From a federal level with Dr. Theresa Tam, to Ontario’s Dr. David Williams and Alberta’s Dr. Deena Hinshaw, Canada's top doctors have been in the spotlight since COVID-19 was declared a pandemic in March 2020.
Most commonly referred to as chief medical officers of health (CMOH), they've often been the main communicators for their jurisdictions’ COVID-19 response, having their public health messaging dissected and scrutinized daily as physicians in the political realm. Providing televised addresses to the public, governments have put CMOHs front and centre in an attempt to show that they're "following the science."
There's an expectation that CMOHs serve autonomously, to be critical with their public communication and decision making, such as with their ability to impose restrictions to address public health threats. In reality, they’re still government employees, who as appointed civil servants provide recommendations to elected officials who consider more than just public health. Together, they’re tasked with creating a unified message for us to follow. We've seen in the past year how it's been increasingly difficult for CMOHs, who’ve tried generating public trust in a government's COVID-19 response, while maintaining their own professional integrity amid a health crisis.
“Although they’re scientists, they operate in a constraining political environment,” says Daniel Béland, Director of the McGill Institute for the Study of Canada. “Sometimes there are things that they cannot say because it goes against the official hierarchy. It’s a minefield, not just because of the relationship with the public, the media and social media, but also between them and their political masters.”
Their working dynamics have put them in awkward positions over the past year. CMOHs' roles are defined differently across jurisdictions, but they incorporate a mix of legislative responsibilities common for a confidential government advisor and a public health advocate. It's created not only confusion about what their roles entail, but also doubt on if they're actually serving the public, which has looked to them for clarity and guidance.
A January 2021 survey by Proof Strategies found that scientists and medical doctors are viewed as the most trustworthy source to the Canadian public, at 75 per cent and 74 per cent, respectively. It’s down since September, and even more since early May’s survey, but vastly higher than the government at 32 per cent and politicians at 20 per cent.
Trust in CMOHs for COVID-19 information lands between the two, naturally when considering they are medical experts in the political realm; 63 per cent of Canadians trust Canada’s CMOH and 61 per cent trust their provincial equivalent. In comparison, the prime minister is at 46 per cent and “your provincial premier” at 45 per cent.
For CMOHs, mistakes in their communication have had resounding effects, says Béland, both politically and on the public health of Canadians. Their messaging plays a critical role in building public trust, among the misinformation and conspiracies that have circulated COVID-19 from its infancy. That’s progressed to the current vaccination rollout, with only 64 per cent of Canadians saying they trust it to be safe and effective, according to Proof Strategies’ survey.
“I have often said that good communication is as important as a vaccine when it comes to public health response to epidemics [and] pandemics,” said Tam in a statement to Yahoo Canada.
Building trust amid changes in public health messaging
Consistent messaging has proven to be a critical factor in building public trust. But throughout the pandemic we’ve seen “the messiness of how science in action actually works,” says Maya Goldenberg, an associate professor for philosophy at the University of Guelph, with a research focus on trust in public health.
When Canada's top doctor updated her guidance to recommend that the public adopts general mask use in late-May, backlash ensued. “Dr. Theresa Tam needs to go,” tweeted then-Conservative MP Derek Sloan. Other Canadians followed suit, from a former star NHL hockey player, who called the update a “disgrace,” to citizens who expressed confusion about what to believe, and who to trust.
Tam said the recommendation was based on emerging scientific evidence. But her contradictory update fuelled the perception that Canada’s top doctor didn’t always have public health at the top of mind. Goldenberg says she was perceived by the public to be uneducated on the matter, but also caught up in political or economic concerns that people were going to hoard masks. It made her come off as insincere in her recommendations, a perception that Goldenberg doesn’t believe Tam ever fully recovered from.
Before switching her recommendation, Tam said she’d be flexible with her guidance as scientific evidence evolved. But she also said mask use could provide a false sense of security, and encourage the wearer to touch their face. She wasn't the only one who didn’t encourage masks, with mask shortages being a global concern as officials tried to reserve them for front-line workers.
Sajjad Fazel, a researcher at the University of Calgary who’s focusing on misinformation and vaccine distrust, says to start the pandemic, Canadians reacted well to seeing CMOHs being the main communicators. It shifted the focus from elected politicians, who’ve historically been viewed to have an agenda.
Throughout various survey groups, Fazel says the mask issue was the “biggest point” that Canadians brought up when discussing their distrust in the system. Instead, they preferred to simply hear CMOHs admit that they didn’t have a definitive answer.
Béland says that the messaging has led to a loss of confidence, providing fuel to skeptics with masks becoming a political statement.
Despite the switch up, experts say Tam’s done a commendable job. She can’t tailor her advice to varying situations across Canada, where provincial doctors and politicians set the majority of guidelines. Mix that in with conflicting information from experts making their own TV appearances, political backlash and distrust in the media, and there are many factors that chip away at her messaging.
