Dr. Robert J. Kyle, Durham Region, Ontario

What are the key factors that have led to changes in Public Health over the last 10 to 20 years?

I think the main reason is SARS in 2003. SARS led to changes in the mandate of Public Health, together with the publication of the Ontario Public Health Standards, 2008, and protocols. It also led to the creation of new structures such as Public Health Ontario, the Provincial Infectious Diseases Advisory Committee (PIDAC), the Regional Infection Control Networks, and the Emergency Management Branch in the Public Health Division of the Ontario Ministry of Health and Long-Term Care. Legislative changes to the Health Protection and Promotion Act improved and enhanced the emergency powers of the Chief Medical Officer of Health.

What tasks does the Public Health system face that didn’t exist 20 years ago?

I have worked in Durham Region for about 20 years. If I look at the system as a whole, I think that the main changes centre on a more consistent approach to the management of infectious diseases through the Ontario Public Health Standards and protocols. Health promotion was coming to the fore in the late 1980s and early 90s. Lately, the focus of Public Health has broadened to include  broader prerequisites of health and the social determinants of health. There is also an increased focus on research and knowledge exchange. New Public Health disciplines have emerged such as public health librarians. And of course, something we often forget, 20 years ago we didn’t have the Internet – information technology has had a huge impact on Public Health. 

Looking back, I think Public Health has become more complex. I think there are new disciplines, new players, far more community partners, and we are way more interconnected than before. Even though the Public Health focus is a local one, certainly one has to see the big picture with respect, for example, to multi-jurisdictional outbreaks. The Ontario Public Health Standards and protocols speak to this. The days where one tackles particularly complex issues, such as obesity prevention, or injury prevention, in isolation – working in silos or with one agency owning a particular issue – are long gone. Today, there is an expectation to tackle problems more holistically and to form partnerships.

New professions have come into play such as epidemiologists – how do you see the role of epidemiologists changing over the next 10 years?

If you simplify their role, it is about collecting data, analyzing data and translating data into user-friendly products. These may include, for example, info-graphics, and interactive local health neighbourhoods maps. In addition to translating data into useful information, I think that there is an increasing need, driven by colleagues and by the community, that epidemiologists (and public health units in general) need to connect with their audiences in order to assure that the data products produced are user-friendly, and used as much as possible.

In terms of knowledge translation, I think when you are looking at a data set, rather than crunching the numbers and then thinking through your knowledge translation strategy, this must come in the beginning of the process. Maybe this is already becoming bred into the DNA of epidemiologists. When we are planning our products we need to address: What is your knowledge translation plan – who, what, where, when and why? 

I suspect this is common across the public health sector. With the rise of social media, peoples’ attention spans have lessened – they want information to be as simplified as possible. With respect to the medical community, I know that if we can’t get our message on one page, it is unlikely that our message will be heard. This differs radically from earlier, when local health status reports were always massive documents including tons of data and data analyses, and so forth, which nobody read. Today, I think one really needs to think about one’s audience’s attention span. It has been shortening in part because there is so much information out there, and I think that the social media and the way information is being portrayed has helped feed that kind of expectation.

What do you think are critical factors for success in public health in general, and for Durham specifically?

I think you need to be locally relevant and performance-driven. You need to develop sound plans, robust performance indicators and targets, and you need to evaluate your programs. I think there is an expectation among ourselves as well as in the broader community that we are evidence-informed. Particularly in the age of the Internet, everybody has an opinion and you can get a whole lot of misinformation not formed with sound evidence. We have been trying to train our staff on what steps need to be followed with regard to evidence-informed decision making. Additionally, you need to be passionate, at times a risk-taker, and you need at all times to understand that you are the steward of public funds. You are working in the public’s interest, and you need to be proud of what you do day in and day out, and strive for excellence.

Where do you focus your efforts in collecting Public Health data?

There is a ton of data out there that we can access, so the challenge is to have relevant data at the municipal or sub-municipal level – in other words, to focus your effort. Regarding the Rapid Risk Factor Surveillance System (RRFSS), for example, we were one of the original partners when the system was established in the beginning of 1999. We still find RRFSS data relevant today. For us it is pure gold – certainly with respect to getting local data that can be translated into useful local products. For a number of years, we have had a partnership with the Centre for Addiction and Mental Health where we get an oversample of local data on student alcohol and drug use and related information. This again is pure gold for us in terms of developing new programs on a number of fronts relating to drug and alcohol use and other risky behaviours. We have developed an Infant Feeding Surveillance System that has been in place since 2007 and we have data from about 5,000 clients who have received support from us.

Most recently, we have spent a lot of time and effort on mapping a range of data that we can access in what we call the Health Neighbourhood Project. We defined Durham Region into 50 neighbourhoods. Each neighbourhood has a special social profile and has been mapped with health information. This data has been on our Intranet site for a couple of years, and we are planning to go live on the Internet this November. These are examples of local surveillance systems that we have put in place to supplement other data that is out there on Durham Region. We did this because the program staff has identified a strong need for more local data sets. All of these information products can be found on the Health Statistics in Durham Region tab of our website. 

What made you focus on the neighbourhood level?

I guess it was a belief that when you are planning a particular targeted programming, such as smoking cessation, we realized that focusing on the municipality as a whole was too big a population size, in the sense of appropriateness. Our program planning is driven by availability of data, technology that allows us to map this data, and an alignment with analysis that can be translated into effective implementation of programs and services. I should say that in north Durham we have three, fairly sparsely populated municipalities, and then along the lakeshore [Lake Ontario] we have five, fairly heavily populated municipalities. So of course you will have more health neighbourhoods in the south than in the north, because of their respective population densities. 

What are the challenges you face in collecting Public Health data, analyzing it and publishing the results?

On one hand there really is a wealth of data – data that is available at the public health unit level. And we are part of a municipal data consortium so we can access even more data. There is probably not a “set of data” out there that we cannot access. We are living in a time of abundance for data, and the major challenge we find is that despite the breath of available data, it needs to be synthesized into a very precise and easily accessed type of product. I think that the other challenge is to adapt social media in an appropriate way as a means of capturing a wider audience.

How do you see the public health units (in general) evolving in the future and what kind of role do you see PHUs playing to improve the future health of the people of Ontario?

I think that public health has been well served by the former Mandatory Health Programs and Services Guidelines and the current Ontario Public Health Standards and protocols. The Standards of course will be reviewed from time to time. Attached to the Standards are various protocols which were put in place to provide consistent practices among the PHUs across the province – in particular relating to the health protection side. In my opinion, that has been achieved more or less. I think that the mandate of Public Health will continue to evolve. There are gaps out there that I think were identified in the Ontario Public Health Sector’s 2013 Strategic Plan “Make No Little Plan”, – I am particularly thinking about more targeted programming in respect to early childhood development, built environment, and mental health programming. 

In addition to advancing the Public Health Sector’s Strategic Plan, Public Health will continue to have to respond to emerging issues – Ebola is happening as we speak - and that has already led to new management guidelines. 

Canada is a land of immigrants so I think cultural diversity will continue to play a role in public health programming. We are living in an age of austerity, with the expectation that tax increases are minimal, and governments are focused on growing the economy by cutting red tape and creating a more receptive business climate. All that will play out in terms of resources available for public health. I think in order to adapt to a changing world we need to stick to our knitting. We need to continue to be locally relevant, embrace new technologies in order to get to new audiences, look for opportunities for new programming, continue to reduce health inequity, and develop new tools and try to improve and develop staff on the new core competencies. <>

By Jostein Algroy