HLTB16 Fall 2024 Lecture 2: History of Public Health in Canada Part 1 PDF

HLTB16 Lecture 2: History of Public Health in Canada Part 1. David Schlueter, PhD From Last Week … Ten Essential Public Health Services Prevention and Intervention Epidemiological Triangle Another approach to designing interventions is to think of an illness or injury as the result of...

HLTB16 Lecture 2: History of Public Health in Canada Part 1. David Schlueter, PhD From Last Week … Ten Essential Public Health Services Prevention and Intervention Epidemiological Triangle Another approach to designing interventions is to think of an illness or injury as the result of a chain of causation involving an agent, a host, and the environment. Host This approach is traditional when thinking of infectious diseases: the agent may be a disease-causing bacterium or virus; the host is a susceptible human being; and the environment includes the means of transmission by which the agent reaches the host, which may be contaminated air, water, or food, or it may be another human being who is infected. Prevention is accomplished by interrupting the chain of causation at any step. Agent Environment History of Public Health in Canada Part I.  The Beginning—Quarantine and Sanitation Indigenous peoples have inhabited the North American continent for thousands of years and their health, social, economic and physical conditions were adversely affected by increased European immigration, which began in the 1600s. As the fur trade drove French and British expansion across North America, smallpox, measles, tuberculosis and alcohol destroyed many Indigenous lives. As European immigration grew, vessels arriving at the Port of Quebec often had large numbers of sick passengers, especially due to typhus fever. Early Disease Spread Haphazard efforts to inspect ships before they landed passengers became more organized beginning in 1710, followed by a quarantine act in 1721 that was enacted because of fears of the Black plague that was spreading Europe. The plague never made its way to New France but despite the legislation, the number of typhus and smallpox outbreaks did not abate. A physician was appointed as Health Officer of Lower Canada in 1816, in response to a high incidence of illness occurring among thousands of new immigrants—“the wretched and miserable class of starved people that annually https://www.environmentandsociety.org/arcadi a/plague-provence-early-advances-centralizati arrive” in Quebec City from Britain. on-crisis-management Inoculation The idea that smallpox could be prevented through arm-to-arm inoculation was introduced in Britain in the 1720s, although the practice had been known in Asia centuries earlier. In 1796, British physician Edward Jenner used fluids collected from cowpox lesions on livestock to protect humans from smallpox infection, creating the first effective vaccine. Cholera Spreads to the Colonies In the early 1830s, pandemic cholera spread across Britain and Europe and some physicians had linked cholera and other fevers with impoverished living conditions. They argued that diseases could be prevented if the community took steps to improve the deplorable conditions endured by the poor while others argued that cholera was due to “miasma,” an ill-defined poisonous vapour or mist believed to emanate from rotting organic matter. Vibrio cholerae Early Government Action The government of Lower Canada authorized the establishment of local boards of health in Quebec, Montreal and elsewhere as needed, and appropriated funds for these boards and the costs of quarantine. As cholera spread across Lower Canada, the colonial governments of New Brunswick, Nova Scotia and Newfoundland took steps to prepare by establishing central boards of health and passing temporary legislation to strengthen quarantine provisions In 1849, the government of the United Canadas (Upper and Lower) created a Central Board of Health with new legislation, but when the threat of a cholera epidemic ended, the Central Board was dissolved. Strengthening Infrastructures There were consolidations of public health legislation during the early 1850s in Nova Scotia and the United Canadas with the establishment of permanent local boards of health and the strengthening of quarantine laws. When cholera returned in 1854, the Canadian Central Board of Health was revived and the government assumed full control of Grosse Isle Irish famine and migration In 1847, some 100,000 poor Irish emigrants fled famine and en route to British North America fell victim to typhus in large numbers. A report to the British Parliament said “6,100 perished on the voyage, 4,100 on their arrival, 5,200 in the hospitals, and 1,900 in the towns to which they repaired. The total mortality was 17 percent of the number emigrating.” According to official Canadian statistics, 5,424 died of typhus fever at Grosse Isle in 1847, while thousands of others died in Quebec City, Montreal, New Brunswick and Upper Canada.5 Meanwhile in Britain Britain’s 1848 Public Health Act resulted in more proactive measures to prevent disease and promote health, including the establishment of vital statistics. During a cholera outbreak in London, England in 1854, British physician John Snow discovered that a neighbourhood water pump on Broad Street was the cause of hundreds falling ill and many deaths. Snow’s work followed Edwin Chadwick and other physicians in Britain and New York