Tam’s working relationship with Prime Minister Justin Trudeau at the federal level has given her a spotlight, but it's also made her a target. Even before Tam’s mask guidance switch-up, Sloan questioned if she was working for China, not Canada, while Alberta's Conservative Premier Jason Kenney said she was “repeating talking points” from China.
Béland says we can feel better when we compare ourselves to others. In this case, it’s our closest neighbour the United States. The same day Tam switched her mask guidance, members of parliament sported them on their way to the House of Commons, followed by Trudeau saying it's a personal choice that's aligned with "what public health is recommending." In the COVID-19 epicentre of the world, Donald Trump regularly criticized Dr. Anthony Fauci, sowing doubt into those leading the nation’s public health response.
Following Joe Biden’s inauguration, Fauci said it was “uncomfortable” because Trump made claims that weren’t based on “scientific fact.” Instead of continuously contradicting the former U.S. president, he felt compelled to stay quiet because he was afraid of any “repercussions.”
Who's leading Ontario's public health response?
Differentiating political factors from public health has been a difficult task as governments weigh the pandemic’s impact on all facets of society. It’s important officials can justify their actions, because we've seen public distrust grow when they’re passed off as if their decisions are in the best interest of public health.
That’s happened in Ontario, where the public has expressed concern that Williams has been unduly influenced by political interests, putting scientific integrity aside, says Goldenberg. It's in turn led to widespread calls for his resignation.
On the federal level, in British Columbia and in Ontario, CMOHs uniquely have legislative power to report on public health issues in any manner they find appropriate, such as independently of the government. Despite that, Goldenberg says it's appeared that Williams hasn't been able to speak as freely as his more successful CMOH counterparts.
An Ontario auditor general report in the fall noted that Premier Doug Ford was the key media spokesperson for public health decisions — concluding that Williams “did not lead” the province's COVID-19 response, a stark contrast to major provinces such as British Columbia and Alberta.
Anna Banerji, the Director of Global and Indigenous Health at the University of Toronto, says even though Ford says he’s speaking with public health experts, it doesn’t mean he’s following their advice.
“I have a lot of respect for Dr. Williams," says Baneriji. "But I think the politics with Doug Ford has really moved the agenda.”
Banerji points to Ontario’s holiday stretch, which fuelled Ontario’s second wave. Cases were rising at an alarming rate, and in response Ford announced a province-wide lockdown for Dec. 26. Banerji says it sent a cue to Ontarians that they could finish their holiday shopping, and then visit friends and family in time for Christmas.
Actions from the holiday stretch helped fuel Ontario’s record-high of 4,249 cases on Jan. 8. The province continued to see an alarming growth in their daily case numbers, until its “stay-at-home” order produced an impact. Getting to that point wasn’t easy. Immediately after it was announced Jan. 12, it was deemed confusing, as even local officials tried understanding what’s allowed, and how the rules differ from previous ones.
Williams was at the press conference for Ford’s stay-at-home announcement, but Ontario’s top doctor made no remarks; he was also never called upon by the premier to provide context on questions from reporters. The next day, Williams was entirely absent from Ford’s presser, where he defended the order.
Williams finally had time to provide clarity Jan. 14 — two days after the order was announced and more than 12 hours since it came into effect. He said the overall messaging has been "clear," while asking Ontarians to contact a respective ministry or to consult the government website’s questions and answers list for clarity. The official order cites 29 exceptions to the stay-at-home mandate. The FAQ list directs Ontarians to use their "best judgment,” while also stating it "cannot determine what is essential" on multiple occasions.
Both their updates left questions answered, but by not speaking together, Ford and Williams avoided the chance of providing contradictory information. That's been a concern throughout the pandemic, such as when Ford, Williams and two other officials all provided different nuanced explanations for what's allowed in terms of Thanksgiving gatherings, says Goldenberg.
Williams' office did not respond to comment from Yahoo Canada.
Maintaining a unified front between politicians and CMOHs
The importance of clear restrictions has been felt recently in Ontario. Before that, Alberta was dealing with how to convey what’s best for public health, without compromising a superior's political agenda.
Controversy arose in November, when CBC obtained leaked recordings and transcripts of meetings between Alberta officials discussing their COVID-19 response. It showed the tensions between Kenney’s government and civil servants such as Hinshaw, who were at times overruled on matters.
It fuelled calls from the public, and the opposing NDP party, for transparency to know which of Hinshaw’s recommendations were rejected. Hinshaw has stayed quiet, keeping a unified voice in the Alberta government while often appearing solo at press conferences. This all occurred while Alberta’s case numbers consistently rose — figures she presented daily.
John Church, an associate professor at the University of Alberta with a focus on health policy, applauds Hinshaw’s ability to navigate the pandemic. She’s worked with Kenney, who’s appeared heavily worried about ideological concerns such as violation of human rights and economic concerns.
But for all the messaging, officials are also expected to lead by example, which hasn’t always been the case. In December, Kenney drew public outrage when he was seen maskless in an indoor meeting, days after a public health order was issued requiring masks in those settings. Alberta minister Doug Schweitzer also pretended to use hand sanitizer at a press conference.
