The Canadian Community Newspapers Association Annual Conference Gala Awards Dinner

Friday, May 9, 2008
Westin Harbour Castle Hotel, Toronto, Ontario

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

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It really is a pleasure to be here.

I know it might be hard to believe, but for a number of years I actually had a regular column on health issues in some thirteen weekly and daily newspapers in part of central Ontario. I also had a weekly radio column and continued that radio tradition when I moved to Saskatchewan as the first Chief Medical Officer for that province.

It is, I believe, a very important way of communicating on health issues, with a focus on helping people to understand and to discern what would make sense for them. It’s something I look forward to resuming this year.

I want to congratulate all of tonight’s nominees and winners, and I also would like to congratulate you and your colleagues who are involved in the work of community-based journalism.

I found great solace and wisdom in the words of one of my high school volleyball gymnastics coaches. What he said, and I try to take it to heart, is that even when you don’t win, you are better than all those who didn’t try … you can tell I wasn’t among the most skilled on the team.

And the reason I tell the story is not as a personal confession, or to in any way diminish the considerable talents of those nominated or winning this evening. It really is about the importance of engaging, of viewing what we do and accomplish not only in personal terms, but as a team sport.

Woody Allen might say that 80% of success is showing up. But it is more than simply showing up. It is the active engagement in something that is important, that we learn from, or contribute to. Individual excellence is important, but much of what we do and our success is defined by collective action, whether it’s families, communities or work groups. Community-based papers are connected to the life, to the celebrations and the challenges of a community. Pretty fundamental stuff I think.

Now public health has many definitions, but the one I use is: “the organized efforts of society to improve health and well-being and to reduce inequalities in health.” And by definition it is actually political, though it must be non-partisan. It is, also like politics, the art of the practical, not the perfect. It’s about getting things 90% right for everyone as opposed to 100% right for just a few. It is the first public good in health, and as such, the first concern that governments have traditionally engaged in. This, in spite of the recent distraction, important as it is, of managing an insurance system for medical treatment.

So what do you think of when I refer to public health?

Is it the publicly administered health care system?

Is it plagues and pestilence? The stuff of a possible pandemic, or SARS whose impacts give rise to the Public Health Agency of Canada and this position that I have the privilege to hold?

Is it clean water and sewage treatment, which have wiped out many previously common diseases?

Is it immunization, which has made the scourges of childhood and previously devastating plagues like smallpox fears of the past -- at least in our country?

Is it the reality that eating out is now safer than at home due to public health regulations and inspections? And while we hear of the restaurant or catering illnesses because they are public and affect large numbers, about one-third of us get food poisoning each year from eating at home or at a friend’s – but just one, two or three people at a time rather than tens or hundreds.

What about the epidemic of chronic disease, and risk factors like smoking or obesity, and the fact that if trends do not change this generation of children may be the first to die younger and sicker than their parents?

What about the fact one of the most important -- absolutely important -- inventions for human health has been soap? The washing of hands is one of the simplest and most effective ways of preventing the spread of many common and nasty infections.

And it’s interesting to note that when there’s a lot of media around bird flu, and we are talking about the importance of washing hands, it was rare to walk out of a washroom – or, at least the male washrooms, which are the ones I know about --  it was rare to see someone walking out without washing their hands.  But we are slipping back, it’s becoming more common again. And yet it’s such a simple thing.

Or is it the constellation of social determinants -- the important factors of economics, social position, education, connections and others that underlie our basic risk for premature illness and death?

So what is public health?

Well, put simply, it’s about promoting good health, preventing disease, protecting the population and prolonging life. It asks the questions: what is preventing us from being as healthy as possible, and what can we do about it?

Health care is largely about the individual, and while there are some prevention elements it is fundamentally focused on getting treatment for disease and injury and supportive care.

Public health on the other hand focuses on the whole population, and while there are treatment and care elements, it is mainly targeted at preventing or reducing the need for treatment.  Together they make for a complete health system.