https://education.nationalgeographic.org/reso urce/mapping-a-london-epidemic/ Introduction of vaccination Compulsory vaccination measures to prevent smallpox were introduced in the early 1860s in the United Canadas and Prince Edward Island. The Hudson’s Bay Company, which served as a de facto public health agency in the west from the late 18th to the early 19th century, launched a vaccination campaign that kept the disease under some control among some Indigenous communities, although the importation of smallpox into British Columbia from California during the gold rush of the early 1860s was particularly devastating to the First Nations who lived there.7 As the Fathers of Confederation worked on the drafting of the British North America Act, they were not concerned with public health, despite the experience of major epidemics since the 1830s, a new cholera threat in 1866, and the advances being made in understanding the importance of clean water and proper sanitation. Discussion Points to Think About - Pre-confederation what difficulties might local governments have faced regarding disease sperad and management? - What were some of the social institutions of the time and how might they have related to disease spread? - How does this reflect back to what we learned in lecture 1? The Sanitary Idea 1867–1909 Hygiene and Sanitary Reform The creation of permanent local and provincial boards of health was still a work in progress but their efforts to control infectious diseases and build effective water and sewage systems were aided by discoveries of the bacteriological revolution in the 1880s. As knowledge and infrastructures developed, a growing number of voluntary organizations and individual sanitary reformers preached the gospel of hygiene. Germ theory and sanitation measures The invention of the microscope permitted the discovery of the microbe in the late 17th century, but the field of bacteriology didn’t develop until the 19th century and popular acceptance of “the germ theory” was not widespread until the early 20th century The specific causative bacillus was identified in 1880 with definitive proof that it caused typhoid in 1896. The discovery and successful testing of both the diphtheria antitoxin and rabies vaccine in the 1890s were major achievements and provided the first reliable and scientific biological tools for the control of these deadly diseases Sanitation Knowledge about how infectious diseases were spread brought the realization that individuals and communities could do something to prevent the spread of disease and benefit from early detection. This new way of thinking was called the sanitary idea, and it first spread amongst medical elites and then was gradually adopted by the educated middle classes and then later by the population at large. Let’s think back to the epidemiological triangle…. Designed by freepik.com Confederation and Growth Confederation permitted the creation of larger political and economic structures and economic growth in turn resulted in expanded immigration from continental Europe, in addition to the usual American and British sources. ○ The social, political and economic elites, however, remained broadly Anglo-American.3 If health concerns for Indigenous peoples were considered at all, it was by missionaries, traders and individual physicians. The health of First Nations and Métis people had begun to seriously deteriorate by 1900, due to the decline of the fur trade and relegation of Indians to under-developed and isolated reserves https://www.thecanadianencyclopedia.ca/en/ article/confederation Models for Public Health Great Britain and its Public Health Act of 1875 were models for sanitary reform in Canada. This landmark legislation enshrined the British government’s responsibility for the health of the people, most of whom were living in old but rapidly changing cities and densely populated rural areas. In contrast, the first generation of Canadian sanitary reformers: ○ “functioned in relatively new cities which were trying to erect basic industrial, housing, and sanitary infrastructure while often absorbing immigrants on a scale not seen in Europe.” Outside Canada’s towns and cities, the widely scattered populations often living in wilderness conditions had no counterpart in Western Europe.”5 Edward Playter, A Leader in Canada’s Sanitary Reform One of the most important early sanitary reformers was Dr. Edward Playter (1834–1909). This physician, based in Toronto and later in Ottawa, single-handedly published Canada’s first professional public health journal from 1874 until 1892. Playter recognized that the practice of medicine went beyond treating the sick to include the prevention of sickness and the promotion of health—not only to save lives and suffering but, as he often argued, to protect the economic health of the country Playter financed, produced and promoted The Sanitary Journal, (first published in1876) “devoted to public health and individual hygiene.” ○ Playter’s first editorial argued that more attention was needed to look after the health and development of infants, children, youth, mothers and their unborn. He also called on the medical profession to work at improving the recently implemented Ontario Public Health Act of 1873 and to lobby the government to establish a sanitary bureau. Expansion of Municipal Public Health Awareness of public health was gradually increasing within some local governments. For