“It’s like cutting off the public health messaging from its knees,” says Fazel.
Nationally, elected officials drew criticism for travelling over the holidays, despite CMOHs’ advice. Then-Ontario minister Rod Phillips even went on vacation while his Twitter account gave the impression he was still in the province.
Fazel says it furthered the conspiracy of “COVID-19 isn’t real,” while creating a perception that not everyone should be held to the same restrictions. In turn it caused further confusion about what and who to follow.
“It’s the politicians who have been sending these mixed messages,” says Church.
“Don’t shoot the messenger”: What's required from the CMOH's role
Professor Patrick Fafard of the University of Ottawa, who’s been studying the role of the CMOH, says the position is made out to be far more than it actually is. Instead of CMOHs being viewed simply as advisors, they’ve come across as decision makers.
That false perception falls in part on top elected officials, who use phrases like "I'm following the science" or noting that they're simply listening to their top medical advisor to fuel their decision making.
“You want the buck to stop with the politicians,” says Fafard. “We don’t want to be in a world in which an unelected official calls the shots.”
Fafard says that if we were to redo our public health messaging, we shouldn’t follow Alberta’s approach. He says the Alberta government is essentially misleading the public when issuing restrictions, because they’re giving the impression that it’s the CMOH who’s creating the decision, and not elected officials.
In Alberta, announcements on restrictions are styled to come from the CMOH based on the Public Health Act. Hinshaw and other CMOHs have the ability to issue restrictions to act quickly against public health threats, but most decisions ultimately rest on cabinets and premiers, which is in line with our democratic values.
That misunderstanding is then reinforced by Hinshaw often appearing alone at press conferences to announce the latest on Alberta’s COVID-19 situation. It puts the onus on Hinshaw to answer difficult questions that aren’t her responsibility such as ones on policy change, says Fafard.
While a CMOH can provide credibility, in the long term it creates confusion about whether they’re a government spokesperson or a public health expert. As governments make more controversial decisions, the public has had trouble differentiating between the spokesperson and government policy they don't like. Throughout the pandemic, we've seen the public's anger grow toward CMOHs, with some receiving death threats.
In Alberta’s legislature, and several others nationwide, it isn’t clearly indicated if the CMOH has authority to communicate with the public on any health issue in the manner they feel appropriate. Hinshaw has said that she simply acts as an advisor to the government and not a decision maker. But because of how her responsibilities are defined in Alberta’s legislature, giving her the ability to impose restrictions, the public has asked why Hinshaw doesn’t overrule the government. Theoretically it's possible but it would ultimately break trust in her working relationship.
Alberta’s former CMOH, Dr. Jim Talbot, said to the CBC in November that if you disagree with the government you have three options. You can resign; you can differ publicly with the government and likely be fired; or you can work behind the scenes to get the best possible outcome.
“You can't publicly disagree with the prince on one day, and expect to be able to advise the prince the next day,” says Fafard.
Fafard believes CMOHs understand they have an opportunity to shape government policy if they “don't go too far too fast.” By quitting, there’s also the fear of who’d ultimately replace them amid a health crisis.
What should we expect in the future from CMOHs?
Creating separation between science and other political factors remains vital for CMOHs to generate public trust. In the current landscape that includes their TV appearances, where we've seen a plethora of approaches across jurisdictions, all with their own flaws.
On the federal stage, Goldenberg says Tam has come across as an “influential figure” within the Liberal’s pandemic response. She has the platform to independently address the public, but there are often ministers that share the stage as a “sign of solidarity.” Sometimes that includes Trudeau seated directly beside Tam, when he’s not providing a press conference at a separate location an hour before.
Fafard says that Dr. Horacio Arruda and Premier François Legault have struck a fair approach in Quebec. Appearing together, Arruda can present the scientific viewpoint, and Legault can give an official government response that weighs all factors. But by putting them on the same stage, says Béland, “it creates a public perception that they’re a political animal.”
Béland says it can distort the image of a CMOH, who should not be perceived as partisan. Arruda’s friendly, often jocular, relationship with Legault has led to scrutiny especially upon renewal of his three-year, $959,100 contract in August.
Hinshaw said in a January presser that a CMOH’s role has always been public facing. However, the current legislative makeup of their roles never expected a pandemic of this size and length, says Fafard. Throughout this past year, we've seen how their roles need clearer legislative meaning to help the public understand their responsibilities, which should also help focus their efforts toward maximizing one integral role.
Currently, CMOHs are being asked to be both the regulator and an advisor for their governments. As a confidential advisor, it would clearly label them as members of a government, ones that shouldn't be expected to advocate publicly. Being only a regulator would allow them to be critical in their work as medical experts. Just like with other regulatory boards, governments have the power to overrule them, a decision that doesn't come lightly considering they're going against experts that serve the public.
In the end, it would still be on the governments and their top elected officials to make their own decisions.