4 Public Health Governance: A Journey of Expansion and Tension

Lindsay McLaren, Rogelio Velez Mendoza, and Donald W.M. Juzwishin

Introduction

Public health, by definition, involves multiple societal sectors and the tensions between them; these include the public sector (government), the private sector, and civil society. Although all are important, public health’s reliance on “the organized efforts of society” to promote and protect the health of the population means that the public sector has always been prominent.¹ In this chapter, we consider legislative and institutional dimensions of Alberta’s public health governance throughout the province’s history. Specifically, this chapter focuses on settler-colonial public health administration. The federal structure that has provided some colonial public health services for First Nation and Inuit communities — and how those communities have revamped it to their benefit — is considered in Chapter 7.

There are at least two reasons why a historical study of public health governance is of value. First, law provides, at least in theory, a powerful mechanism for action. But that mechanism is not necessarily straightforward and cannot be assumed to be positive, thus shedding light on important nuances of public health. For instance, as outlined in Alberta’s current provincial Public Health Act, when a communicable disease has been confirmed, a medical officer of health is authorized to “take whatever steps [they] consider necessary” to protect public health.² As seen clearly during the COVID-19 pandemic, these legal authorities and the politics that surround them can contribute to key tensions and contested dialogue around lines of authority.³ A second reason why the historical study of public health governance is useful is that legislative and institutional dimensions contribute to shaping the contours of public health by providing parameters around its scope. The broad vision of public health embraced in this volume requires collaboration across sectors and departments (e.g., those focused on housing, social services, environment, labour, social services, education, finance, etc., as well as health care), which governance arrangements, such as where public health is administratively situated and mechanisms for coordination with other departments or sectors, may facilitate or impede.

The objective of this chapter is to chart key legislative and institutional aspects of public health governance in Alberta, in a way that illustrates how these dimensions contribute to shaping its scope and boundaries over time. Our chapter narrative is built around two key pieces of information: the administrative structure of the provincial department responsible for public health, and the provincial Public Health Act. Although there are many pieces of legislation at multiple levels of government that are pertinent to public health, Alberta’s Public Health Act is central and has existed for nearly as long as the province itself, thus providing a consistent source of information to consider change over time. Key sources include: 1) An Administrative History of the Government of Alberta, 1905–2005, which is a historical compilation of Alberta public administration created by the Provincial Archives of Alberta; 2) the legislation itself, that is, the various iterations of Alberta’s Public Health Act and amendments; 3) the annual reports of the provincial Department of Public Health and other departments historically responsible for public health in Alberta; 4) provincial task force reports and commissions; and finally, 5) discussion and debates within the legislature, as recorded in the Alberta Hansard and Scrapbook Hansard.⁴

Setting the Stage: The Broad Context of Alberta’s Public Health Governance History

To organize this chapter, we have divided it into six chronological sections corresponding to what we considered to be meaningful periods or eras of Alberta’s public health governance history. As a backdrop for those sections, we provide several tables and figures. First, Table 4.1 presents a chronological overview of formal public health governance in Alberta, including the provincial department or ministry responsible for public health, along with the minister, deputy minister, and provincial medical officer of health.

Gender and ethnic diversity in these leadership positions has been rather limited; this is a legacy with which public health, with its emphasis on social justice, must continue to contend. Moreover, Alberta’s provincial government has been characterized by long periods of time with the same government. These include the thirty-six-year period of Social Credit leadership (1935–1971), which saw the transition from the Department of Public Health to the Department of Health; and the forty-four-year period of Progressive Conservative leadership (1971–2015), during which time there were several iterations of the provincial department responsible for public health.

Next, Figures 4.1 presents the divisions and branches that constitute the department responsible for public health, from 1919 to 1993.

Note: This figure includes all divisions/branches at higher levels in the organizational structure. In some cases, the highest level was not illustrative of the organization; in that case, the next level was used. The table also excludes administrative or support divisions. Some reports are not clear about structure.

The figure illustrates that the number and breadth of divisions and branches within the Department of Public Health have changed significantly over time. It also provides a glimpse into the changing nature of how public health was understood and organized within government, as we discuss further below and in Chapter 2.

Finally, Table 4.2 identifies several health-related commissions, committees, and reports of the Alberta government, from the 1920s to the 2010s.

We have omitted some potentially important recent reports, such as the 2019 ten-year review of Alberta Health Services commissioned by the United Conservative Party government, which require more time to pass before their historical significance becomes clear.⁵

1) Public Health Governance Prior to 1905: Early Foundations of Public Health

Public health activities in Alberta predated the formal establishment of the province in 1905. Indeed, collective efforts to promote the well-being of communities date back millenniums, to long-standing practices of Indigenous Peoples. One example from Treaty 7 territory is the Kainai Nation’s Kainayssini or guiding principles for protecting and preserving their culture and community, including traditional ways of using the land, language, and spirituality, all of which are fundamental dimensions of health and well-being (see Chapter 7).

In terms of settler-colonial society, organized public health efforts are different, and much more recent, dating to the late nineteenth century. They illustrate public health’s firm origins in communicable disease control with physicians in leadership roles — an enduring and challenging legacy. Under the territorial Public Health Ordinance that was in place between 1870 and 1905, public health activities were governed locally. In 1871, for example, a territorial board of health was established at Fort Edmonton, the Hudson’s Bay trading post, in response to a smallpox outbreak.⁶ In one of many illustrations of the colonial orientation of early formal public health practice, although reports suggest that most of the local residents were Cree or Métis, the board, which was named the Saskatchewan Board of Health, after the river Edmonton sits on, was comprised of non-Indigenous Hudson’s Bay officials and local missionaries⁷ who were unlikely to fully reflect local interests. The board was temporary; it ceased when the outbreak abated and was re-established when smallpox re-appeared in the area in 1876. The intermittent and reactive nature of early formal public health infrastructure was not unique to Alberta.⁸

In 1892, the incorporation of the Town of Edmonton permitted the creation of a more permanent local board of health at that location. Once again prompted by a smallpox outbreak, the council for the new town promptly passed a bylaw to establish a board of health, which was made up of the mayor, Matt McCauley, and four councillors.⁹ Although the town of Calgary was incorporated in 1894, it did not establish a formal board of health until 1909. However, it did have a precursor: a Market and Health Committee, which council established in 1884 and which was responsible for sanitation, public scales, and the removal of dead animals from the streets.¹⁰

The Town of Edmonton’s first medical officer of health, appointed upon the establishment of the board, was Dr. Edward Braithwaite, who also served as surgeon to the Royal North-West Mounted Police, coroner, and medical officer to the Canadian National Railways and the lumber industry.¹¹ Although a breadth of roles in this context is not surprising, from the point of view of a broad vision of public health concerned with upstream determinants of health equity, public health’s early connections with colonial and extractive sectors and industries that are harmful to health equity are important to note. Within the context of rapid population growth (for example, between 1896 and 1913, the “wheat boom” drew over 60,000 people to Edmonton), conditions were challenging. A historical article by medical officer of health for the Edmonton Board of Health James Howell described living conditions during the 1890s in the new town: “Many lived in tents on the riverbank and drank river water. Mud houses were common, water and sewage systems almost non-existent. Unwanted garbage, impure food and milk, overcrowded living conditions and smelly slaughterhouses continued to dominate the list of problems.”¹² In that context, Dr. Braithwaite had a considerable range of responsibilities including inspection of public and private premises, placing quarantines, and ensuring that the “poor and indigent” were looked after; the latter signalling some downstream recognition of connections between social conditions and health.¹³

2) 1905–1918: Navigating the Challenges of an Emergent State

Upon establishment of the province of Alberta in 1905, provincial authority for public health activities was assigned to the Department of Agriculture, where it remained until 1918.¹⁵

There were only six government departments in the early years of Alberta public administration — Agriculture, Attorney General, Public Works, Provincial Secretary, Treasury, and Education.¹⁶ Accordingly, the activities and functions of each were in some cases not obvious from the department name. The Department of Agriculture was a case in point, with its initial purview including “all that part of the administration of the Government of the Province which relates to agriculture, statistics and the public health, including hospitals.”¹⁷

In 1906, a Public Health Branch was established within the Department of Agriculture, and the Minister of Agriculture, Hon. W.T. Findlay, appointed Dr. A.E. Clendennan as the province’s first public health officer.¹⁸ In the 1906 annual report of the new branch, limitations of the territorial ordinances were identified, including that they assigned jurisdiction to the Dominion government in certain domains. These limitations prompted Alberta’s first Public Health Act, which was passed in 1907.¹⁹ Also under the territorial ordinance, a bacteriological laboratory had been established in Regina, which Alberta continued to use via arrangements with the new Saskatchewan government (also established in 1905). However, long delays before results were received led to a desire for a laboratory in Alberta. A provincial laboratory was established in 1907 as a branch of Alberta’s Department of Agriculture, with Dr. D.G. Revell, provincial bacteriologist and professor of anatomy at the University of Alberta serving as the inaugural (1907–1911) director.²⁰ ProvLab, as it came to be known, was transferred to the University of Alberta in 1911²¹ and fell under the joint jurisdiction of the provincial government and the University of Alberta, thus initiating an enduring relationship between the two institutions.²²

The 1907 Public Health Act provided for the formal creation of a provincial medical officer of health and a provincial board of health, a structure that would remain largely unchanged until 1970.²³ The general duties and functions of the board²⁴ included to “take cognizance of the interests of health and life among the people of the province” and to make investigations and inquiries concerning “the effects of localities, employments, conditions, habits and other circumstances upon the health of the people.”²⁵ This early wording appears to align with a broad view of health and its determinants, albeit focused in practice on communicable disease control.²⁶ The provincial board’s purview included studying and making use of vital statistics; making inquiries and investigations about the causes of disease; and making and implementing strategies to prevent, limit, and suppress disease. These latter activities were enshrined in the provincial board’s authorization to make and issue regulations for a wide range of scenarios and purposes.