example, Winnipeg implemented By-Law No. 13 in 1874 with regulations against adulterated food and tainted meat, the defiling of water and allowing stagnant pools to stand, and keeping dead animal carcasses in the city. ○ The law required every home to connect a privy and keep it clean and to collect all dirt into one place and keep filth off the lots and streets, with penalties of a fine up to $20 or a jail sentence up to 21 days.10 https://en.wikipedia.org/wiki/File:Crest_of_Winni peg_fair.svg Measures in Toronto and Montreal In Toronto at this time, sanitary reformers were concerned about expense and safety of the city’s proposal to build a trunk sewer line across the waterfront to channel the sewage into the lake, three miles from the city, in the questionable hope that currents would not carry it back to where the water supply was drawn. Public health activity also expanded in Montreal, where before 1870, these matters related only to the control of nuisances, with a few policemen giving attention to cleaning yards, lanes and privy-pits. Discussion question: How does this piece of history relate to some of the discussions in lecture 1 about why Pubic Health is Controversial?  Smallpox in Montreal During the 19th century, Montreal recorded the highest mortality rates of all British North American cities. Montreal had become the industrial centre of Canada and rapid settlement resulted in working class families living in crowded, unsanitary and poorly built housing. As was common in other Canadian cities during or after epidemics, Montreal’s city council established a health committee with limited powers after a smallpox outbreak in the 1870s. At a public meeting called by the mayor, a Citizens’ Public Health Association was established, supplanting the Montreal Sanitary Association, to “increase and diffuse knowledge on all subjects relating to the public health, by the discussion of sanitary subjects, by exposure of sanitary evils, and by promoting sanitary legislation.” In 1875, the Province of Quebec adopted compulsory smallpox vaccination, despite strong opposition https://www.thecanadianencyclopedia.ca/en/article/smallpox The Montreal Smallpox Epidemic, 1885 In the spring of 1885, two Pullman-car conductors infected with smallpox had arrived in Montreal from Chicago. ○ The disease spread within and then beyond the Hotel Dieu hospital. Public health officials tried to enforce vaccination and isolation of the sick but were met with resistance and some were assaulted as they tried to remove corpses from the worst-infected neighbourhoods. ○ On September 28, police from all over the city assembled to disperse an angry mob that roamed the streets while hurling stones Smallpox in Ontario A smallpox epidemic that struck eastern Ontario in 1884 gave the Provincial Board of Health its first opportunity to manage a serious infectious disease threat. When the head of a hastily assembled local board of health fell ill, residents of nearby towns called in the Provincial Board of Health. Peter Bryce, Secretary of the Provincial Board, ordered schools and churches banned public gatherings, suspended stagecoach service into the community, and posted constables on the roads and railway stations to control the movement of anyone who might be carrying the disease. He also brought in medical students to conduct house-to-house vaccinations, disinfected and fumigated all infected houses, and issued a special pamphlet that attacked the anti-vaccination views of a local practitioner. By January 1885, and after 202 cases and 45 deaths, smallpox was kept from spreading outside the township. Amendments to Laws Ontario had amended its Public Health Act to compel the appointment of a local medical officer of health and sanitary officers answerable to the provincial board and if necessary, to appoint local health officers and tax municipal funds to pay closed, them. In the end, this interprovincial strategy was remarkably effective, limiting smallpox deaths in Ontario to 30 in 1885, while the death toll in Montreal reached 3,157, with a total of 19,905 cases and 5,964 deaths across Quebec that year. The Montreal outbreak would prove to be the last uncontained outbreak of smallpox in a modern city and in its aftermath, Quebec passed a public health act in 1886 and established a provincial board of health in 1887. The Montreal smallpox experience also led to a requirement that all passengers and crews of arriving vessels had to show evidence of smallpox vaccination or submit to vaccination upon their arrival in Canada.17 Bacteriology and Public Health Laboratories In 1882, Louis Pasteur successfully demonstrated his anthrax vaccine for sheep and Robert Koch announced his discovery of “the germ of tuberculosis.”18 In 1886, Dr. Alexander Stewart of Palmerston began producing smallpox vaccine on behalf of the Ontario Board of Health and the Ontario Vaccine Farm was soon shipping to other provinces. Ontario established the first public health laboratory in North America in 1890. Louis Pasteur https://www.britannica.com/biography/Louis-Paste ur Diphtheria Diphtheria incidence had increased sharply around the world during the second half of the 19th century. Its causative bacterial organism was identified in 1883–84 and the specific endotoxin produced by the disease was recognized in 1888. The New York City Department of Health produced and administered the first supplies of diphtheria antitoxin on the