelts or motorcycle helmets, for example) and sometimes lifestyle choices win out (tobacco, alcohol, fried foods or sugared drinks for example). But when the government decides to actively discourage otherwise sensible health precautions recommended by those trained in disease prevention, as they've done by implementing this vaccination fee, the pendulum has swung too far. Get these people away from my health care.