Clean water, sanitation systems, nutrition labels, vaccines, seat belts, disaster and disease responses, work place safety, food and restaurant inspections, not to mention all that’s done to prevent chronic diseases like cancer and diabetes, lung disease, heart disease. Even social welfare programs, employment insurance, affordable housing -- these all factor very much into the population’s health.

So public health as we know it is that whole body of policies, regulations, programs and people dedicated to these things and more. It involves all levels of government, and it involves all sectors of society, from health to transportation to justice and beyond.

And it is about community. What makes for healthy, functional, successful communities?

Why is it that different outports or villages can have the same economy, the same genetic background, the same geography, but one is healthy and one, fundamentally, is not?

You can drive into communities in Saskatchewan or any other place, and you can tell if the community is healthy by the way the houses look, how the yards look, how people interact, how they greet you or not. What is the difference, and how can we move from relative dysfunction to function in communities?

It’s all connected. More than just about obvious public health resources or services, more than just health care services, our health and prosperity does rely on the interplay between all of these elements.

So what about health itself?

Most of us, I think, would prefer to not need bypass surgery than to recover from it. But you might not realize that given the focus of what hits the news.

More care is not always better.

For instance: how many know that when results of cataract surgeries were reviewed in a major Canadian city, one-quarter of the patients ended up with worse vision? Did they really need the surgery then? On the other hand, there are those still unable to read or drive any more and on someone’s waiting list. So the issue is more one of management, rather than simply an issue of need.

Or when we closed small rural hospitals in Saskatchewan, what happened to health? Well adjusting for factors like age and other important things, health on average improved across Saskatchewan, but it improved most in the communities where the hospitals were closed. And the worst outcomes were in the communities of similar size and situation where the hospital was kept open.  Counter-intuitive? Not really. For example it is better to drive a little further for good hospital care when it’s really needed, rather than being delayed where little intensive support can be done. Also, focusing more on good primary care and prevention is actually more effective than waiting for the problems and trying to fix them.

Does anyone talk about how repeated studies have shown that if you are not at risk of dying soon, and you are on a waiting list and you get your heart transplant, that you don’t on average live any longer than someone at the same stage who did not get their heart transplant? Interesting.

Here in Canada, chronic diseases alone cost us over $100 billion every year -- that’s between lost productivity and actual direct cost. And while we can never prevent all chronic disease, we can prevent much of it.

And it’s not so much about living a year or two more. Quite honestly, it’s not about an extra year or two, it’s about the five or ten years of disability that most people are concerned about in terms of quality of their own lives. Or as Huxley said: “I’d like to die young but at as old an age as possible. “

Or let’s take an infectious disease like polio. Polio may be far from most of our minds -- but we do concern ourselves about wait times for things like hip and knee surgery.

But look at it this way: if we had never eradicated polio in Canada, we wouldn’t even be talking about those hip and knee surgeries – they would be secondary concerns to the damage caused by polio. It’s likely that every orthopedic surgeon that we could ever train would simply be too occupied with treating the after-affects of polio to ever get to those hip and knee surgeries.

Interestingly, it costs about $60 million a year in Canada to immunize against polio -- but if we were not vaccinating, we would be probably be spending about 45 times that amount just for iron lungs – all that for just one form of treatment for a very small minority of the total.

And if not for war and social disruption, we would actually have already wiped out polio as we have smallpox. Frankly, without vaccines, hospital wards would still be cramped with young people with complications from measles, whooping cough and other once common epidemic diseases, and many of our graveyards would have a lot more young people in them. Instead of just seeing a few cases of these diseases every year we would still be experiencing epidemics of thousands and tens of thousands.

Now we have this ongoing debate -- there is always this debate – around balancing prevention and treatment. Both are essential, both are important. And it is an important debate because, more broadly, it is about what kind of society we want to build. The evidence would show us that the society that understands the importance of balance between preventing and treating illness and of strengthening social foundations that are major factors in determining our health, traditionally have been more successful. And if health is the outcome, we have to focus on what gets us to the best health however it is achieved.