continent in 1895 and a former collaborator of Pasteur’s set up the New York Bacteriological and Pasteur Institute in 1889, becoming one of the first companies to produce and market the new antitoxins in North America The cost of importing diphtheria antitoxin was the focus of a lively discussion at a meeting of the Ontario Medical Association in 1905. https://www.ncbi.nlm.nih.gov/books/NBK7971/ Pushing for Progress Meanwhile, Edward Playter and other sanitary reformers kept working to keep public health issues alive at the federal level in Canada. Playter gave detailed addresses to the Members of Parliament, focused on Canada’s death rate, which was 25% higher than in Great Britain and on “the immense money loss in Canada through preventable sickness and deaths.”20 Doctors pointed to the amount of public money being spent on preventing and stamping out infectious diseases among animals and plants by the Department of Agriculture, while little, if anything, was being spent on preventing or stamping out human diseases. Education and Scientific Knowledge Appearing before Prime Minister Wilfrid Laurier in 1908, the Canadian Medical Association stressed that “we are not making full use of the scientific knowledge of the age in preventing many forms of disease that have been traced to their source.” It was estimated that the cost of typhoid in Canada amounted to $5.5 million a year. There were also some 40,000 cases of tuberculosis and 8,000 deaths in Canada annually at an estimated cost to the economy of $8,800 each, or a total of $70,400,000 per year.23 Public education remained fundamental to reformers’ public health crusades. While the new bacteriological understandings were embraced by the medical and social elites in Canada, significant numbers of the rural and working classes—most of whom were illiterate—clung to the old beliefs and fatalistic attitudes towards infectious diseases Transformation and World War I 1910 –1919 Infantile Paralysis: The New Epidemic In July 1910, a little girl from the Hamilton, Ontario area was taken to hospital with what was thought to be rabies, where she died. It was later discovered that she was a victim of infantile paralysis (poliomyelitis). Rabies and poliomyelitis are both viral diseases that affect the central nervous system and symptoms of the two were frequently confused. Indeed, at the 1910 Congress of American Physicians and Surgeons, poliomyelitis received more attention than any other subject. MacMurchy added that the “toll of the victims of tuberculosis grows smaller every year,” while polio “now counts its victims by the thousand where it used to count them by the couple.” Polio was not like other diseases that struck “the poor, or delicate” and its cause was unknown. https://polioeradication.org/about-polio/history-of-polio/ Typhoid Persistence in Canada Medical Advisor, Charles Hodgetts. Hodgetts focussed on the persistent incidence of typhoid due to contaminated water in Canadian cities. Canada’s typhoid death rates exceeded those in the United States, the United Kingdom and most European countries and the Toronto Globe reported that Hodgetts declared that it was time “that we were alive to our responsibilities and made haste to put our house in sanitary order.”12 Hodgetts recommended more efficient and federally-enforced legislation, with the cooperation of the provincial departments of health. The conference called for the establishment of a federal council of health, government action to prevent pollution of public water supplies, establishing subsidized federal and provincial tuberculosis sanatoriums and funding for an educational campaign against the white plague (tuberculosis). The conference also recommended the creation of a laboratory to conduct research and manufacture vaccines and antitoxins. Canadian Public Health Association On October 12, 1910, at an evening meeting chaired by Peter Bryce, Toronto physicians Duncan MacKenzie Anderson and Lester McDonnell Coulter met with 14 public health officials attending the conference to formally organize the Canadian Public Health Association. The Association’s purpose was to establish professional public health standards, conduct research and provide technical and scientific information. CPHA’s objective was “the development of the science and art of general prophylaxis with promotion of social welfare, in judicious https://www.cpha.ca/ conservation of natural resources, popularization of eugenics and more effective national and international co-operation along all lines of public health. Typhoid Not long after CPHA’s initial meeting, the city of Ottawa provided a compelling demonstration that poor sewage control could result in a major outbreak of typhoid. There had been cases of typhoid in the area for several years, but they were largely confined to the poorer areas of the city and all but ignored by city officials. In January 1911, typhoid cases suddenly appeared in all areas of the city, leaving 987 stricken and 83 dead by March. Amid considerable alarm and criticism of the local government, Ontario’s chief officer of health, J.W.S. McCullough, and the secretary of the Dominion Board of Health, Charles Hodgetts, joined the local health commissioner to investigate. They found sewage-contaminated water from the Ottawa River was entering the city’s water supply. There was little action taken on a recommendation to begin a water treatment program as rival water