Paternalistic public Health?

Paternaliste, la Santé publique?

Photo: Paul Chiasson, The canadian Press
The national director of public health, Horacio Arruda

Wear a mask ? The population could badly use it. Reveal scenarios of evolution of laCOVID-19 ? The understanding would be difficult. Allow the elderly to get out of their residence ? Too dangerous.

Since the beginning of the crisis caused by the coronavirus, many have addressed to the public Health in quebec — here embodied by its national director, Horacio Arruda — criticism regarding the use of a tone of “infantilizing” used to explain actions deemed to be ” paternalistic “.

Thus the examples cited above. That suggested that Quebecers could not understand that a mask or covers the face — not a substitute for other measures of protection.

Or that they cannot enter as scenarios of projection of the curves are only that : assumptions, which give an idea of the possible evolution of things, to the best of what science can see.

But behind what may seem like a reluctance to make full trust of the population, and behind the instructions constantly repeated in the media (and the frequent use, by Mr. Arruda, the sentence : “I don’t know if you understand “), there is… a need, to belong to several experts consulted by The Duty.

“As national director of public health, Horacio Arruda has only one patient : the population of Quebec,” recalls Louise Potvin, who manages, among others, the Centre for research in public health. “It means well-educated people, and other most vulnerable who have least means to implement recommendations that are at risk. “

Former Health minister and professor at the School of public health, University of Montreal, Réjean Hébert speaks about a “balance, always difficult to reach” when it comes to pass on a message in public health. The risk ? The explanations have the air ” too simple and childish “, or conversely ” understood only to initiates “.

However, judge said he, Horacio Arruda navigates well between the two poles. “I think it happens to join my aunt Theresa and my uncle Gerard, who have not gone to university, but who represent the majority of the population. “

Luc Bonneville, a professor at the University of Ottawa and communications specialist in the field of health, points out that since the 1950s, “public health has developed a discourse that aims at the prevention and the awareness of a set of behaviours, risks or events that we want to control as much as possible” to the scale of the entire population. It is his role, his mission.

Of the cholera cigarette

But there is the way. And when asked if there is something paternalistic in that the quebec authorities have put in place since the beginning of the crisis, Réjean Hébert replied that this is an old debate in public health. “This discussion-here, it goes back to the cholera epidemic in England in the middle of the Nineteenth century “, he recalls.

At the time, the research conducted by the physician John Snow had discovered that cholera was transmitted by contaminated water, and not through the air (the miasma). Snow had even been able to locate the water pump specifically responsible for the scourge. The authorities have solved the immediate problem, before working to improve the quality of the water.

“Since that time, and this response, is often associated with public health and paternalism “, said Mr. Hébert.

In a document produced by the Institut national de santé publique du Québec in 2018, we are reminded that many believe that ” public health is, in its essence, paternalistic, since it tends to use the power of the State to intervene on behalf of the health of individuals, even when they have not asked “.

Ce text is part of our “Outlook” section.

The article cited as a reference the definition proposed by the philosopher Gerald Dworkin, namely that paternalism is ” the interference of a State […] with another person, against their will, and defended or motivated by the belief that it will be better or that it will be protected from evil “.

Over the years, many quebec policies of public health have been qualified as paternalistic : the obligation to wear a seat belt in the car or wear a helmet on a motorcycle ; the ban on the purchase of cigarettes to minors ; the use of zoning regulations to deter the eating of junk food in schools ; etc

In the era of the COVID-19, several measures could be included in the list. But all that relates to the social distancing — a measure that comes closer to the personal behaviour of every citizen — or the mask-wearing would not qualify for the category.

To the letter

The current crisis brings back to the essence of what is the public health. On each day of the advice, instructions, and directives to try to control the epidemic.

“They do it to the letter, writes Louise Potvin. Would they have been able to have a more coherent message ? Perhaps, but it is in hindsight easy to say. I have an idea of with what they are working, because I see it to pass the literature… that says one thing and its opposite both days. “

“There is an immense pressure to make decisions that are based on knowledge not solid, adds the political scientist Éric Montpetit (Université de Montréal), who was interested in the issues of public health. It is extremely difficult. “

Mr. Montpetit savings its criticism regarding the management of the file of the mask : the scientific debate is real on this issue. It is also what they say to Réjean Hébert and Louise Potvin.

“The science has evolved on it, indicates the first. The prime minister, the minister of Health and the mayor of Montreal have all been handled incorrectly, adds Louise Potvin. If even our leaders are not doing so well… It must not be forgotten that if I wear it wrong, I put myself at risk more than me to protect the other. “


The dashboard on the evolution of the coronavirus in Quebec, in Canada and in the world

Transparency ?

But there is an aspect of the attitude of the public health Eric Montpetit denounces strongly : the lack of transparency of the latter relative to the data. Several researchers have expressed the same concern in the last few weeks.

“I cannot explain that we don’t have access to the analyses, figures, data. Other countries are doing a lot better. When they presented scenarios [in mid-April, and after that Dr. Arruda had expressed serious reservations about the value of such an exercise], we saw two charts, without that, we are told, how they had subscribed to these scenarios. “

The publication of “the science behind the decisions” is essential, thinks Mr. Montpetit. “The science must be able to be reproduced. Because the truth is constructed through the questioning of facts that are presented. “

In other words : the “paternalism” of the State or the public health may be required… but it must also be able to be cross-checked, and criticized. It would be ” healthy “, believes the political scientist.

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