MEDICINE, POLITICS A VOLATILE MIX

Ottawa's outgoing medical chief says trying to boil health issues
down to simple arguments was not something he enjoyed, Patrick Dare writes.

Dr. David Salisbury won't miss the 20-second soundbite.

Leaving one of the toughest, but most important jobs at the City of
Ottawa today, Dr. Salisbury, Ottawa's medical officer of health, was
no fan of the political game at City Hall. When people became enraged
at the prospect of the city handing out crack-pipe equipment as a way
to reduce the spread of disease, city council got on to the issue and
killed the program, without benefit of thorough committee discussion
of the science.

Dr. Salisbury shakes his head.

"We didn't have that debate," he says.

"We live in a society that wants to reduce all of these complex
issues into 20-second soundbites," he says. "I did 25 years to try to
learn my craft, with 25 years of experience after that before I got
to run a health department as big as the City of Ottawa's. It's
pretty hard to distill that down to a 20-second soundbite."

Dr. Salisbury fought city council, fought the police chief and
sometimes lost battles. His interim successor, Dr. Isra Levy, is
talking diplomatically about working with council to tackle public
health problems in the city. But Dr. Salisbury says the way the city
manages public health must be changed.

Dr. Salisbury took over from Dr. Robert Cushman as the city's top
public health official in 2005 when Dr. Cushman was recruited to run
the health planning agency for Eastern Ontario. The medical officer
of health post is a big job, with a $42-million budget and 450
full-time employees.

The eloquent Dr. Cushman revelled in the medical officer of health
job, arguing forcefully through the media, and before city council,
about the need for public health programs. His biggest success,
against huge opposition, was a sweeping new law that banned smoking
in public places, including bars and bingo halls, years before other
municipalities.

Dr. Salisbury has the respect of many councillors for his medical knowledge.

But he ran into conflicts with council on several issues. He advised
council to ban cosmetic uses of pesticides and council declined. He
advised council to keep a dental program for poor children and
council cut it in a budget crunch. He emphatically defended the
distribution of drug paraphernalia to addicts as a logical public
health measure. Council killed the program anyhow. He sparred with
police Chief Vern White over the drug issue.

Councillor Rick Chiarelli said council's relationship with Dr.
Salisbury deteriorated when councillors tried to question the
scientific basis for handing out crack pipes and needles, and found
the doctor unwilling to consider other views. Mr. Chiarelli said
councillors properly questioned how city health officials could be
handing out drug equipment while the city's police officers go out
and confiscate it. But he said their concerns weren't considered legitimate.

"He thought he knew everything about it and thought we knew nothing
about it," said Mr. Chiarelli. "He was dismissive of political
representatives and police."

Mr. Chiarelli is not saddened to see Dr. Salisbury leave the city for
a federal government post supervising the health of pilots in Canada.
Mr. Chiarelli said the former medical officer of health, Dr. Cushman,
was better able to offer evidence and offer his opinion, and then
live with the decisions of council.

"You start to lose confidence in each other," said Mr. Chiarelli.
"There's a feeling that the next candidate shouldn't be at war with
the council and the police chief all the time."

There are hopes that the physician hired to take over for Dr.
Salisbury until a permanent successor is found will set a new tone
for the relationship between council and its medical officer of health.

Dr. Isra Levy, 45, was educated in South Africa and worked there and
in England before coming to Canada. Here, he's worked with the
Canadian Medical Association on issues such as the SARS outbreak in
2003. He joined the city in 2006 as associate medical officer of
health, managing the surveillance, emerging issues, education and
research division.

Dr. Levy, who keeps his hand in front-line medicine by working at a
clinic a few hours each week, is conciliatory when talking about
contentious issues like handing out needles to drug addicts.

Dr. Levy says councillors are only "doing their job in holding us
accountable" by scrutinizing such programs.

The city is likely to go through a full competition for a permanent
replacement for Dr. Salisbury. But Councillor Diane Deans, chairwoman
of the community and protective services committee that oversees
public health, says she is "extremely impressed" with what she sees
in Dr. Levy.

She says he is "collaborative, open minded," and she hopes he will be
able to bridge the "two solitudes" on issues such as the city's drug
strategy. "I have great faith in him," she said.

Changing the person in the job, however, could just be the start of a
change in governance for public health in Ottawa.

Dr. Salisbury says the structure of City Hall operations were part of
his frustration in the job. Ontario's municipalities used to have
independent boards that oversaw public health, separate from city
council. When the new City of Ottawa was created in 2001, the goal
was to reduce the number of politicians and officials, in part by
having councillors overseeing everything from public transit to health.

But Dr. Salisbury says it hasn't worked. The councillors have too
many responsibilities to really become knowledgeable on the medical
facts around health issues. Dr. Salisbury didn't have the time to
meet with councillors individually and go over all the details. And
councillors "have other political imperatives," he says.

"Public health is political, but I can't afford to be a politician,"
says Dr. Salisbury. The medical officer of health "cannot afford to
play politics."

One possible change is for public health to be taken out of municipal
government so that it isn't subject to the whims of city politicians
and the uncertainties of city finances. An advisory panel to the
Ontario government in 2006 urged a return of health boards, funded by
the provincial government. A response from the province is expected this year.