A New Era in Public Health

More than five years have passed since the SARS crisis hit Toronto. Few will forget Sheela Basrur (MD 1982, MHSc 1987, DSc Hon. 2008), the city’s top medical officer, calmly updating residents while health-care workers searched for a way to arrest the spread of the fatal virus. Before SARS could be stopped, it killed 44 people, led to the loss of millions of tourist dollars and exposed weaknesses in Canada’s once-peerless public health system through a barrage of humiliating publicity. The crisis dramatized the importance of vigilant public health measures and how Canada – historically a world leader in health care – had taken the system for granted. “Many inside and outside the public health field had been lulled into a false sense of security,” says Dr. David Naylor, the dean of U of T’s Faculty of Medicine when SARS hit.

In the wake of the SARS crisis, Naylor, who is now president of U of T, led a team of health experts who assessed the country’s ability to deal with a major infectious disease outbreak, and then advocated an overhaul of the public health system. Previous to SARS, the chair of public health sciences at U of T had enlisted a group of colleagues, including Naylor, to champion the idea of a school of public health. Following the SARS crisis and the release of Naylor’s report, the idea gained momentum and U of T developed a plan for the new school. Five years later, thanks to a timely donation from philanthropists Paul and Alessandra Dalla Lana, the vision became a reality: in September, U of T opened the Dalla Lana School of Public Health.

To lead the school, U of T sought a world-class researcher with experience building an internationally renowned public health program. The university found that person in Dr. Jack Mandel, an international expert on the lifestyle, environmental and occupational causes of cancer who was chair of the department of epidemiology at Emory University’s Rollins School of Public Health in Atlanta. Between 2002 and 2008, under Mandel’s direction, the Rollins School hired more faculty, increased student enrolment and expanded cancer research.

Mandel, like many public health professionals, demonstrates broad interests and expertise. He moves with little apparent effort from discussing scientific studies in minute detail to musing philosophically about the health-care responsibilities of government, universities and the private sector. A Winnipeg native, Mandel came back to Canada after 36 years in the U.S. because he believes U of T can be a world leader in public health education. “My goal is that within five years, the Dalla Lana School will be a global destination, ranked alongside Harvard and Johns Hopkins,” he says.

Mandel is not building the Dalla Lana School of Public Health from scratch, of course. A public department has existed in the Faculty of Medicine since 1975. But Mandel intends to broaden the school’s mandate and raise its profile so it plays a central role in the renewal of public health in Canada and around the world. As he sees it, the Dalla Lana School, one of only a handful of graduate schools of public health in Canada, will perform three main functions: it will educate public health practitioners and researchers at the master’s and PhD levels; conduct groundbreaking research into some of today’s most important public health issues; and work with governments and agencies to develop better health policies.

Educating new public health professionals and enabling existing practitioners to update their skills is an important aspect of the school’s mandate, says Mandel. “There’s a tremendous demand for people trained in public health in all segments of society – public and private,” he says, noting that the school could accept only 20 per cent of the 600 applicants for the current academic year. Mandel would like the school to continue to enrol students from many different backgrounds – as well as international students, who Mandel says eventually return to their home countries to build public health infrastructure and help U of T forge international research collaborations. “One of my goals is to expand our capacity to better accommodate the many highly qualified people who apply,” he says.

The school’s curriculum marries hard and soft sciences to teach students about the interplay among human biology, behaviour and health. The field tends to attract broad-minded thinkers from a mix of academic backgrounds who learn how to probe the determinants of health – culture, biology, genetics, the environment and social networks. Researchers affiliated with the school are studying a range of issues, from how to reduce workplace injuries, to the health effects of second-hand cigarette smoke, to how genetics affect the body’s absorption of nutrients. Faculty and staff will work with public health agencies in Canada and abroad to ensure the country is prepared to stop SARS-type crises as they emerge. (The school is forging a partnership with the new Ontario Agency for Health Protection and Promotion, which is headed by U of T’s former provost, Dr. Vivek Goel.)

U of T’s department of public health sciences has worked closely with partner hospitals and community organizations. The Dalla Lana School will maintain this tradition. “What’s unique about the University of Toronto compared to other schools in North America is its large number of affiliations with community health agencies and the practice side of public health,” notes Mandel. Many people working in health agencies outside the university teach classes, mentor students and give students research opportunities that often lead to full-time positions after they graduate. “Hundreds of people contribute to the educational mission of this school,” he says, noting that this group includes staff at Cancer Care Ontario, the Centre for Addiction and Mental Health, the Toronto Department of Public Health and several hospitals, among many others. “Building those bridges showed remarkable foresight, allowing students to form practical connections with the agencies they may work for one day. We couldn’t have done that if we had lived in isolation all those years.”