The provincial board’s extent and scope of authority subsequently expanded. For example, the inaugural (1907) Public Health Act authorized the provincial board to “make and issue such rules and regulations, not conflicting with any law in force in the province” (italics added).²⁷ The 1910 act did not contain this stipulation, and instead clarified the legal supremacy of the Public Health Act: “should any Act in force within the province conflict with this Act, then, and in every such case this Act shall prevail” (italics added).²⁸ Also, whereas the 1907 act provided an itemized list of issues and circumstances for which the provincial board could create regulations,²⁹ the 1910 act and subsequent iterations clarified that the list should not be taken as comprehensive; that is, it “shall not be taken to curtail or limit the general power to make orders, rules, and regulations.”³⁰

Alberta’s early provincial legislation also contributed to strengthening local public health governance, which in some areas such as Edmonton already existed. Local boards of health were established in Lethbridge and in Calgary between 1908 and 1909.³¹ Membership of local boards, under the provincial legislation, was to consist of the mayor (or commissioner), the clerk of the municipal council, the city engineer, and the medical health officer.³² This arrangement, which was most apparent in the cities where public health governance advanced most quickly, illustrates formalized overlap between public health governance and city governance more generally,³³ which continued in Alberta until approximately the 1980s.

On 1 January 1918, provincial authority for public health in Alberta shifted to the Department of the Provincial Secretary.³⁴ Under the leadership of Hon. George P. Smith, a public health nursing branch was added, sanitary inspectors were hired and acts were drafted, including the Venereal Diseases Prevention Act and the Municipal Hospitals Act.³⁵ Only a few months later, in August 1918, the administrative home for public health once again changed, to the provincial Department of Municipal Affairs.³⁶ Although situating public health within Municipal Affairs would appear to be a good fit with public health’s local orientation at the time, there is little to be gleaned from this relationship from the department’s 1918 annual report.³⁷

A serious outbreak of influenza reached Alberta in 1918: over 38,000 people in Alberta got ill and over 4,300 hundred died. A need for stronger public health infrastructure was identified by government and public health leaders, which set the stage for the passing of Alberta’s Department of Public Health Act in 1919.³⁸

3) 1919–1929: Prioritizing the Public Health: Establishing a Provincial Department

The need for a provincial public health department in Alberta had been discussed at least as early as 1917. At a South Edmonton Conservatives rally held on 25 May of that year, one of the speakers, Mrs. Clyde Macdonald, quipped that the minister of agriculture, to whom responsibility for public health fell, “value[d] noxious weeds more than human life, as proven by his expenditures,” advocating for a separate department for public health.³⁹ A separate department was also supported by “medical men” including the Alberta Medical Association, the Edmonton Academy of Medicine, and the Edmonton Dental Society.⁴⁰ At least some Alberta doctors were more concerned with leadership than with departmental structure: according to a 28 November 1917 article in the Edmonton Journal, “it is suggested by the doctors that there should be a competent deputy minister, presumably a trained medical man, at the head of the health department, which might be attached to any one of the existing government departments so long as it had a separate official at its head.”⁴¹ However, in an early illustration of tensions that persist today, others were opposed to the idea that leadership would be best served by a doctor because “medical men are concerned only with curing the ills which beset us from day to day, and are not interested in preventive measures such as it is the business of a public health department to establish.”⁴²

Following an address delivered at the January 1919 United Farm Women of Alberta Convention,⁴³ Hon. A.G. MacKay introduced Bill 19 to establish a department of public health to the legislature on 18 February 1919; second and third readings took place later that month.⁴⁴ On 17 April 1919, An Act Respecting the Department of Public Health received royal assent under the provincial Liberal government, making Alberta the second province in Canada, after New Brunswick, to establish such a department. MacKay became Alberta’s first Minister of Health, Dr. T.J. Norman was appointed deputy minister; and Dr. W.C. Laidlaw was appointed provincial medical officer of health under this new arrangement.⁴⁵ The new department was responsible for “all that part of the administration of the government of the province, which relates to public health,” which included matters falling under the following legislation: the Public Health Act, the Public Health Nurses Act, the Registered Nurses Act, the Municipal Hospitals Act, the Hospitals Ordinance, the Venereal Diseases Act, the Medical Profession Act, the Alberta Pharmaceutical Association Act, the Dental Association Act, the Marriage Ordinance, and the Vital Statistics Act.⁴⁶ Responsibilities were wide ranging and included control and monitoring of infectious diseases, inspections, approval of plans for waterworks and sewage, education about public health matters, vital statistics, and the provincial laboratory.⁴⁷

Not surprisingly, the next decade was an active one in terms of infrastructure, legislation, and program development. In the 1920s, several new branches and divisions were added, including for venereal diseases, infectious diseases, social hygiene, dental public health, and public health education.⁴⁸ By the mid-1920s, only the cities of Calgary and Edmonton had full-time medical officers of health; accordingly, the early activities of the new infectious disease branch included helping smaller communities across the province to implement efforts to control the spread of communicable diseases.⁴⁹ In 1928, the newly established Eugenics Board, and newly-passed Sexual Sterilization Act fell under the authority of the new department (see Chapter 1).

4) 1930–1970: Public Health in Alberta: Expansion and Compromise

The 1930s saw the continued evolution of local public health infrastructure in rural areas. A 1929 amendment to the provincial Public Health Act had allowed the minister of health to establish full-time health districts, the precursor to health units⁵⁰ that consisted of several municipalities, which made possible the organization and delivery of a range of programs and services in communities that were too small to support specialized services on their own.⁵¹ Although the legislation was in place, the Great Depression of the early 1930s meant that the ambitious plans had to be put on hold. Under an initiative by the private, philanthropic Rockefeller Foundation to support health units in rural areas across North America, two health units in Alberta were created on a pilot basis in 1931: Red Deer, and Okotoks-High River, which was later named Foothills.⁵² Writer Bill Carney describes this innocuously as a return to an earlier tradition of seeking charitable assistance to support health services.⁵³ In fact, this significant contribution of the Rockefeller Foundation to early public health infrastructure should be viewed critically as an early example of philanthro-capitalism and the depoliticized views about the causes of ill health that usually come with it.⁵⁴

Meanwhile, in the larger cities, strong local public health governance continued.⁵⁵ A 1934 amendment to the provincial Public Health Act enhanced the capacity of city boards of health, by authorizing them to provide medical and dental services to schoolchildren, including to enter into agreements with school districts to do so. With respect to intersectoral dimensions of public health, there are several examples of connections between local public health and schools around this time. In Edmonton, for example, the membership parameters for the local board of health during the 1930s included representatives from the Edmonton public and separate school boards, along with previous members such as the mayor and local physicians.⁵⁶ In Calgary, a relationship between local public health authorities and school boards materialized around health record-keeping, led by the city’s Medical Officer of Health, Dr. W.H. Hill, and which Hill later credited with increasing immunization uptake by enabling public health practitioners to be in closer contact with children.⁵⁷

Efforts to strengthen public health services in the late 1920s and early 1930s became connected with attempts to establish universal health care insurance. In 1928, the legislature formed a committee to examine the feasibility of introducing “state medicine” in Alberta (see Table 4.2).⁵⁸ A state medicine motion was introduced in the legislature but was defeated, with legislators instead opting to emphasize preventive health services, child and maternal hygiene, sanitary inspections, and public health education.⁵⁹ The issue of provincial health insurance was raised again in 1933, and Alberta’s Health Insurance Act of 1935 described a five-year plan to provide health insurance.⁶⁰ The act was passed but not proclaimed because the new Social Credit government was not prepared to implement the plan. Although universal health care insurance was not yet forthcoming, interest and support for the public health component of the 1928/29 state medicine report remained, perhaps underscored by the report’s statement that prevention lies “at the very base of any efficient health structure.”⁶¹

Social assistance at municipal, provincial, and federal levels evolved during and following the Depression (see also Chapter 12). To accompany programs provided by municipalities, Alberta’s provincial Department of Public Health had a Charity and Relief Branch that, from 1926 to 1932, provided accommodation, food, clothing, and medical services to residents outside of municipalities and to “transients.”⁶² In 1936, perhaps in recognition of the significant health implications of economic destitution, provincial responsibility for the Child Welfare and Mothers’ Allowance Branch was moved to the Ministry of Health from the attorney general.⁶³ Administration of provincial public relief functions followed suit in 1937; these social welfare functions remained in the Department of Public Health until 1944 when the provincial Department of Public Welfare was created.⁶⁴ Federal social programs were also created around this time; for example, in 1930 the federal government introduced a means-tested pension program for those over age 70 with an annual income of less than $125 with matching contributions from Alberta.⁶⁵ National unemployment insurance was introduced in 1940, but it initially excluded over half of the workforce; exclusions included, for example, farm workers, domestic workers, fishers, forestry workers, other seasonal workers, and married women.⁶⁶ Speaking to weaknesses in efforts to address social determinants of health, there were no universal social programs in Canada prior to the Second World War.