treatment plans from city aldermen with mayoralty aspirations had turned the public health crisis into a political one. When a second epidemic sickened 1,378 and killed 91 in July 1912 McCullough imposed a $100 per day fine on the city. Push for Education Scientific discoveries and preventive medicine became a central element of local and provincial public health disease control strategies. Inspired by major exhibits in the United States and Europe, increasingly elaborate provincial exhibits became a key part of public health education strategies Of particular interest for public health education were a number of specific disease threats that had recently been identified through bacteriological investigations. Houseflies, public drinking cups, and kissing were particular concerns. Microscopic attention to common insects identified flies as “germs with legs” that could contaminate food and household items, leaving a trail of filth and bacteria.20 To prevent the “massacre of the innocents,” people were advised to “screen therefore your doors, your windows and your food against this pilot of pollution. Swat Musca Domestica and sweep him from the confines of your home.”2 Venereal Disease Education A subject rarely mentioned at this time was venereal disease, although the Canadian Medical Association Journal estimated that in 1916, 50% to 60% of adults would have gonorrhea at some time in their lives.25 In 1912, the Public Health Journal proposed that this serious public health threat could be prevented through sex hygiene education targeted at public school children. The journal had reported the previous year that a number of private schools in the United States had demonstrated the practicality of sex instruction and that the state of Washington made it mandatory. The Public Health Journal called Ohio’s 1912 legislation for education of the young in sexual matters “the most radical step in the direction of social hygiene ever taken by Public Health officials, and it is the initial effort to make practical a theory that is becoming widely accepted as being of paramount importance from the viewpoints of health and morals. Discussion: why might this have been controversial? https://vdarchive.newmedialab.cuny.edu/items/show/395 Provincial Structures In the fall of 1911, Ontario’s newly appointed chief officer of health, John McCullough, pressed for more comprehensive public health legislation, targeting local health organizations and responsibilities. In 1912, the Ontario government thus implemented a comprehensive revision of its Public Health Act, creating 10 health districts (although three in northern Ontario were “left in abeyance”). Each district would have full-time medical officers of health, who would be “paid a reasonable salary fixed by law” and be independent of municipal control, provided they pass a post-graduate course at the University of Toronto’s Department of Hygiene. Similar health districts were created in Quebec and Saskatchewan, while Manitoba strengthened its control of infectious diseases and provided free supplies of smallpox vaccine and diphtheria antitoxin.32 Canadian Red Ensign 1868-1922 Discussion: How can districts like these can help alleviate outbreaks? Ongoing Challenges: WWI After the First World War began in August 1914, the Canadian Public Health Association’s annual meeting was cancelled.34 Physicians and nurses were called into military service in growing numbers and the public health field struggled with limited personnel to manage ongoing challenges, including polio, venereal disease and influenza. Beginning in July 1916, one of the most severe polio epidemics ever seen developed in the north eastern United States, causing some 27,000 cases and 6,000 deaths. McCullough and FitzGerald traveled to Windsor, Ontario to investigate a significant outbreak where 38 cases and one death had occurred. While it was thought to be of a “rather mild nature,” a report presented to a conference of Ontario officers of health, described the Windsor polio epidemic as “one of the worst calamities that had ever befallen our city.” A strict quarantine was imposed, “thereby quarantining the wager earner. By quarantining these families in such a drastic measure, we were obliged to feed Second Battle of Ypres all these people, costing our city an immense sum of money, but money, I dare say, well spent for the protection of our people.” At the Second Battle of Ypres, Belgium, 1915. (painting by Richard Jack, courtesy Canadian War Museum/8179) https://www.thecanadianencyclopedia.ca/en/article/f irst-world-war-wwi Persistent diseases during WWI The threat of venereal diseases became a dominant issue as the war progressed. An estimated 28.5% of Canadian troops were infected by venereal diseases in 1915. Public interest spiked after a report by the British Royal Commission on Venereal Diseases in February 1916 said some 13% of public ward patients at Toronto General Hospital had positive tests for syphilis. The high incidence of syphilis prompted a delegation of Toronto physicians to take their concerns to the Commission of Conservation Provincial venereal disease legislation focused on syphilis, gonorrhea and chancroid and gave public health the power to detain women suspected of having venereal disease. Those infected were required to seek professional medical treatment through provincially-funded hospitals and the provincial government or its agents were to be