In the early 20th century, public health professionals concentrated on infectious diseases. While the postwar era brought great strides in controlling infections such as tuberculosis and influenza, smoking rates soared and cancer rates soon followed. In the 1960s, public health was redefined to include chronic conditions such as cancer and heart disease, as well as positive factors such as nutrition and exercise. Many considered modern medicine to have “beaten” infectious diseases. Then AIDS emerged. SARS struck. And health-care workers discovered superbugs – bacteria that are highly resistant to antibiotics.

Mandel believes the Dalla Lana School must play a leading role in educating the Canadian public about the alarming spike in lifestyle diseases, such as obesity and diabetes, which threaten to burden our health-care system. “Too often, there’s been too much hype about public health issues, and people can’t separate the wheat from the chaff,” he says. “The only source of information is the mass media, which is not always accurate or comprehensive. We must weigh in on a neutral basis and present the facts as we see them.”

Ultimately, though, part of the school’s mission is to ensure that the next generation of public health practitioners is equipped to handle health issues as they arise. “Who could have predicted SARS?” he asks. “Who knows what the next major crisis will be? We’ve got to prepare our students the best we can to have the skills and flexibility to deal with new challenges as they emerge.”

Before the first World War, rapid industrialization and immigration overwhelmed Canada’s primitive public health system. There was no federal department of health. Public health measures were local, reactive and poorly co-ordinated. In Toronto, polluted water and unpasteurized milk caused cyclical typhoid epidemics; the national infant mortality rate spiked to 20 per cent. For decades, diphtheria victims, mostly children, suffered and died while their families watched helplessly; only the rich could afford to import the American antitoxin. Early in 1914, Dr. John Gerald FitzGerald (MD 1903) proposed to the university that he manufacture a safe, effective diphtheria antitoxin at a minimum cost to doctors, pharmacists and boards of health across Canada who would provide it to patients for free. FitzGerald’s idea spawned Connaught Laboratories, which set up shop in a cramped basement lab in the medical school. FitzGerald’s radical vision – of a full range of preventive medicines being free to all Canadians regardless of class or income – was unprecedented.

The confluence of the Great War, a golden age of medical philanthropy and the epic discovery of insulin at U of T quickly vaulted Canadian preventive medicine to a world leadership position. In 1924, the Rockefeller Foundation pledged $650,000 to the university to establish a School of Hygiene – only the third in North America, after Johns Hopkins University in Baltimore and Harvard University in Boston. As the academic arm of Connaught Labs, the School of Hygiene, at 150 College St., became a scientific and political hub of the public health movement. By delving into the best of European and American thinking, the school trained hundreds of public health workers and policy-makers domestically and internationally. In 1940, the New York Times rated U of T’s model – with its unique blend of training, research and production of preventive medicines as a public service – as the finest in the world.

Throughout the first half of the 20th century, Connaught Labs helped other nations reap the benefits of its achievements – insulin and diphtheria toxoid in the 1920s, the anticoagulant heparin in the ’30s, penicillin in the ’40s and polio vaccine in the ’50s. Billions of doses of Connaught vaccines saved countless lives, domestically and overseas; insulin alone has saved more people than were lost in both world wars. Working with the World Health Organization, Connaught was a major player in the decades-long global campaign to wipe out smallpox, a dream realized in 1979. Smallpox is the first disease – and to date, only disease – to have been globally eradicated.

In 1972, in a controversial move, the University of Toronto sold Connaught Labs. Today it’s the Canadian arm of Frenchowned Sanofi Pasteur, the largest commercial vaccine producer in the world. Following the sale, U of T’s Faculty of Medicine absorbed the School of Hygiene. With the steep decline in the incidence of infectious diseases, many saw the labs and school as victims of their own excellence.

The mandate of keeping people healthier longer is challenging to put into action. The major difficulty: translating scientific findings into actual health improvements. Mandel’s own research suggests that Aspirin and calcium may help prevent colon cancer. But obtaining scientific evidence of a substance’s health effects is only the first step. “Once we accumulate the science and can establish a causal link between a disease and a behaviour or a substance, what do we do then?” he asks. “It’s never easy.”