The Rockefeller Foundation funding for the experimental health units ran out in 1936. With the support of most involved areas, legislation to continue this organizational structure was created and passed throughout the 1930s and 1940s, culminating in the Health Unit Act of 1951.⁶⁷ The number of health units grew rapidly, and by 1960 there were twenty-four health units across the province, serving approximately 93 percent of Alberta’s population outside of Edmonton and Calgary.⁶⁸ Their purview continued to emphasize prevention of mostly physical health concerns; key activities included physical examinations, education in child and maternal hygiene, and control of communicable diseases including via immunizations.

Reflecting the health concerns of the time, various new branches and divisions were created within Alberta’s Department of Public Health during this period (Figure 4.1), including those focused on mental health (1930), tuberculosis control (1936), cancer control (1941), entomology (1944), nutrition (1947), industrial health (1963), and alcoholism services (1965). Existing divisions, such as Sanitation, adapted to new demands, including those presented by growing infrastructure in towns and cities.⁶⁹ Federally, following important civil society activism, the targeted pension program for seniors became universal in 1951. Seniors thus became, and continue to be, among the groups best served by social programs in Alberta and across the country, with demonstrable benefits for population well-being and health equity.⁷⁰ In 1966, the federal Pearson government implemented the Canada Assistance Plan, which supported provinces, territories, and municipalities in providing social programs, including income supports. The Canadian Assistance Plan was significant in that it embodied — to a greater extent than programs that came before — society’s responsibility for well-being and its social determinants.⁷¹

5) 1970s to 1980s: Individualism and Efficiency

The 1970s marked the beginning of the Progressive Conservative reign in Alberta government, which lasted over forty years (Table 4.1). As articulated by Edward LeSage, professor emeritus of government studies at the University of Alberta, Premier Peter Lougheed (1971–1985) brought in “sweeping modernizing reforms to the provincial public administration” that represented a “pronounced break from the Social Credit administration and policy ambitions.”⁷² For public health, changes that occurred in this context signalled an inflection point.

The nature of local boards of health seemed to be shifting. While local boards in 1973 consisted of the mayor, the medical officer of health, the municipal engineer, and three appointed taxpayers, by 1977 they required simply a representative from city council, who could be the mayor or a city councillor, the medical officer of health and eight members from the community. In Calgary, where city council had been serving as the de facto board of health since its 1922 city charter, these changes may have been particularly significant.⁷³ Furthermore, while local boards of health continued throughout the 1970s to include public health professionals, there were important changes: in 1977, the position of medical officer of health became non-voting, and the position of municipal engineer had been eliminated.⁷⁴

On a national and international scale, important social trends were occurring, including the health promotion movement (see also Chapter 10), signalled federally by the 1974 report, A New Perspective on the Health of Canadians by then federal Health Minister Marc Lalonde, and the 1986 Ottawa Charter for Health Promotion, which presented “new” ways of thinking about public health.⁷⁵ It explicitly embraced a holistic vision of health (encompassing physical, mental, and social well-being), to be supported via a range of actions at individual, community, health services, and broader societal levels.⁷⁶ Further, foreshadowing the later prominence of the social determinants of health, the Ottawa Charter identified “prerequisites for health” including peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity.⁷⁷

Against that backdrop, an amendment to Alberta’s Public Health Act in the early 1970s revised the preamble to Section 7, General Duties of the Provincial Board of Health, to read “the . . . Board may . . . make and issue orders, rules and regulations for the protection and improvement of health and the prevention, mitigation and suppression of disease” (italicized wording was not included in the previous act).⁷⁸ This change hints at some alignment with health promotion’s emphasis on improving health to accompany the existing focus on preventing illness. Aside from this, however, the collective and upstream spirit of health promotion seemed to be largely thwarted by a prominent and rapidly growing sentiment of individualism and a focus on efficiency in all government departments including health.

The new Public Health Act of 1984 provides an illustration of this shift. The new act was to be a “total rewrite”; it was Alberta’s first entirely new Public Health Act since 1910, and was intended to replace the previous act, which was described as “archaic and overlapping.” The new act would be streamlined by a redrafting of the “tremendous number of regulations,” as well as consolidation of existing public health legislation. From the outset, the language used to describe the new act, for example, “greater flexibility,” “restructuring,” “in the spirit of deregulation,” “increased financial autonomy,” betrayed a pervasive government concern with rationalization and systematization,⁷⁹ suggesting a concern with system efficiencies more so than peoples’ well-being. Although health promotion was discussed, its framing did not align with how the concept was intended to be used —as a lens or approach to create supportive environments for all. Rather, content such as an emphasis on health campaigns to support the financial autonomy of local boards suggests that it was more accurately a vehicle for the individualized “lifestyle drift” that has come to characterize health promotion in the neoliberal era.⁸⁰

There were several other features of the proposed act, which was introduced to the legislature on 6 April 1984 by PC MLA Janet Koper. For example, the Provincial Board of Health, which had existed since 1907 with the broad mandate to understand and take action to prevent or limit disease, was eliminated. The mandate of its replacement, the Public Health Advisory and Appeal Board, was to advise the minister, and to hear appeals of decisions by local boards. It also had a new membership: whereas the provincial board had specified membership from certain public health roles, the membership of the new board was open ended, consisting of seven to eleven members appointed by the lieutenant governor in council; there were no requirements for public health specialists.⁸¹

Despite the breadth of revisions and their potentially significant implications for the role and substance of public health, the ensuing legislative debate focused almost entirely on one item in the act: a new section on “recalcitrant patients.” While the act had always bestowed considerable authority on medical officers of health to act as they deemed necessary to prevent or limit disease spread, the proposed 1984 act articulated powers to “apprehend” and “detain” people in circumstances where they refused to comply with a public health order (e.g., an isolation order). Considering the context of George Orwell’s 1984,⁸² it is perhaps unsurprising that these sections of the proposed act preoccupied discussion and debate including in the media. For example, one article published in the Edmonton Journal described the act as giving “sweeping powers to medical officers of health, allowing them to enter premises without a warrant.” An editorial in the same newspaper likened the new act to “arbitrary arrest and incarceration” that would permit doctors to “short-circuit the legal process . . . to detain patients, with or without their consent” to address communicable diseases.⁸³

Although resistance to language like “detainment” is not surprising, one must recognize that this debate was occurring in the context of advances in human rights legislation. The Canadian Charter of Rights and Freedoms, which purports to “protect the rights of all Canadians from infringements by laws, policies or actions of governments” became part of Canada’s Constitution in 1982, and Alberta passed a Bill of Rights in 1980.⁸⁴ From 1910 to 1980, Alberta’s Public Health Act had paramountcy; starting in 1984 that clause was revised to state that “this Act prevails over any enactment with which it conflicts, other than the Alberta Bill of Rights.” Furthermore, the creation with the 1984 act of an Advisory and Appeals Board led to a lengthy new section detailing the appeals process that appears near the beginning of the 1984 act, speaking to its prominence in that legislation.

Considering this broader context, the fixation on the new section on recalcitrant patients thus seems somewhat disproportionate and may have crowded out discussion and debate on other potentially significant changes such as the elimination of the provincial medical officer of health and the Provincial Board of Health. The fixation also seems rather narrow when considered alongside other government activities at the time that brought massive implications for population well-being and health equity, such as significant cuts to public sector activities including public education, where problematic narratives of “parental choice,” underpinned by an incorrect assumption that marketplace competition is appropriate for public sector services, opened the door to public funding for private schools⁸⁵ (high-quality public education is a key social determinant of health). With respect to other content in the Public Health Act, there was some limited discussion around the proposed movement of milk pasteurization legislation from the Public Health Act to the Dairy Industry Act. The Health Unit Association of Alberta publicly expressed concern about this proposed change, suggesting that it would weaken public health considerations by municipalities around this issue. However, the issue was largely dismissed on the basis that the legislation would be transferred intact to the new act, arguing that it would thus not constitute a change in procedures.⁸⁶

Ultimately, the discussion and debate, which largely focused on the “new” powers of public health officials, subsided, and Bill 25, The Public Health Act 1984, passed third reading on 30 May 1984, receiving royal assent the following day.⁸⁷

6) 1990s–Present: The Neoliberal Legacy and Self-Critical State

Considering the significance of the changes to the Public Health Act in 1984, it is perhaps not surprising that some subsequent amendments represented a return to the pre-1984 structure. In 1998, for example, an amendment added the provincial positions of chief (and deputy chief) medical officers of health, whose duties included monitoring the health of Albertans and making recommendations to the minister and to regional health authorities on measures to protect and promote health and prevent disease and injury.⁸⁸ These positions appear reminiscent of the provincial medical officer of health position that existed for much of Alberta’s history (1907 to 1970), although they now functioned in a different socio-political and epidemiologic context.