the only source of educational Bogaert, Kandace. “Treating the ‘Undesirable’: Venereal Patients in literature, a measure aimed at patent medicine vendors and the Canadian Expeditionary Force, 1914–1918.” Environment & Society Portal, Arcadia (Spring 2017), no. 2. Rachel Carson Center medical quacks for Environment and Society. doi:10.5282/rcc/7743. “Spanish Flu” The new and unusually deadly influenza strain originated in China in February and likely first spread to France via a group of transient workers. The war provided an ideal environment for the flu to infect, multiply and spread across the globe with remarkable rapidity. It reached the United States in March 1918, appearing in a Kansas military camp. Troop, hospital and civilian ships sailing from England into Grosse Isle, Montreal and Halifax were the main routes of infection into Canada by late June and early July, followed by spread across the country via the railway in the summer. By the time the pandemic eased, at least one-sixth of the Canadian population, predominately young adults, had been stricken and 50,000 died, accelerated by complications from infections such as pneumonia. Quebec and Alberta were the most severely affected provinces. Indigenous communities were especially hard hit by the epidemic. The Department of Indian Affairs reported 3,694 deaths out of a national Indigenous population of 106,000—a mortality rate five times the national average. Influenza was so severe among the Haida living on islands off the north coast of British Columbia that entire settlements were wiped out. Emergency hospital during influenza epidemic, Camp Funston, Kansas. Emergency hospital during influenza epidemic (NCP 1603), National Museum of Health and Medicine. National Coordination The end of the war in 1918, coupled with the influenza pandemic and the persistent venereal disease threat, brought growing pressure from national organizations with an interest in health for the establishment of a federal department. On the suggestion of military authorities, Prime Minister Robert Borden called a national conference in Ottawa on February 3, 1919 to organize a national Social Hygiene program aimed at controlling venereal diseases. This conference set in motion the political process that led to the drafting of legislation creating a federal department of health. Attending the conference were most provincial officers of health, as well as several provincial and federal cabinet ministers and officials, along with key leaders of the social hygiene movement. The conference’s principal resolution said, “It is in the interests of the future health and life of the Citizenship of Canada that there should be immediately established a Federal Department of Health.” Modernization and Growth 1920 –1929  Maternal and Child Health Concerns about the effects of factory work on pregnant women and the health of mothers with small children brought maternal and child health concerns to the forefront, especially since the influx of women in the workforce during World War I. In 1920, the Dominion Council of Health endorsed an international minimum standard for women working in industry before and after childbirth that had been developed at the 1919 International Labour Conference. MacMurchy also estimated that the maternal mortality rate averaged 5.5 per 1,000 live births between 1900 and 1920, but these rates were under-reported by as much as 25% until the 1930s. Compared to most other industrialized countries, Canada rated poorly in both infant and maternal mortality and the rates varied widely across the country. Rural women had very little, if any, access to obstetrical, pre-or post-natal medical care.2 https://www.nobelprize.org/ prizes/peace/1969/labour/hi story/ Continued In 1920, the Canadian Red Cross Society funded a new child welfare section of the Canadian Public Health Association, enabling it “to initiate immediately, a most energetic movement, along educational lines looking to the reduction of infant mortality throughout Canada.” The Dominion Council of Health endorsed CPHA’s Child Welfare Section as the national focus of voluntary child welfare programs to work with public health departments at all levels of government. The condition of children and women living in rural areas were a particular concern to the DCH. In addition to a lack of safe and available food, farm women were seen to be working themselves to death. About half of Canada’s modest but growing population (from 8.4 million in 1920 to 10 million in 1929) was spread sparsely across large rural areas and the provision of public health services was a challenge. Rural schools received limited medical inspection and home sanitation Increased Investment in Programs Manitoba established the first provincial public health nursing service with five nurses in 1916 and by 1922, had 53 working around the province. Dalhousie University in Halifax offered the first substantive public health nursing course in February 1920, followed shortly thereafter by the University of Toronto, McGill University, the University of Western Ontario, the University of British Columbia (UBC), and the University of Alberta. Public health nursing at UBC was a supplement to the baccalaureate in nursing program it had established in 1919, the first such nursing degree program in the British Empire. The universities required financial assistance to develop public health nursing courses and to