Public health workers must communicate scientific findings in a way that stands out amid the hundreds of other messages reaching the public each day. And these findings need to motivate people to change their behaviour to improve their health. Mandel believes that one way to accomplish this is to focus on the cause of the disease rather than the disease itself. “We can’t think of only one disease when we think about prevention,” he says. “Unfortunately our system is set up with distinct organizations – the Heart and Stroke Foundation or Canadian Cancer Society, for instance – that focus on only one disease.”

Developing the right message is also a challenge. It has been known for years, for example, that eating a healthy diet and getting regular exercise are the best ways to prevent Type 2 diabetes, yet many people still fail to eat well or get the exercise they need. New habit-changing techniques might be required. The Dalla Lana School’s Health Promotion Group examines how the social and physical environment affect health. “If we change our environments – if schools introduced longer recesses and more exercise, for example – it forces people to change.”

Influencing the general public is one thing; changing longheld practices of government and the medical profession is another. The federal government devotes less than five per cent of Canada’s $160-billion health-care budget to preventive medicine, and many doctors subscribe to a pill-for-every-ill mentality. “For a long time, people were lamenting the unequal distribution between clinical and preventive care,” notes Mandel. “It’s not a new thing, but we’ve seen the balance get progressively worse. Advances in medicine are keeping more people alive longer. Aging baby boomers are going to be experiencing chronic diseases such as diabetes and Alzheimer’s disease, which are ruinously expensive to treat.

“Preventing disease is clearly cheaper than treating it. Ideally, we must try to prevent premature illness, particularly in the young. Think of the tragedy of young people who become ill from diseases we could have prevented. Why wouldn’t we make the investment to prevent a disease that consumes huge resources? People live a long time with that disease, and it causes a tremendous drain on the health-care system. What are we leaving for the next generation?”

Mandel acknowledges that 20th-century public health efforts – improved water safety, strict seatbelt laws, aggressive anti-smoking campaigns and mass immunizations – have raised life expectancy and led to a healthier population. Yet the diffuse, near-invisible nature of public health has continued to take a back seat to the more glamorous treat-and-cure arm of medicine.

“I don’t know what it takes,” Mandel says with a sigh. “Public health has never been sexy. It doesn’t seem to draw the money or get the credit from politicians. Public health education in American medical schools has virtually disappeared. We’re more inclined to put money into transplanting organs – hardly the long-term solution.” Mandel was shocked by a recent newspaper headline reporting that, between meeting patients, only 28 per cent of physicians wash their hands. “And I’m not easily shocked,” he says. “We must not forget the basic teachings.”

Public health changes come in slow, painstaking increments. For example, the Ontario government’s recent legislation banning smoking in cars carrying children, based on a recommendation by the Ontario Tobacco Research Unit (of which the Dalla Lana School is a principal sponsor), typifies the kind of inch-by-inch struggle that public health professionals engage in. One of Mandel’s own studies lasted for more than a quarter century. A major breakthrough, such as the discovery of insulin, happens only once every few generations.

“In medical practice, doctors affect one patient at a time while a good public health measure can affect whole communities,” Mandel observes. “That’s one of the reasons I was drawn to the field. It’s very satisfying to know that you can help significantly reduce rates of disease and death. In public health, you can make that kind of difference on that kind of scale. Not to mention the reduction in pain and suffering – you can’t put a price on that.”

If a SARS-like threat were to hit Ontario today, a vastly improved public health system is now poised to respond. Teaching hospitals, education, research and labs are working together to confront re-emerging infections and proliferating lifestyle diseases with a growing arsenal of intellectual and practical firepower.

The torch of passionate, pragmatic idealism and selfsacrifice that burned in the early pioneers has clearly passed to the current generation of public health professionals at U of T. No doubt FitzGerald and his colleagues would be heartened to see such a dedicated renewal of energy, resources and vision in this fresh “outbreak” of MSc and PhD students. If slippery superbugs can mutate into ever-more intelligent adversaries, so can human beings.

James FitzGerald wrote a profile of his grandfather, Dr. J.G. FitzGerald, in the Spring 2002 issue of U of T Magazine. Random House of Canada will publish his book An Irish Madness, a blend of family and medical history, in summer 2009.