Starting in the 1990s, several additional significant changes to public health administration in Alberta occurred, within the broader context of neoliberalism, which arrived with vigour in Canadian federal and provincial politics in the 1990s. A hallmark of neoliberalism is a scaling back of government intervention in regulatory processes and public services, in favour of private and corporate responsibility for well-being, underpinned by a dominant ethos of individualism and overarching concern with economic growth. Neoliberal economic and social policies, whose manifestations include public sector funding cuts and restructuring, have demonstrably negative effects on population well-being and health equity.⁸⁹ An important federal example was the 1996 demise, under the Chretien Liberals, of the Canada Assistance Plan. Its replacement, the Canada Health and Social Transfer, combined federal transfers for health care and social programs and reduced the total budget by $7 billion over three years. In contrast to Canada Assistance Plan, where transfers were conditional upon provinces and territories agreeing to provide aid to all in need without exception, the Canada Health and Social Transfer gave provincial governments more discretion over how to spend the funds, which is highly problematic in a neoliberal context where government cost-cutting becomes an orchestrated imperative.⁹⁰

Public sector cuts and restructuring were dramatic in Alberta under PC Premier Ralph Klein, whose 1992 election victory, as described by Professor of Political Science, John Church, “signalled a shift from a moderate, urban-based conservative agenda to a more radical and rural-based right-wing agenda.”⁹¹ Despite the fact that significant privatization and public sector cuts had already occurred under the prior PC government of Don Getty,⁹² Klein effectively created a narrative of “out of control spending” by government, which he used to justify a series of ideologically driven actions that further gutted the public sector with massive implications for health care, health determinants, and social and health equity.⁹³ For example, one of the first initiatives, described as “a clear harbinger of things to come,” was to drastically reduce the number of people on social assistance by introducing “workfare,” a highly punitive and stigmatizing initiative where persons receiving social assistance must work for their benefits.⁹⁴ Under regionalization of Alberta’s health care system, about which much has been written, in 1995 seventeen regional health authorities replaced the previous 148 health facility and health unit boards; in the process, local boards of health, including in Calgary and Edmonton, were dissolved.⁹⁵ More restructuring followed: in April 2003, the regional authorities were further consolidated into nine health regions.⁹⁶ The process of regionalization was experienced by some as fracturing the public health community in the province by making it more difficult for people to connect, and significant efforts — such as the Alberta Public Health Association’s Millennium Project — were made to try to mend that fracture. ⁹⁷

Beyond the formal public health system, that is, the narrow version of public health, Klein’s neoliberal activities eroded social determinants of health through drastic cuts to public services, programs, and workers. This was aptly described by author and former provincial politician Kevin Taft in his scathing critique of Klein, Shredding the Public Interest, who gave a sense of the magnitude of the cuts and how they were experienced.

In the first year [1993], they cut more than $800 million from public spending. Public sector job reductions were immense, including in the first year alone 778 teachers and 2300 hospital staff. They reduced or eliminated various benefits and programs, usually with sharpest effect on seniors, families with young children, and the poor (though some benefits were actually increased to very low-income seniors). They imposed a 5 percent pay cut on MLAs and public sector workers, including civil servants, teachers, nurses, and university staff. They raised health care insurance premiums substantially while de-insuring many services.

The cuts continued the following year. By the end of 1995, public spending had fallen $1.9 billion since the Klein government came into office, and more than 4500 civil service jobs had been eliminated. Many hundreds more were cut in 1996. Direct fees and premiums for public services continued to climb. In Calgary the Grace Hospital, the Colonel Belcher Hospital, and the Holy Cross Hospital were closed, and the Calgary General/Bow Valley Centre was slated for closure. In Edmonton . . . hospital-bed numbers were cut by 44% from 1994 to 1996.

Under Ralph Klein’s government, public programs in Alberta became the most poorly supported in Canada. . . . The cuts occurred so quickly and in such confusion that they became hard to follow. By fiscal year 1995/96, per student funding for schools dropped to 14% below the Canadian average. From 1992 to 1995 the Calgary Regional Health Authority lost about 1400 staff, and the Capital Health Authority about 4000. From 1992 to 1995, the total province-wide loss of employed registered nurses was estimated at almost 8275, or a staggering 43% of all employed nurses in Alberta. . . .

Under the [previous] Getty government, support for Alberta’s public programs went from the highest in Canada to below average; under the Klein government it hit rock bottom. ⁹⁸

In short, it would be a considerable understatement to say that the Klein administration and its ideological underpinnings had a negative impact on public health, understood broadly as the science and art of preventing disease and promoting health through organized societal efforts, in which social determinants of health figure prominently. On a constructive note, emblematic of the damage of the Klein government was the 1996 founding, in response, of the Parkland Institute, a non-partisan research centre whose vision of “research and education for the common good” aimed to provide an antidote to the dominant narratives of privatization and austerity and provide a space and community for alternative perspectives and policies; it continues to serve this role.⁹⁹

In May 2008, in the context of public discontent with the regional health system structure, Premier Ed Stelmach (PC) announced another significant episode of health system restructuring, in which the health regions were consolidated into a single, provincial authority. Alberta Health Services became the largest health care delivery organization in Canada; analysis of this change is available from many sources.¹⁰⁰

With respect to the broad vision of public health that anchors this volume, we conclude with brief reference to the historic 2015 provincial election that led to a majority NDP government under Premier Rachel Notley, thus ending over 40 years of Progressive Conservative rule in Alberta. As described by reporter Graham Thompson,

After years as a social justice champion, Notley became a social justice premier. Her government raised the minimum wage to $15 an hour, instituted an Alberta Child Benefit, reduced school fees, protected gay-straight alliances in schools and introduced workplace protections for farm workers.¹⁰¹

The NDP reign was ultimately short-lived, as the 2019 provincial election resulted in a majority United Conservative Party government under Premier Jason Kenney, once again to the detriment of Albertans’ health and well-being.¹⁰² We will eagerly await what light is shed on these most recent governments, with respect to population well-being and health equity, by the next 100-year history of public health in Alberta.

Conclusion

Although we focused on Alberta in this chapter, there are broad similarities with public health governance in other Canadian provinces.¹⁰³ The work of political scientist Jack Lucas is illustrative.¹⁰⁴ In his work on historical urban governance in five policy domains — policing, public health, public schools, public transit, and water — across six Canadian cities in three provinces, Lucas showed that, rather than city- or province-specific histories, there was evidence for domain-specific histories (e.g., history of public health governance) that transcend geographies.¹⁰⁵ Such cross-jurisdictional patterning reminds us that the public health governance story in Alberta is part of a larger trajectory of governance across Canada, although certain periods — such as Klein’s austerity and restructuring measures of the 1990s — continue to stand out.

Our chapter omits many significant aspects of governance such as how institutional arrangements were experienced and the nuance of how governance activities played out “on the ground.” Indeed, any number of points made in this chapter could benefit from more in-depth analysis. Nonetheless, we draw attention in closing to an apparent thread where the incoherent and misunderstood version of public health seen today has roots in: the likely non-innocuous financial contributions of the Rockefeller Foundation in the 1930s, the growing separation of public health from peoples’ daily lives through weakened connections with local governments in the 1970s, and the destruction of social determinants of health under the ideological tentacles of neoliberalism in the 1980s and 1990s.

notes

1. 1 Christopher Rutty and Sue Sullivan, This Is Public Health: A Canadian History (Ottawa: Canadian Public Health Association, 2010), https://cpha.ca/sites/default/files/assets/history/book/history-book-print_all_e.pdf.

2. 2 Public Health Act, R.S.A. 2000, c. P-37.

3. 3 Marjorie MacDonald, “Introduction to Public Health Ethics 1: Background,” in Briefing Notes, edited by National Collaborating Centre for Healthy Public Policy (Montréal: National Collaborating Centre for Healthy Public Policy, 2014), accessed 2 November 2018, http://www.ncchpp.ca/docs/2014_Ethics_Intro1_En.pdf/; Sammy Hudes, “Following weeks of pressure, Kenney declares state of emergency, closes high schools,” Calgary Herald, November 25, 2020, https://calgaryherald.com/news/local-news/live-at-430-kenney-to-unveil-new-covid-19-restrictions-following-weeks-of-pressure.

