Opening Session of the 7th Canadian Immunization Conference

December 3rd, 2006 ‑ 1:30 p.m.
Winnipeg, Manitoba

Dr. David Butler-Jones,
Chief Public Health Officer of Canada

I'm going to start with a quote from Sir William Osler - who was probably, at least in many minds, one of the greatest clinicians that ever existed. He grew up in Southern Ontario and taught north and south of the border.

He would say: "To prevent disease, relieve suffering, and heal the sick; this is our work." And I don't think he put it in that order unintentionally.  It is a matter that all three are essential to our work, but clearly, if we don't focus on the first two, and only, as we seem to, often focus on the last, we will not be successful this effort. 

I think too that it is fitting that the conference, being titled Celebrating Immunization in Canada, begins on a day of the week that many set aside for rest, reflection and thanksgiving. Because the story of immunization really is something for humanity to be very, very grateful for. 

It is easy to forget, or take for granted, the impact that vaccines have had on the world's health, alongside fundamental reductions in infectious disease that have come about from say: food, water, improved economics and social conditions, and smaller families. 

I must start by thanking you all for your participation at the conference, for the organizers in pulling together such a great program and for your ongoing contribution to furthering the goals of preventing disease, and protecting and promoting health through immunization.

So how do we measure the worth of immunization?  Well, there are obviously many ways but at a time when health professionals, governments and citizens alike are concerned about escalating health care costs, it makes sense to at least start with some of the financial implications. 

And on this front, immunization is a certifiable good news story - saving lives, and often money, compared to the treatment alternatives.  Universal immunization programs are not only the most effective means of preventing serious communicable diseases, but they also constitute some of the most cost efficient medical interventions going.

As just one example, Canada spends about $12 million a year on Haemophilus influenza immunizations - which sounds at one level like a lot of money, until you realize that doing so saves $30 million in treatment costs.  Now, the American Centers for Disease Control estimates that on average - and it will vary by a vaccine, but on average - society saves about $27 in medical and social costs relative to every dollar spent on vaccines. 

Now, the economics are just as easy to understand when we think about the five dollars or so of the vaccine cost at least for one influenza dose compared to the issues of complications, pneumonia, heart failure, etcetera.

And where else in the health care system do we realize such immediate savings, particular in terms of human suffering?  Many of us in the room still bear the scars from vaccinia, the vaccine against smallpox. And, fortunately, children born in the last 30 or so years have not needed that because we have eradicated one of the great scourges of mankind.

Vaccine programs reduce the burden on frontline health practitioners and acute care institutions B preventing people from becoming ill, freeing up hospital beds and reducing doctor out-patient and emergency room visits, and they reduce long‑term disability. In the process they also help to shorten wait lists B and prevention has to be a fundamental part of any wait list strategy. 

So we might wonder why new vaccines are not considered in comparison with treatment alternatives, rather than the other, more cost-effective, public health interventions. An interesting policy discussion, I think, we need to have. 

And the impact of immunization on wait lists goes far beyond this year's influenza vaccine; it extends to include a realm of professionals and procedures that we may not always think of in association with vaccines. 

We all see the headlines regularly focusing our attention on things like wait times, the need for knee and hip replacement surgery - but if we hadn't developed a vaccine for polio and implemented population wide programs of immunization that have essentially wiped out polio, at least in our part of the world, we wouldn't have time to even consider joint replacement surgery.  All the orthopedic surgeons in the world would be too busy addressing the needs of those crippled by the virus.

So it's useful to consider what Canada might have looked like today without the advances we have made through immunization.  Hospital wards would be cramped with young people with complications from measles, whooping cough and other once common epidemic diseases. Polio patients in iron lungs would still be commonplace. But instead, iron lungs are an invention most people under the age of 50 know very little about.

Without the immunization programs we take for granted, regular epidemics of mumps, measles and pertussis would be killing many patients and leaving others deaf, infertile or brain‑damaged.  Just the impact of rubella on pregnant women would translate into frequent miscarriage and much higher rates of birth defects.  Instead of seeing just a few cases of these childhood diseases every year, we would be experiencing epidemics affecting thousands and tens of thousands.