attract and support students. First full-time county health unit Canada’s first full-time county health unit was created in Saanich, British Columbia, in 1921, although many urban areas had full-time health departments staffed by well-qualified, full-time medical officers of health. Quebec was the second province to create a full-time county health unit in 1926 and more populated and developed county structures facilitated the efficient establishment of county health units, Saskatchewan, with almost fully rural conditions, took a different approach by providing free consultative health clinics Services for Indigenous Communities Indigenous communities also had very limited public health services. As it is today, the federal government was responsible for health promotion and protection for Canada’s Aboriginal peoples, but few services were provided at this time. The Indian Health Service did not begin to develop until 1927, when Dr. E. L. Stone succeeded Dr. Peter Bryce as Medical Superintendent General. Bryce had been an outspoken critic of the federal government’s failure to provide health care and services for First Nations and his persistent advocacy effectively ended his career in the federal public service. Indigenous Health Remarkably high rates of tuberculosis in Indigenous communities became more publicly known in the mid-1920s, when the Canadian Tuberculosis Association undertook a two-year study of coast and interior bands in British Columbia on behalf of the Department of Indian Affairs.13 The first substantive federal effort to provide health services to Indigenous people in the North began in 1922 with the appointment of Dr. L.D. Livingston as Medical Officer for the Northwest Territories and Yukon Branch of the Department of the Interior. Catholic and Anglican missionaries operated small northern hospitals, often duplicating their efforts in the same area, much to Livingston’s annoyance. He also objected to the building of hospitals to serve the very sparse and nomadic northern Indigenous population. Lapses in Oversight: Smallpox and Typhoid Persistent outbreaks of typhoid and smallpox demonstrated unacceptable lapses in public health oversight and highlighted a longstanding neglect by some local governments. Anti-vaccination sentiments among some members of the public and the medical profession were often reinforced when physicians improperly stored or administered vaccines. When a smallpox outbreak occurred in the Toronto area and resulted in 33 deaths in 1920, city authorities hesitated to carry out compulsory vaccinations. As a result, the United States required proof of recent smallpox vaccination in order to cross the border, and similar quarantine restrictions were imposed on anyone from Toronto entering Manitoba and Quebec. The epidemic in Toronto eased after 200,000 voluntary vaccinations were given, while a more severe smallpox outbreak in Windsor, Ontario in 1923–24 resulted in a mortality rate among the unvaccinated of 71% of the reported cases. No one who had been vaccinated over the previous 12 years contracted the disease and no one who had ever been vaccinated died in Windsor. When the emergency was over, local health officials concluded, “the value of vaccination as a means of prevention has been proven as never before.”21 Typhoid in Ontario and Quebec A major typhoid epidemic in Cochrane, Ontario in March 1923 and another in Montreal four years later illustrated other lapses in public health oversight. In Cochrane, typhoid-contaminated sewage entered the water supply, resulting in more than 800 cases and 50 deaths among a population of 3,400. The Provincial Board of Health provided engineers, general and public health nurses, as well as $20,000 to help the town. The Montreal typhoid epidemic was caused by contaminated milk and left more than 5,000 stricken and 533 dead. Public health authorities were struck with “amazement that such a situation could possibly develop in a modern civilized city,” The ground-breaking 1929 Montreal Health Survey Report reflected a sophisticated and early understanding of the importance of using statistics and placing public health within its social context. Outbreaks of typhoid and other enteric diseases exposed weaknesses in sanitary controls of milk supplies. These outbreaks and the persistent threat of milk-borne tuberculosis enflamed the debates between advocates of raw milk and those calling for compulsory pasteurization Poliomyelitis In contrast with the successful control of diphtheria, poliomyelitis (often shortened to “polio”) increased dramatically in incidence, first in British Columbia and Alberta in 1927, Manitoba in 1928, Ontario in 1929, and Quebec in 1930. Polio was still widely called “infantile paralysis,” although the new and strange disease did not strike infants only. A magazine article entitled, “Death Walks in Summer,” urged parents to “suspect everything” since no one could predict Convalescent serum was used in which case would prove mild, “or which will cripple hopelessly.”27 early Covid-19 The only weapon against polio at this time was a human https://www.sciencedirect.com/science/article/abs/pii/S0196 “convalescent” serum made with blood collected from polio 439921000052 victims. The serum was freely supplied in most provinces to prevent polio’s paralytic effects, although its effect was unclear. MORE NEXT WEEK! Reminder: Tutorials begin next week - Attendance will be recorded