4. 4 Provincial Archives of Alberta, An Administrative History of the Government of Alberta, 1905–2005 (2006), https://open.alberta.ca/publications/0778547140. Alberta’s Public Health Acts and Amendment Acts were accessed via the HeinOnline database of historical government documents, available through the University of Calgary library system; many of these documents are also available through the Government of Alberta’s open source database, https://open.alberta.ca/dataset. The annual reports of provincial departments were available in electronic or hard copy from the University of Calgary library or Alberta’s Legislative Library in Edmonton. The Alberta Hansard (https://www.assembly.ab.ca/assembly-business/transcripts/transcripts-by-type) is the official record of the Legislative Assembly, starting with the 1st session of the 17th Legislature in 1972. Prior to 1972, insight into legislative debates is available from the Scrapbook Hansard (https://librarysearch.assembly.ab.ca/client/en_CA/scrapbookhansard).

5. 5 Ministry of Health, “Alberta Health Services Review” (Government of Alberta, last updated April 16, 2020), https://www.alberta.ca/alberta-health-services-review.aspx.

6. 6 Gerald Predy, “A Brief History of Public Health in Alberta,” Canadian Journal of Public Health 75, no. 5 (1984); Bill Carney, Public Health: People Caring for People (Edmonton: Health Unit Association of Alberta, 1994); James M. Howell, “Edmonton Board of Health Celebrates 100 Years — or More,” Canadian Journal of Public Health 83, no. 4 (July/August 1992).

7. 7 Howell, “Edmonton Board of Health,” 306.

8. 8 Howell, “Edmonton Board of Health,” 306; Rutty and Sullivan, This is Public Health.

9. 9 Predy, “A Brief History of Public Health in Alberta”; Howell, “Edmonton Board of Health,” 306; Jack Lucas, “Historical Overview: Public Health Governance in Calgary” and “Historical Overview: Public Health Governance in Edmonton,” in Canadian Urban Policy Governance Backgrounders, ed. Jack Lucas, (Calgary: Canadian Urban Policy Governance Backgrounders, 2015), https://doi.org/10.5683/SP/HLKDPK. As described by Lucas, the bylaw to establish Edmonton’s Board of Health was created by a Civic Health and Relief Committee that existed prior to 1892, and then approved by the Council of the new town.

10. 10 Lucas, “Historical Overview: Calgary.”

11. 11 Howell, “Edmonton Board of Health,” 306–07.

12. 12 Howell, “Edmonton Board of Health,” 306.

13. 13 Carney, Public Health.

14. 14 “Provincial Health Officer” in the 1907 Public Health Act became “Provincial Medical Officer of Health” in the 1910 Act.

15. 15 Bow and Cook, “The Department of Public Health”; John J. Heagerty, “Provincial Department of Health, Alberta,” in Four Centuries of Medical History in Canada and a Sketch of the Medical History of Newfoundland (Toronto: The MacMillan Company of Canada Ltd, at St. Martin’s House, 1928), 372–75.

16. 16 Provincial Archives of Alberta, An Administrative History.

17. 17 Act respecting the Department of Agriculture, S.P.A. 1906, c. 8; Provincial Archives of Alberta, An Administrative History, 517.

18. 18 Heagerty, “Provincial Department of Health,” 372–75; Alberta Department of Agriculture, Annual Report 1905–6, 162.

19. 19 Alberta Department of Agriculture, Annual Report 1905–6; An Act respecting Public Health, S.P.A. 1907, c. 12; Heagerty, “Provincial Department of Health,” 372–75.

20. 20 Alberta Health Services, “History: ProvLab, Laboratory Services,” accessed 1 June 2020, https://www.albertahealthservices.ca/lab/Page14604.aspx/.

21. 21 Alberta Health Services “History: ProvLab.”

22. 22 Alberta Health Services “History: ProvLab”; Doug Wilson, interview by Rogelio Velez Mendoza, 12 December 2019.

23. 23 An Act respecting Public Health, S.P.A. 1907; Heagerty, “Provincial Department of Health,” 372–75.

24. 24 The provincial medical officer of health was a key member of the provincial board of health, serving as secretary (as per the 1907 Public Health Act) and then as chair (1910–1970). See An Act respecting Public Health, S.P.A. 1907; An Act respecting Public Health, S.P.A. 1910, c. 17; An Act respecting Public Health, R.S.A. 1922, c. 58; An Act respecting Public Health, R.S.A. 1942, c. 183; An Act respecting Public Health, R.S.A. 1955, c. 255; and Public Health Act, R.S.A. 1970, c. 294.

25. 25 This wording first appeared in the Public Health Act in 1907 and remained there until the early 1980s.

26. 26 Canadian Public Health Association (CPHA), Public Health: A Conceptual Framework, Canadian Public Health Association Working Paper, Second Edition (Ottawa: CPHA, 2017), https://www.cpha.ca/sites/default/files/uploads/policy/ph-framework/phcf_e.pdf

27. 27 An Act respecting Public Health, S.P.A. 1907.

28. 28 An Act respecting Public Health, S.P.A. 1910.

29. 29 Amongst the list of circumstances for which the provincial board could make and issue regulations, the 1907 Public Health Act did contain a clause accommodating “generally, all such matters, acts and things as may be necessary for the protection of the public health and for ensuring the full and complete enforcement of every provision of this Act.” Nonetheless, the new explicit statement in 1910 seems illustrative of the growing scope of authority of the provincial board.

30. 30 An Act respecting Public Health, S.P.A. 1910. A similar sentiment was conveyed in subsequent acts (see 1922 R.S.A.; 1942 R.S.A.; 1955 R.S.A.; 1970 R.S.A.; 1980 R.S.A.)

31. 31 Heagerty, “Provincial Department of Health;”; Lucas, “Historical Overview: Calgary.”

32. 32 Provincial legislation concerning the membership of local boards of health changed in 1908, to the mayor, the medical health officer, the city / municipal engineer (if there was one), and three ratepayers appointed by municipal council. In 1921, this changed again, to clarify that appointed ratepayers serving on local boards of health were not allowed to be members of local council; this latter stipulation was removed in 1923. Lucas, “Historical Overview: Calgary.”

33. 33 In Calgary, the 1922 City Charter stated that the city’s board of health and the city council would be one and the same, and that “the city council had all the powers and duties of a local board of health under the Public Health Act.” Lucas, “Historical Overview: Calgary.”

34. 34 For example, the Report of the Provincial Medical Officer of Health and Deputy Registrar General, within the 1917 Department of Agriculture annual report, noted that “the Public Health Branch was, late in the year, transferred to the Provincial Secretary’s department, and in future, reports will be issued under that department.” Alberta Department of Agriculture, Annual Report 1917 (Edmonton: Printed by J.W. Jeffery, King’s Printer, 1918), 165.

35. 35 Heagerty, “Provincial Department of Health;”; An Act for the Prevention of Venereal Disease, S.P.A 1918, c. 50, assented to 13 April 1918; The Municipal Hospitals Act, S.P.A 1918, c. 15.

36. 36 Bow and Cook, “Department of Public Health”; Heagerty, “Provincial Department of Health.”

37. 37 Alberta Department of Municipal Affairs, Report 1918 (Edmonton: Printed by J.W. Jeffery, King’s Printer, 1919), 6.

38. 38 Predy, “A Brief History of Public Health,” 366.

39. 39 “Temperance Workers Stormed Sifton and Thus Forced Him to Grant People Their Rights,” Edmonton Journal, 26 May 1917, 9.

40. 40 “To Ask Premier for a Separate Health Branch: Delegation of City Doctors Will Present Request to Government Officials,” Edmonton Journal, 28 November 1917, 3. See also “Care of School Children Outlined in Report to Public by Medical Men,” Edmonton Journal, 8 September 1917, 5 and “Alberta Doctors Want Department of Public Health,” Edmonton Journal, 29 September 1917, 5.

41. 41 “To Ask Premier for a Separate Health Branch,” Edmonton Journal.

42. 42 “As I Was Saying Today,” Edmonton Journal, 4 January 1919, 9; “As I Was Saying Today,” Edmonton Journal, 18 January 1919, 7.

43. 43 “United Farm Women of Alberta Convention Program,” Edmonton Journal, 21 January 1919, 17.

44. 44 Bill No. 19, An Act respecting the Department of Public Health (Edmonton; J.W. Jeffery, King’s Printer, A.D. 1919); “Separate Health Department, Public Hospital Changes Bill Introduced in Legislature,” Edmonton Journal, 19 February 1919; “Loans Dangerous Remarks MacKay Over Seed Bills,” Edmonton Journal, 27 February 1919, 16.

45. 45 MacKay continued to serve as minister of municipal affairs during the initial stages of the Department of Public Health, thus holding two ministerial roles. Laidlaw began his term as provincial medical officer of health in 1912 and remained until 1914 when he was granted leave of absence to serve overseas. Upon return, Laidlaw served again as provincial medical officer of health and deputy minister. Bow and Cook, “Department of Public Health.” Alberta Department of Public Health, Annual Report 1919. “Bill Regarding Establishment of Employment Agencies among Important Measures Taken Up,” Edmonton Bulletin, 25 February 1919, 36.