Improvements in the past century were never a given. In the 1700s, French philosopher Jean-Jacques Rousseau was able to say without challenge: "One half of children die before their eighth year. This is nature's law. Why try to contradict it?"  Well, life expectancy in his days had changed little from the bronze age, so you can understand where he was coming from. And even by 1900 in Canada, one out of five infants still died.  Today, average infant mortality is just over five per thousand.  However, this as we know is not evenly distributed - some of our worst rates of infant mortality are within walking distance of sophisticated teaching hospitals. 

Those basic determinants that influence our risks of ill-health and death can be mitigated by measures like immunization, but not eliminated.  We see around the world some of the worst impacts in war-torn places like Afghanistan, where even today, two out of every five children do not survive past age five - statistics eerily similar to Rousseau's days some 250 years ago.  It is an important mitigation; immunization has transformed life for many of us. 

We recognize, for example, in many northern communities and First Nations communities that clean water and adequate housing are fundamental determinants related to a disease like Hepatitis A. In Saskatchewan, when I lived there, every 10 to 15 years we would see another epidemic that would affect untold numbers, so that by the age of 15, virtually every child living on remote reserves and small communities would have had Hepatitis A at some point in their lives - many of them having died, and a much larger number having been in hospital and having been sick as a result. 

So while we work on these fundamental determinants that influence the risk of disease, we at least at that point, 10 years ago, had a new vaccine for Hepatitis A and have essentially wiped out Hepatitis A in that population in Saskatchewan. But is it in place everywhere in Canada that is affected? No. Another challenge that we face. 

Immunization has truly transformed childhood, a benefit for all, whatever one's social or economic status.  In fact, given what we know about the critical role childhood development plays in adult prosperity, it's no wonder that immunization is now recognized as a human right - that it constitutes one of the millennium development goals.  Protection from devastating diseases in childhood can be a fundamental part -  along with nutrition and parenting - to a child's capacity to acquire the learning skills, coping mechanisms and resiliency that predict later life success. 

Immunization gives us the capacity to help level the playing field of life in an unprecedented way.  Few public health measures have such a history of success and are as easy to apply so equitably. 

Now, the National Immunization Strategy (NIS) has proved some dramatic points around this. As Parliamentary Secretary Fletcher just reminded us, the NIS has made great progress.  Today, as a result of the equitable expansion of routine immunization, twice as many Canadian children and youth in every province and territory are protected from the dangers and debilitations of pertussis, meningitis, pneumococcal pneumonia, and chickenpox. 

The Immunization Strategy has supported us, too, in other ways. We have convened a consensus conference of national goals and recommendations for vaccine preventable diseases, and the first national research priorities workshops on influenza and human papillomavirus vaccines.  We forged new collaborations between public health and experts in immunization, sexually transmitted diseases and cancer prevention. And we were the first country to establish a pandemic influenza vaccine with a supplier with domestic capacity to immunize all Canadians. 

It is a team sport. It requires all of us to be engaged across sectors, across perspectives, across expertise, and together we are making gains towards realizing the goals of improving the efficiency, affordability, security and safety of immunization in Canada. Ensemble, nous avançons vers les objectifs d'améliorer l'efficacité, l'innocuité, la sûreté et le coût de la vaccination au Canada. (Together, we are making gains towards realizing the goals of improving the efficiency, affordability, security and safety of immunization in Canada. )

But continued commitment is needed because at a time when our focus is on reducing both mushrooming costs and wait lists, one of the most immediate and cost‑effective tools for protecting health does lie in immunization, and despite the demonstrable value, it remains underutilized globally.

The increasing number and costs of vaccines,  the difficulties presented by new target populations of adolescents and adults, and issues of supply are just some among the challenges. 

