Public Health in Québec

In one sense, “public health” refers to the health of the population as opposed to that of the individual. In another sense, the term refers to all of the measures that a society takes to prevent disease and promote health and all of the institutions that it establishes for this purpose. In the 19^th century and the first half of the 20^th century, the expression “public hygiene” was used with this meaning instead. The term “public health” became more common in the 1950s and 1960s, was superseded by “community health” in the 1970s and 1980s, and came back into favour in the early 1990s.

Like the terminology, the concepts and practices associated with public health also have varied over the years. In the 19^th century, the conceptual focus was on the environment as the source of infectious disease, and hence public-health practices emphasized sanitation of the physical environment. At the turn of the 20th century, the focus shifted to the microbial theory of disease, and hence to case detection—in other words, from the cleanliness of the physical environment to the well-being of the individual.

This conceptual shift had a decisive influence on public-health practices, leading to the era of preventive medicine. Vaccination prevented diseases in individuals and epidemics in the population. Screening made it possible to provide individuals with early treatment, identify their contacts and conduct epidemiological investigations to determine the causes of their diseases and prevent them from spreading. Environmental sanitation began to focus more specifically on preventing contamination of food and drinking water. Health-education programs attempted to change the public’s understanding of the origins of infectious diseases and the ways of fighting them. At the time, it was thought that simply providing people with information would suffice to change their behaviours. Public-health practices emphasized the fight against venereal diseases, tuberculosis and diseases of infancy and childhood.

In 19th-century Québec, responsibility for fighting these diseases fell to the municipalities. But as the 20th century dawned, the Québec government created the Hygiene Council and began to exercise some oversight over the municipalities. This body became the provincial Hygiene Service in 1922 and the provincial Department of Health in 1936. Starting in 1926, in light of the growing evidence that rural and semi-rural municipalities had neither the resources nor the political will to run effective public-health services, these municipal services were gradually replaced with provincially operated public-health units at the county level—a network of effective, modern preventive-care services under the direct authority of the provincial Department of Health. This network was eventually expanded to include all of Québec except for Québec City, the city of Montréal and other municipalities on Montréal Island. As of 1960, there were 73 of these county-level public health units in Québec.

Designed essentially to combat infectious diseases, Québec’s public-health system had difficulty in transition to the epidemiological approach that began gaining favour in the 1940s, as cardiovascular disease, cancer and accidents replaced infectious diseases as the primary causes of mortality and morbidity.

In Canada in the 1960s, there was a strong trend away from the traditional approach to public health. Instead, there was constant discussion of topics such as preventing cancer and cardiovascular disease and practicing “total medicine” (combining preventive and curative medicine in the same practice), along with constant questioning of the traditional public-health system. To underscore the difference between the traditional system and newer approaches, the expression “public health” was replaced with “community health”. The concept of community health includes practicing total medicine and involving community members in managing local health-care centres and planning activities to prevent disease and promote good health.

In Québec, a radical reform in the organization of health and social services began in the early 1970s. The existing county health units and municipal health services were replaced by new public-health agencies—primarily community health departments (DSCs) at the sub-regional level and local community service centres (CLSCs). The mandate of the community health departments was to study the health needs of the communities they served, to investigate epidemics and take appropriate steps to deal with them, and to develop and implement preventive-health programs in co-operation with the CLSCs.

In practice, the community health departments now deal less and less with infectious diseases and instead focus on preventing chronic diseases and promoting good health. There are a total of 32 of these departments in the province, based in 32 different hospitals. Their mission includes building working relationships with the curative medical services—an innovation compared with the practices that had prevailed since the start of the 20th century, when preventive and curative services were kept separate and had little interaction with each other.

Before the reforms of the 1970s, one of the largest gaps in Québec’s health-care system had been the lack of public institutions delivering front-line health-care services, and the consequent dependence on private medical practices and outpatient clinics. It was precisely to fill this gap that the CLSCs were established. Their mission is threefold: to provide curative and preventive health care, to deliver social services to individuals, and to engage in “community action”. Originally, the CLSCs were designed to be the gateway into the health-care system. There were supposed to be some 200 of them throughout Québec, but this number was subsequently reduced. As of the year 2000, there were 146, and the services that they provided included general medicine, occupational medicine, immunizations, pre- and post-natal care, family planning, health education, general social services (including socio-economic and psychosocial assistance) and preventive activities. In addition, the CLSCs deliver more targeted programs, such as home-care programs for seniors, assistance for persons with physical and mental disabilities, child care, and health and social rehabilitation services for children and adolescents. Most of these programs apply a holistic, community-based, multidisciplinary approach.

Not all CLSCs provide all of these programs. Which programs a CLSC provides depends on what kind of area it services (urban, rural, residential, disadvantaged, etc.) and the number and type of professionals on its staff. In general, each CLSC’s services are organized into programs designed to reach specific segments of the population and delivered by a variety of professionals, including nurses, social workers, community organizers, and physicians, among others. Since the 1990s, many of Québec’s CLSCs have merged with long-term care hospitals and hence have a dual mission.

Together with the community health departments (DSCs), the CLSCs, which replaced the former county health units, constituted the most original elements of the reforms of the 1970s.

Since the early 1980s, a number of developments have made the authorities increasingly recognize the importance of the public health system’s older, traditional mission of protecting public health. These developments include the emergence of new infectious diseases, such as AIDS; the return of other diseases that had been thought to be under control, such as tuberculosis; and the growing awareness of how industrial pollution threatens the health of the environment and the public. In this context, Québec, like many other jurisdictions, conducted an evaluation of its public health services to determine how well equipped they were to carry out this mission effectively.

The conclusion drawn from the Québec evaluation was that the 1972 reforms had weakened the ties among the various components of the public health system, and that in order to protect the public’s health effectively from the new threats mentioned above, this system had to be made more cohesive again, with a return to a more hierarchical structure and stricter regulations to enable rapid intervention at the highest level and mobilization of the system if the need should arise. These changes were introduced through the passage of a framework law on health and social services in 1991.

To clearly mark this change in direction (and to respond to pressure from certain professional associations), the term “community health” was completely removed from the legislation and replaced with the term “public health”. The 1991 statute called for the Minister of Health to appoint a director of public health to head each of Québec’s regional health boards, which were made subordinate to the central authorities for the function of protecting public health. Compared with public health services in other Canadian provinces, the United States, and certain western European countries, Québec’s public health services have large, highly qualified staffs.

As part of these changes, the community health departments were eliminated, but the CLSCs have maintained their place in Québec’s health care system.