46. 46 An Act respecting the Department of Public Health, S.P.A. 1919, c. 16, assented to 17 April 1919.

47. 47 An Act respecting the Department of Public Health, S.P.A. 1919.

48. 48 Alberta Department of Public Health, Annual Report 1920 (Edmonton: Printed by J.W. Jeffery, King’s Printer, 1921); Alberta Department of Public Health, Annual Report 1924 (Edmonton: Printed by W.D. McLean, Acting King’s Printer, 1926); Alberta Department of Public Health, Annual Report 1925 (Edmonton: Printed by W.D. McLean, Acting King’s Printer, 1926); Alberta Department of Public Health, Annual Report 1926 (Edmonton: Printed by W.D. McLean, Acting King’s Printer, 1927); Alberta Department of Public Health, Annual Report 1928–29 (Edmonton: Printed by W.D. McLean, King’s Printer, 1930).

49. 49 Other than Edmonton and Calgary, local boards of health at the time had medical practitioners who served the medical officer of health role in a part-time capacity, which was not always effective for several reasons: “The medical practitioner [of local boards in outlying areas] does not make a competent health officer for the reason that he has not the special training, and further, he is dependent upon the goodwill of the people for his livelihood, and any measures such as quarantine, prosecution for maintaining insanitary conditions and matters of this description, tend to injure his local practice.” “Infectious Diseases Branch,” Alberta Department of Public Health, Annual Report 1924, 7.

50. 50 For a detailed analysis of the health units, see Adelaide Schartner, Health Units of Alberta (Edmonton: Health Unit Association of Alberta Co-Op Press, 1982).

51. 51 An Act to amend the Public Health Act, P.S.A. 1929, c. 36, assented to March 20, 1929. Bow and Cook, “The Department of Public Health.”

52. 52 Carney, Public Health; Alberta Department of Public Health, Annual Report 1931 (Edmonton: Printed by W.D. McLean, King’s Printer, 1932).

53. 53 Carney, Public Health, 23. By “earlier tradition,” Carney was referring to the charitable support of the Grey Nuns who tended to the ill as part of their missionary work starting around 1860 in what was to become the province of Alberta.

54. 54 Anne-Emanuelle Birn and Elizabeth Fee, “The Rockefeller Foundation and the International Health Agenda,” The Lancet 381, Issue 9878 (2013); Anne-Emanuelle Birn, “Philanthrocapitalism, Past and Present: The Rockefeller Foundation, the Gates Foundation, and the Setting(s) of the International/global Health Agenda,” Hypothesis 12, no. 1.

55. 55 For example, the 1924 Annual Report of the Department of Public Health notes that only Edmonton and Calgary had full-time local medical officers of health at the time; “all other local boards employ[ed] a part-time man.” Alberta Department of Public Health, Annual Report 1924, 7.

56. 56 Specifically, as summarized by Lucas, the Edmonton Board of Health consisted in 1930 of “the mayor, medical officer of health, city engineer, and a member of the board of trustees from the Edmonton School Board and one from the Separate School Board, along with two aldermen and two medical practitioners qualified under Alberta law,” and in 1936 of “the mayor, one member of the public school board, one member of the separate school board, two aldermen and two doctors.” Lucas, “Historical Overview: Edmonton.”

57. 57 W.H. Hill, “Recording Child Hygiene Activities in Calgary,” Canadian Journal of Public Health 36, no. 7 (July 1945). Dr. W.H. Hill was also the inaugural president of the Alberta Public Health Association.

58. 58 Alberta Legislative Assembly, Report of the Inquiry into Systems of State Medicine, Sessional Paper No. 43, 1929 (Edmonton: W.D. McLean, King’s Printer, 1929).

59. 59 “Alberta Not Ready to Start Scheme of Health Insurance,” Edmonton Journal, 25 February 1930, 11; “Cost Is Stumbling Block in State Medicine Scheme,” Edmonton Journal, 28 February 1929, 13; T.B. Windross, “More Than One Thousand Lives Saved Annually by Alberta Health Services,” Calgary Herald, 21 July 1934.

60. 60 Alberta Legislative Assembly, Commission on State Medicine and Health Insurance, Final Report of the Legislative Commission Appointed to Consider and Make Recommendations to the Next Session of the Legislature as to the Best Method of Making Adequate Medical and Health Services Available to All the People of Alberta (Legislative Assembly of Alberta, 1934); “Contend ‘State Medicine’ Real Need in Province,” Edmonton Journal, 4 March 1932; David Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911–1966 (Kingston and Montreal: McGill-Queen’s Press – MQUP, 1986), 54–6; “‘State Medicine’ Bill Introduced,” Edmonton Journal, 19 March 1934.

61. 61 Alberta Legislative Assembly, Final Report of the Legislative Commission, 10–11.

62. 62 “Charity and Relief Branch,” in Alberta Department of Public Health, Annual Report 1926, 25; Provincial Archives of Alberta, Administrative History, 285, 289.

63. 63 Provincial Archives of Alberta, Administrative History, 285.

64. 64 Provincial Archives of Alberta, Administrative History, 285.

65. 65 James Muir, “Alberta Labour and Working-Class Life, 1940–1959,” in Working People in Alberta: a History, Alvin Finkel et al. (Edmonton: AU Press, 2011).

66. 66 Alvin Finkel, Social Policy and Practice in Canada: A History (Waterloo, ON: Wilfrid Laurier Press, 2006).

67. 67 Several amendments to the Public Health Act during the 1930s and 1940s served to clarify and strengthen the legislative parameters of health districts and then health units (e.g., 1929, 1932, 1937, 1938, 1942, 1944, 1945, 1947, and 1949). These details were largely transferred to the Health Unit Act upon its creation in 1951 (An Act to provide for the Constitution and Establishment of Health Units (“The Health Unit Act”), S.P.A. 1951, c. 38). The Health Unit Act was repealed upon proclamation of the 1984 Public Health Act, which once again included a lengthy section on health units. Public Health Act, S.A. 1984, c. P-27.1, assented to 31 May 1984.

68. 68 Predy, “A Brief History of Public Health in Alberta,” 367; Alberta Department of Public Health, Annual Report 1960 (Edmonton: Printed by L.S. Wall, Queen’s Printer, 1962), 27.

69. 69 Provincial Archives of Alberta, Administrative History, 285.

70. 70 Muir, “Alberta Labour and Working-Class Life.” See also J.C. Herbert Emery and Jesse A. Matheson, “Should Income Transfers be Targeted or Universal? Insights from Public Pension Influences on Elderly Mortality in Canada, 1921–1966,” The Canadian Journal of Economics 45, no. 1 (2012).

71. 71 Finkel, Social Policy and Practice in Canada.

72. 72 Edward C. LeSage, “Introduction,” in Provincial Archives of Alberta, Administrative History, 1905–2005.

73. 73 Lucas, “Historical Overview: Calgary.”

74. 74 Lucas, “Historical Overview: Calgary.”

75. 75 Minister of Health and Welfare, A New Perspective on the Health of Canadians — A Working Document (Ottawa, ON: Minister of Health and Welfare, 1981); World Health Organization, “The Ottawa Charter for Health Promotion. First International Conference on Health Promotion, Ottawa, 21 November 1986,” in Health Promotion, ed. World Health Organization (New York City: World Health Organization, 1986), https://www.who.int/teams/health-promotion/enhanced-wellbeing/first-global-conference.

76. 76 World Health Organization, “The Ottawa Charter for Health Promotion.”

77. 77 World Health Organization, “The Ottawa Charter for Health Promotion.”

78. 78 An Act to Amend the Public Health Act, S.A. 1971 (Bill 64), c. 87, assented to 27 April 1971.

79. 79 Alberta. Legislative Assembly of Alberta, 6 April 1982; 23 April 1982; 19 March 1984; 6 April 1984. Note that versions of the proposed changes were discussed in the legislature in 1982, when Hon. Robert Bogle (PC), minister of social services and community health, introduced Bill 30: “The Public Health Amendment Act,” which ultimately “was left to die on the Order Paper” (Alberta. Legislative Assembly of Alberta, 28 May 1984), only to be revived in 1984.

80. 80 Alberta. Legislative Assembly of Alberta, 28 May 1984; “Lifestyle drift” describes a tendency for policy initiatives to tackle the social determinants of health to drift downstream towards individual lifestyle factors; it is a general trend of investing in individual behavioral interventions. See, for example, Gemma Carey at al., “Can the Sociology of Social Problems Help Us to Understand and Manage ‘Lifestyle Drift’?” Health Promotion International 32, no. 4 (2017).