For example, the costs of just one new vaccine can be as much as what not long ago could fully immunize a child for life.  It is important, however, to understand the impact of these competing queries and the fact that immunization is always in danger of becoming a victim of its own success.  Precisely because iron lungs and the horrible childhood deaths from communicable diseases like whooping cough no longer infect individual memories or collective fears, at least in the West, public concern is often distracted by media's health care issues. 

It only takes a generation or two, or maybe less, for complacency to set in as parents have never seen these diseases.  However, they still exist and they continue to threaten the world.  The volume of international travel in today's global community means that gains made in one country can be seriously threatened by the lack of progress in others. 

A recent outbreak of rubella in Ontario served as just one of many sobering reminders.  Rubella was introduced from the Netherlands into a rural area of the province.  The virus was able to establish a foothold in one school where, for religious reasons, 60% of the students had not been immunized.

And in recent years, complacency about disappearing childhood diseases has been exacerbated by misinformation. False and misleading anti‑vaccine claims and poor understanding of science and risk have successfully discouraged some from protecting themselves and their children.  After all, we know umbrellas cause rain, and we know that because we see more umbrellas on a rainy day.  Such simplistic analysis of causation has falsely cast doubt on safety and effectiveness over and over, in spite of the true evidence. And in the process, needless illness and death continue. 

In 2003, polio campaigns were halted in Nigeria because of erroneous information about the oral vaccine. Although the campaign has now resumed, polio has become reestablished in a growing number of countries in sub‑Saharan Africa, and also has recently spread from Sudan to Yemen and Indonesia. 

Even developed democracies have lost ground at times to unfounded fears.  Many of you will remember in the United Kingdom the campaigns against pertussis, which caused immunization rates to fall dramatically.  The result was large-scale pertussis epidemics ending in brain‑damage and death far in excess of the most outlandish claims of harm from vaccines. 

We forget at our peril the critical gains we've made in public health. But this is an all too well worn path in human history.

There is an old saying that when the Israelites remembered God, they prospered, but when they prospered, they forgot God. It is not just about religion, for when we suffer and when we are in need, we struggle to find solutions. And once we have prospered, it is our frustrating and unfortunate tendency to forget what it was that gave us deliverance in the first place. We cannot forget.

The eradication of a disease that once disfigured or killed thousands is a great success story. But people who grew up in a world without regular disease outbreaks have a much harder time understanding the significance of the vaccine that protects against that disease. 

If we take our public health successes for granted, we sometimes lose perspective on what it takes to maintain and build on that success.  We need this perspective so that we are not doomed to repeat the mistakes of the past. 

One of the benefits of this conference is the opportunity it gives us to remember the gains we have made, and the challenges ahead, so that we avoid revisiting the devastations that were once commonplace in previous centuries. 

Immunization is a key component of the health system that worries not just about how to deal with the problems that arise from ill-health, but how to prevent those problems in the first place.  That is why it is vitally important that we all continue to do our part to keep us on a path of balance in the health system - balance between health care that meets the needs of all Canadians, and a public health system that offers equitable and effective protection against future disease through the promotion of health and environments conducive to good health and the best choices. 

One of my favorite quotes is from Van Dyke. And what he would say is "Use what talent you possess, for the woods would be very silent if the only birds who sang were those who sang best."

Our goal in public health is to die young but at as old an age as possible, I think, and while we may not be enthused or embrace the signs of old age, they do in fact reflect the triumphs of public health.

As French actor Maurice Chevalier once pointed out, "Old age isn't so bad when you consider the alternative."  Ultimately, public health measures and advances in immunization have allowed more and more of us to avoid the good old days when life was difficult, fraught with illness, and short. 

Now, I'm going to close with a quote from a prairie kid, Tommy Douglas, who lived down the road next door. And it's one that transcends politics and political perspectives and societies at large. As he might say, "Take courage, my friends, for it is not too late to make a better world."

Cela mérite sans aucun doute d'être célébré.  (Indeed, work worth celebrating.)

Merci à tous pour votre contribution. (Thank you all for your contribution).