We have -- whatever the rhetoric -- a bias, for whatever reason, against prevention. I can’t count how many debates I have been in where I have been challenged that: “Why should we invest in prevention? People just live longer, they continue to go to the doctor and they collect a pension. It doesn’t save us any money.”

I thought that that was the whole point. Otherwise, why was I treated so often as a child for pneumonia as a result of my asthma, just up the street here at Sick Kids? For better or worse, I’m still here. As a result, I continue to use the medical system and perhaps, I hope, might survive to collect some sort of pension.

So living longer, healthy, is a problem? But getting ill and being treated is to what we aspire? Kind of odd, and yet we seem to get caught in that dilemma.

Our happiness, our economy, success, environment, how we look after the basics, how we look after each other -- all of it is connected to our health outcomes and to our success as a population.

It’s interesting to know that between those who are most connected in terms of family, friends, co-workers, etc., versus those who are least connected and most isolated, those who are most connected, doesn’t matter your age, doesn’t matter whether you are male or female, you have half the risk of dying at any age than those who are the least connected. Having connections matters, being cared about, loving and being loved matters.

Benjamin Disraeli had many memorable speeches and statements. One of my favourites is, “There are lies, damn lies and statistics.” In other words, know your science and data so you don’t confuse correlation and causation such as, “umbrellas are the cause of rain.” And we know this because we observe more umbrellas on a rainy day. I can’t count the number of studies that have done that.

But secondly, and more appropriate to what I am trying to talk about tonight: in the early days, in the development of public health as they were countering the great epidemics of cholera, smallpox and typhoid, Benjamin Disraeli, Prime Minister of Britain at the time, said: “The health of the public is the foundation upon which rests the happiness of the people and the welfare of the state.”

Thus, we strive to create those conditions needed to be healthy, or more accurately, that we need in order to have the opportunity to be healthy, and, where choice is involved, to make healthier choices, the easier choices.

It’s interesting that it doesn’t matter where you live in Ontario, in the far north or in Toronto, alcohol is the same price everywhere. And yet milk can be three or four times the price depending on where you are. What does that mean? What are the implications? These are the kinds of questions I think we need to ask. And that is not true just of Ontario, that is of virtually every jurisdiction.

It means looking at the causes of what makes us sick, and then going a step further and looking at the underlying causes of the causes, as Sir Michael Marmot would describe it, towards working across all segments of society to bring about the real changes that are needed.

So, the Public Health Agency and the position that I have the privilege of holding are a consequence of SARS. SARS sparked many examinations and lessons learned, but it was not SARS alone. It was a growing recognition that it is all connected. And it was not just about North Battleford or Walkerton, it was also about the growing burden of chronic diseases and obesity, and of preventable injuries. It was the recognition of emerging infections like SARS or a potential pandemic of influenza that requires better resourcing, focus and coordination.

As part of that response, the Public Health Agency of Canada, and the position of Chief Public Health Officer -- essentially the federal government’s senior medical professional -- were created in 2004. Or as some Prime Ministers and Ministers referred to it, “Dr. Canada.” Cape and accessories sold separately.

I actually prefer to think of it as kind of the family Doc to the nation.

The position of the Chief Public Health Officer wears two basic hats. Firstly, it’s like a traditional Deputy Minister, heading the Agency and advising the Minister of Health.

Secondly, among other things, I must report annually to Parliament on the state of public health in Canada, and the first of those reports is due later this year and will focus on how health status varies between different population groups in Canada, why this should concern us and what we can actually do about it as a society.

What however does make it somewhat unique as a role among deputies is the recognition in legislation that it speaks to governments and the public on matters of public health independently. Or as I sometimes refer to it: a series of multiple career-ending opportunities.

But that is, honestly, the nature of the medical officer’s role locally, provincially, and nationally. And if we don’t take that role seriously and respectfully, we are not doing our job.