81. 81 From 1910 until 1970, the legislated membership of the provincial board of health included the provincial medical officer of health (Chair), the provincial sanitary engineer, and the provincial bacteriologist. The membership shifted with a 1970 Public Health Act amendment to include the deputy minister as chair (the position of provincial medical officer of health was struck from the act in 1970); along with the Director of the Division of Environmental Health and the Director of the Provincial Laboratory. With the 1984 Act, there were no specified parameters of membership on the new provincial board.

82. 82 References to the iconic book, 1984, written in 1949 by English novelist George Orwell appeared in popular discourse, including David J. Lowe, “New law like ‘1984,’” letter, Edmonton Journal, 9 April 1984, and in the legislature; for example, Alberta. Legislative Assembly of Alberta, 8 May 1984 (John Gogo, PC).

83. 83 Janet Vlieg, “Act Would Force Treatment,” Edmonton Journal, 7 April 1984, 8; Roy Cook, “Should Doctors be Above the Law?” Edmonton Journal, 31 May 1984, 6.

84. 84 Alberta’s Bill of Rights followed the creation of various provincial offices during the 1960s and 1970s focused on fiduciary and human rights matters, such as the Office of the Ombudsman (est. 1967), the Office of the Auditor General (est. 1978) and the Office of the Chief Electoral Officer (est. 1977). Provincial Archives of Alberta, Administrative History of Alberta, 1905–2005. The Canadian “Bill of Rights” as a federal statute was passed in 1960 and twenty-two years later was enshrined in the Constitution.

85. 85 Winston Gereluk, “Alberta Labour in the 1980s,” in Working People in Alberta: a History, Alvin Finkel et al. (Edmonton: AU Press, 2011).

86. 86 Rick Pedersen, “Public Health Act Criticized,” Edmonton Journal, 15 May 1984, 12; Alberta. Legislative Assembly of Alberta, 29 May 1984 (Janet Koper, PC).

87. 87 Alberta. Legislative Assembly of Alberta, 30 May 1984; 31 May 1984.

88. 88 Public Health Amendment Act, S.A. 1998, c. 38; Public Health Act, R.S.A. 2000, c. P-37; Public Health Amendment Act, S.A. 2002, c. 38; Public Health Amendment Act, S.A. 2009, c. 13; Public Health Amendment Act, S.A. 2016, c. 25.

89. 89 Ted Schrecker and Clare Bambra, How Politics Makes Us Sick: Neoliberal Epidemics (Basingstoke: Palgrave Macmillan, 2015); David Stuckler and Sanjay Basu, The Body Economic: Why Austerity Kills (Toronto: HarperCollins, 2013); Ronald Labonté and David Stuckler, “The Rise of Neoliberalism: How Bad Economics Imperils Health and What to Do about It,” Journal of Epidemiology and Community Health 70 (2016).

90. 90 Finkel, Social Policy and Practice in Canada.

91. 91 John Church and Neale Smith, “Health Reform in Alberta: the Introduction of Health Regions,” Canadian Public Administration 51, no. 2 (2008).

92. 92 Gereluk, “Alberta Labour in the 1980s.”

93. 93 See for example Lee Parsons, “Canada: Alberta Premier Berates Homeless in Visit to Shelter,” World Socialist Web Site, 22 December 2001, https://www.wsws.org/en/articles/2001/12/can-d22.html.

94. 94 Jason Foster, “Revolution, Retrenchment, and the New Normal: The 1990s and Beyond,” in Working People in Alberta: a History, Alvin Finkel et al. (Edmonton: AU Press, 2011).

95. 95 Regionalization is not unique to Alberta. As stated by Karen Born et al, “Regionalization took place across Canada during the 1990s, transforming the way health care was governed and operated.” Karen Born, Terrance Sullivan, and Robert Bear, “Restructuring Alberta’s Health System,” Healthydebate, 10 October 2013, http://healthydebate.ca/2013/10/topic/politics-of-health-care/restructuring-alberta-health; John Church and Neale Smith, “Health Reform in Alberta: Fiscal Crisis, Political Leadership, and Institutional Change within a Single-party Democratic State,” in Paradigm Freeze: Why it Is so Hard to Reform Health-care Policy in Canada, eds. Harvey Lazar et al. (Montreal & Kingston: McGill-Queen’s University Press, 2013); Paul Barker and John Church, “Revisiting Health Regionalization in Canada: More Bark than Bite?” International Journal of Health Services 47, no. 2 (2016); Born, Sullivan, and Bear, “Restructuring Alberta’s Health System;” Gregory P. Marchildon, Health Systems in Transition: Canada, 2nd ed. (Toronto: University of Toronto Press, 2013). Regional Health Authorities Act, S.A. 1994, c. R-9.07; Lucas, “Historical Overview: Calgary.”

96. 96 Lucas, “Historical Overview: Calgary.”

97. 97 See Rogelio Velez Mendoza, Kelsey Lucyk, Isabel Ciok, Lindsay McLaren, Frank Stahnisch, “The History of the Alberta Public Health Association” (narrative report produced for the Alberta Public Health Association) (Calgary, AB: Alberta Public Health Association, 2017), www.apha.ab.ca.

98. 98 Kevin Taft, Shredding the Public Interest: Ralph Klein and 25 Years of One-Party Government (Edmonton: The University of Alberta Press and the Parkland Institute, 1997), 28–31.

99. 99 “Home,” Parkland Institute, accessed 4 May 2023, https://www.parklandinstitute.ca; Sarah Pratt, Parkland Institute. 25 Years of Research and Education for the Common Good (Edmonton: Parkland Institute, 2021), https://assets.nationbuilder.com/parklandinstitute/pages/1/attachments/original/1645306782/parkland-institute-25-years-research-and-education-for-the-common-good.pdf?1645306782.

100. 100 Lucas, “Historical Overview: Calgary.” For example: Born, Sullivan, and Bear, “Restructuring Alberta’s Health System.”

101. 101 Graham Thomson, “Rachel Notley,” The Canadian Encyclopedia, Historica Canada, last edited 6 September 2019, https://www.thecanadianencyclopedia.ca/en/article/rachel-notley.

102. 102 Cristina Santamaria-Plaza, “Public Policy and Health: A Critical Public Health Analysis of Alberta’s UCP Government Policy Agenda” (unpublished honour’s thesis, Bachelor of Health Sciences Program, University of Calgary, 2020).

103. 103 See for example Rutty and Sullivan, This is Public Health.

104. 104 Jack Lucas, Fields of Authority: Special Purpose Governance in Ontario, 1815-2015 (Toronto: University of Toronto Press, 2016); Jack Lucas, “Patterns of Urban Governance: a Sequence Analysis of Long-term Institutional Change in Six Canadian Cities,” Journal of Urban Affairs 39, no. 1 (2017).

105. 105 Lucas, “Patterns of Urban Governance”.

notes to table 4.1

1. 1 From 1930 to 1952, the Provincial Medical Officer is not specifically listed in the annual report; it is our best guest that either Dr. M.R. Bow (Deputy Minister) or Dr. A.C. McGugan (Director, Communicable Diseases Division), held or acted in this role during these years.

2. 2 Alberta Department of Public Health, Annual Report 1954 (Edmonton: Printed by A, Shnitka, Queen’s Printer 1956), 10.

3. 3 Albert Department of Public Health, Annual Report 1955 (Edmonton: Printed by A. Shnitka, Queen’s Printer, 1956), 2.

4. 4 Albert Department of Public Health, Annual Report 1956 (Edmonton: Printed by A. Shnitka, Queen’s Printer, 1958), 2.

5. 5 Albert Department of Public Health, Annual Report 1957 (Edmonton: Printed by L.S. Wall, Queen’s Printer, 1959), 2.

6. 6 Albert Department of Public Health, Annual Report 1958 (Edmonton: Printed by L.S. Wall, Queen’s Printer, 1960), 2.

7. 7 Albert Department of Public Health, Annual Report 1959 (Edmonton: Printed by L.S. Wall, Queen’s Printer, 1961), 2.

8. 8 Alberta Department of Public Health, Annual Report 1960 (Edmonton: Printed by L.S. Wall, Queen’s Printer, 1962), 2.

9. 9 Alberta Department of Public Health, Annual Report 1961 (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1963), 2.

10. 10 Alberta Department of Public Health, Annual Report 1962 (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1964), 2.

11. 11 Alberta Department of Public Health, Annual Report 1963 (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1965), 2.

12. 12 Alberta Department of Public Health, Annual Report 1964 (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1966), 2.

13. 13 ‘N/A’ – this was during the period when “Provincial Medical Officer of Health” was struck from the Public Health Act, and the Deputy Minister was to serve the role of Chair of the Provincial Board of Health. The 1984 amendment to the Public Health Act stated that the Minister may designate a physician employed by the Department to serve as a medical officer of health for the purpose of Part 4 of the Act (communicable diseases).

14. 14 Chief Deputy Ministers of Social Services and Community Health. Stanley Mansbridge had the title of “Chief Deputy Minister,” and the Deputy Ministers of Public Health (Dr. Jean Nelson and then Dr. Sheila Durkin) and of Social Services (David Stolee) both reported to him. Don Junk (ret’d), former Assistant Deputy Minister: Department of Social Services and Community Health, Policy and Planning (mid-October 1977 to 1 April 1981); Department of Social Services and Community Health, Rehabilitation Services (mid 1981); Department of Hospitals and Medical Care (late 1981 to 1988); Department of Health (approximately 1989 to June 1991), in discussion with the authors.

15. 15 Dr. Jean Nelson was appointed acting deputy minister of Community Health and Social Development in 1974 and as deputy minister in 1975, making her the first woman to hold a deputy minister’s appointment in Alberta. Dr. Nelson died on January 15, 1979. Lloyd C. Grisdale, “Concern for Children,” Canadian Medical Association Journal 120, no. 10 (May 1979): 1276 and W. Helen Hunley “Dr. Jean Nelson: Courage and Spirit,” Canadian Medical Association Journal 120, no. 10 (May 1979): 1276.

16. 16 “Two Ontario Men Ill after Flue Shots,” Edmonton Journal, 22 December 1976, 6.

17. 17 David Stolee was the Deputy Minister of Social Services, within the Department of Social Services and Community Health. Don Junk, in discussion with the authors.

18. 18 Deputy Ministers of Health Services

19. 19 Don Junk, in discussion with the authors.

20. 20 Deputy Ministers of Health Services

21. 21 Dr. John Waters’ obituary (Date of passing: 6 July 2001) stated “For the past 21 years he has been employed as the Provincial Health Officer, Alberta Health and Wellness.” “John Robert Waters M.D. FRCP(C),” Winnipeg Free Press, 8 July 2001, https://passages.winnipegfreepress.com/passage-details/id-62201/John_Waters

22. 22 Stanley H. Mansbridge, until approx. Feb 1981. Don Junk, in discussing with the authors.

23. 23 David Stolee was Acting ADM until approximately July 1981. Don Junk, in discussing with the authors.

24. 24 Deputy Ministers of Health Services

25. 25 Deputy Ministers of Health Services

26. 26 Deputy Ministers of Health Services

27. 27 Deputy Ministers of Health Services

28. 28 Deputy Ministers of Health Services

29. 29 Deputy Minister of Community Health

30. 30 Deputy Minister of Community Health

31. 31 Keith Gerein, “Familiar Face Hired as Alberta’s New Chief Medical Officer of Health,” Edmonton Journal, updated 11 March 2016. According to this article, Dr. Grimsrud “served as the province’s deputy medical officer of health for around a decade before being appointed as the acting chief in 2007. Her stint in that role lasted until the summer of 2008, when she and three other public health officials were told their contracts were not being renewed by Ed Stelmach’s Progressive Conservative government.”

32. 32 Darcy Henton, “Looking for a New Top Health Officer: Dr. Nicholas Bayliss Steps Down,” Edmonton Sun, 8 December 2006. According to this article, Dr. Bayliss “took the province’s top health officer job in 2000” and “will be stepping down from his post March 31 [of 2007].”

33. 33 “10 Calgarians Report Food Poisoning,” Calgary Herald, 23 January 2002, 17.

34. 34 “Mumps Vaccine Campaign on Hold,” Edmonton Journal, 12 December 2007, 1

35. 35 Associate Minister of Health

36. 36 Associate Minister of Health

37. 37 Associate Minister of Health

notes to table 4.2

1. 1 Alberta Legislative Assembly, Report of the Inquiry into Systems of State Medicine (Edmonton: W.D. McLean, King’s Printer, 1929), Sessional Paper No. 43, 1929.

2. 2 Alberta Legislative Assembly, Report of the Inquiry into Systems of State Medicine, Abstract. Robert Lampard, Alberta’s Medical History: Young and Lusty, and Full of Life. (Robert Lampard, 2008).

3. 3 “Alberta Not Ready to Start Scheme of Health Insurance,” Edmonton Journal, 25 February 1930, 11.

4. 4 “Cost Is Stumbling Block in State Medicine Scheme,” Edmonton Journal, 28 February 1929, 13; “More Than One Thousand Lives Saved Annually by Alberta Health Services,” Calgary Herald, 21 July 1934.

5. 5 Alberta Department of Public Health, Annual Report 1930 (Edmonton: Printed by W.D. McLean, King’s Printer, 1931); Alberta Department of Public Health, Annual Report 1931 (Edmonton: Printed by W.D. McLean, King’s Printer, 1932).

6. 6 “Hon. George Hoadley Defends Policy of Importing British Women Doctors into Alberta,” Edmonton Journal, 15 February 1929.

7. 7 Malcolm R. Bow and F. T. Cook, “The History of the Department of Public Health of Alberta,” Canadian Public Health Journal, 26, no. 8 (August 1935): 384–396.

8. 8 Special Legislative and Lay Committee Inquiring into Preventive Health Services in the Province of Alberta. Report (Edmonton: The Committee, 1965).

9. 9 The Committee met on March 6, 1930, Alberta Department of Public Health, Annual Report 1930, 7–8, https://librarysearch.assembly.ab.ca/client/en_CA/search/asset/47192/0

10. 10 Alberta Department of Public Health, Annual Report 1931, 8.

11. 11 Alberta Department of Public Health, Annual Report 1932 (Edmonton: Printed by W.D. McLean, King’s Printer, 1933), 8.

12. 12 Alberta Department of Public Health, Annual Report 1937 (Edmonton: Printed by A. Shnitka, King’s Printer, 1938); Alberta Department of Public Health, Annual Report 1938 (Edmonton: Printed by A. Shnitka, King’s Printer, 1939).

13. 13 Alberta Legislative Assembly, Commission on State Medicine and Health Insurance, Final Report of the Legislative Commission Appointed to Consider and Make Recommendations to the Next Session of the Legislature as to the Best Method of Making Adequate Medical and Health Services Available to All the People of Alberta (Legislative Assembly of Alberta, 1934).

14. 14 “Contend ‘State Medicine’ Real Need in Province,” Edmonton Journal, 4 March 1932); David Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911–1966 (Kingston and Montreal: McGill-Queen’s Press - MQUP, 1986), 54–56.

15. 15 “‘State Medicine’ Bill Introduced,” Edmonton Journal, 19 March, 1934, 1.

16. 16 Alberta Legislative Assembly, Final Report of the Legislative Commission, 10–11.

17. 17 Alberta Legislative Assembly, Final Report of the Legislative Commission, 24.

18. 18 Special Legislative and Lay Committee Inquiring into Preventive Health Services (Edmonton, 1965)

19. 19 Special Legislative and Lay Committee Inquiring into Preventive Health Services, xii.

20. 20 “Committee Blasts Health Region Act,” Edmonton Journal, 8 November 1968, 53; “A Bad Act,” Calgary Herald, 11 November 1968, 4.

21. 21 “Health Regions Plan Scrapped,” Calgary Herald, 25 September 1969, 37.

22. 22 Suggested in Special Legislative and Lay Committee Inquiring into Preventive Health Services, 69.

23. 23 Premier’s Commission on Future Health Care for Albertans, and Louis D. Hyndman, The Rainbow Report: Our Vision for Health (The Commission, 1989), accessed 3 June 2020, https://ia800309.us.archive.org/33/items/rainbowreportourprem/rainbowreportourprem.pdf

24. 24 Gregory P. Marchildon, Health Systems in Transition: Canada (Toronto: University of Toronto Press, 2006), 109.

25. 25 “Rainbow Report — Our Vision for Health,” Making Medicare: The History of Medicare in Canada, 1914–2017, Canadian Museum of History, accessed 3 June 2020, www.historymuseum.ca/cmc/exhibitions/hist/medicare/medic-8g02e.html

26. 26 Alberta Government, Partners in Health: The Government of Alberta’s response to the Premier’s Commission on Future Health Care for Albertans, November 1991, accessed 3 June 2020, https://archive.org/details/partnersinhealth00albe/page/n9

27. 27 “B.C.’s Doctors’ Medicine,” Edmonton Journal, 15 November 15, A14.

28. 28 “Health-care Report Skirts Funding: MD,” Red Deer Advocate, 6 December 1991, A2.

29. 29 A Framework for Reform: Report of the Premier’s Advisory Council on Health, December 2001, http://www.assembly.ab.ca/lao/library/egovdocs/2001/alpm/132279.pdf

30. 30 Open Government description of A Framework for Reform: Report of the Premier’s Advisory Council on Health, accessed 3 June 2020, https://open.alberta.ca/publications/0778515478

31. 31 “Critics Misrepresenting Report, Says Mazankowski,” Edmonton Journal, 14 March 2002, 7.

32. 32 Ak’ingabe Guyon, Trevor Hancock, Megan Kirk, Marjorie MacDonald, Cory Neudorf, Penny Sutcliffe, G. Watson-Creed, “The Weakening of Public Health: A Threat to Population Health and Health Care System,” Canadian Journal of Public Health 108 no. 1 (2017): E1–E6.