Public health is, at its heart, a local activity. It is locally that people live and are either healthy or not. It is at the community level where disasters and outbreaks occur; it may be in many localities at the same time or even in many countries, such as in a pandemic or hurricane, but it is still a series of local events.

But it all needs to be connected from local, to regional, to provincial, to national, and international. Each must be value-added, whether it is in specialized expertise, laboratory services, resources or teams.

For example, today’s bit of excitement about a train in Northern Ontario that was quarantined. When the potential problem was recognized, the local health units, emergency services and provincial people mobilized. We activated our emergency operation center to support coordination of all the players from local, provincial, transportation, rail lines, emergency services, the tour companies, other federal departments, and colleagues in other jurisdictions.  And though tragic for the individual and their loved ones, it turned out to have not been, in fact, a public health concern.

And while the event may not have needed the international headlines it received, the Public Health Emergency systems did work well in response. And this is no accident, as we have developed plans and relationships and an all-hazards approach that serves us well.

And we practice, and practice.

For example, just a couple of weeks ago, we held a table-top exercise in which a number of national media outlets participated.  The scenario was about the potential start of a world-wide influenza pandemic. At first we were looking at smaller outbreaks that were giving only limited warning signs of something that potentially might be troubling. But then the scenario very rapidly developed into a true pandemic, crossing the globe and including Canada.

What these kinds of exercises give us is a way to test our response and communications plans well ahead of time to find the kinks and to work them out before the situation actually develops. Every emergency is messy, and there are always surprises, but the point is to get as much worked out in advance as possible so that we can adapt to those surprises.

In a real emergency, media are essential to get out the right message: what we know, what we don’t know but are working to find out, what is being done and what the public can do to protect themselves and others.

I must say, when I look back on SARS some of the reporting was more like a gothic novel or Robin Cooke fiction: virus oozing from every pore, each organ system one by one shutting down, the mysterious invader... You get the picture.

And I remember having a conversation with the writer who said, “Well, that’s not scary.” Anyways, happily, quickly we moved to the kind of information the public needed and the normal challenge function that the media plays.

Some of you are aware of the recent Auditor General’s report, just another example. It is actually a good news story on surveillance as she recognized the tremendous progress we have made in the few years of the Agency, and that while more formal agreements with the province and territories would be helpful, we are getting the information and have the mechanisms in place. And we do have an agreement not often talked about, that Ministers from across the country have approved in principle, that covers all jurisdictions to share information as needed in an emergency, and we are working on bi-lateral agreements for routine information.

The proof is in the many events that we have already managed, including today, and in the fact that the World Health Organization tells us that in at least 40% of all the outbreaks from around the world, they hear from us first, because of the surveillance systems we operate. Also, that others look to our model of collaboration and effectiveness. Enough said.

I suspect you can all relate to the statement of the great philosopher, economist and humourist, Stephen Leacock that “success is 10% inspiration and 90% perspiration.”

Now, I must say, our American cousins think it was Thomas Edison, but we know better. After all, I saw it on a wall mural in Orillia, so it must be true. Or at the very least, great minds think alike, or perhaps it is not the first Canadian talent or discovery claimed by our cousins to the south. Anyways, it’s not just about good ideas, but hard work that makes it happen. As I said at the outset, it is a team sport.

So I am very much looking forward to working more closely with CCNA in the future. We would like the Public Health Agency of Canada to be an active partner in your work, and you in ours.

We want your people to know that we are available as a resource for information on public health issues. We welcome their inquiries, and can arrange for reporters to speak with one of our experts on a range of files from the flu, to pandemics, to cancer, to healthy pregnancies, to West Nile, to emergency planning and response, etc.

Of course you will look to, and you should look to, the local expertise of your Public Health Units and officers, but we are available if a national perspective is helpful.

It is all part of trying to avoid what George Bernard Shaw called the single biggest problem in communications: “the illusion that it has taken place.”

Congratulations to all, especially the nominees and winners this evening. Thank you for inviting me.