National Meeting on Promotion and Prevention In Acapulco, Guerrero, Mexico

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July 5, 2008
Acapulco, Guerrero, Mexico

Introduction

Thank you, gracias.

Buenos dias, it’s always a great pleasure to come to Mexico.

The discussions I’ve been a part of during my brief stay here so far have been wonderful. Mexico’s experiences in recent years in advancing public health and reforming its health systems are fascinating and instructive, so I’m looking forward to continuing the exchange of information we’ve been having thus far.

I won’t speak for the full amount of time this morning as I want to leave plenty of time for questions and answers afterwards.

What I’m going to talk mostly about is how Canada’s public health story has developed over the last few years. We’ve recently gone through a transition in how we, as a society, approach and think about public health. Mexico’s been having a similar experience in a similar timeframe, re-examining its health system and how to get to the underlying causes of poor health.

And among the challenges we share is how we actually go about delivering health services in the most effective possible way, and how we go about working across jurisdictions so that we’re always valuing what each level brings to the table, rather than just bemoaning the tensions that can so often mark these relations.

A while back, I was involved in a project with FIOCRUZ in Rio de Janeiro. And I was touring one the city’s favelas with one of the Mayors.  He had commented on some of the difficulties they had in building a school – they would build it, and before long it would be vandalized and trashed. The government, though well-meaning, had come in and installed an important facility, but without engaging the people that would be living with it.

In other areas, I’ve seen where they beforehand discussed with the community what was needed, incorporated their ideas in the design, and invited local kids to decorate the school. These schools were more accepted and would have a better chance of working and becoming a part of the community.

And in that one seemingly small issue exists a lot of the challenges and pathways to success for public health. At the basic levels of public health, we recognize problems, see what the underlying causes are, and work with the people closest to those problems to support and adapt solutions. And every level beyond that community level -- whether state, provincial, municipal, territorial, federal – at every level we need to bring another layer of value, contributing to the process rather than getting in the way.

I’ve come to this perspective by way of a career that has taken me from clinical physician, to a local public health officer in the province of Ontario, to the Chief Medical Officer in the province of Saskatchewan, to Canada’s first federal Chief Public Health Officer.

And one thing I learned was that for public health to be successful it must respect, but not be limited to borders, politics, or jurisdictions. The infectious or social problems we face don’t respect jurisdictions and certainly don’t stop at borders. They affect entire communities and populations – and so solutions need to draw from the same broad scope. They require not just local action, but leadership nationally and internationally as well.

While individual jurisdictions will rightly tend to seek to defend their realm, it is my experience that sometimes in public health we need to, not so much sacrifice our jurisdiction, but share it.

Sometimes we have to give up just a bit of our autonomy in order to gain great success. And it does work better this way. Or, as Samuel Johnson said several centuries ago: it’s amazing what you can accomplish when no one has to take the credit.

All this, of course, isn’t really new -- but sometimes when we’re not making use of our knowledge and the lessons taught by history, we forget them … until something happens to remind us why we needed them in the first place.

SARS in Canada

This happened to Canada with 2003’s outbreak of Severe Acute Respiratory Syndrome  – or SARS -- a then-mysterious infectious disease that had emerged in China the year before.

Eventually, about 8500 people around the world were diagnosed with probable SARS, with about 900 deaths – 44 of which were in Canada. Outside of Asia, Canada was the country hardest hit by SARS -- and we were caught unprepared.

Forty-four deaths seems small compared to what can happen, and to what does happen around the world. But in Canada this was a wake-up call.

It challenged people’s trust in the ability of government to offer even basic protections.

It also affected the economy. People stopped coming, conferences were cancelled, and even areas thousands of miles from the cases in Toronto were affected. Even Prince Edward Island’s shellfish industry collapsed with the Toronto restaurant market.

The outbreak highlighted the weaknesses and strengths of our public health system.

On the one hand, our labs moved quickly to identify and share data on the virus. Our health professionals were absolutely heroic under incredibly difficult conditions -- many fell ill;  three died.

There was also a recognition that we needed to be working in the interest of the public good, without consideration for borders or jurisdictions --  and everyone acted accordingly.

On the other hand, we saw weakness in the lack of capacity in our health system to deal with major health emergencies. There were unprecedented demands on our entire public health system for outbreak containment, surveillance, information management, and infection control.

But not everyone cooperated, and a lack of information sharing, among other things. led to Toronto being put on a WHO travel advisory.

As time progressed, the outbreak also helped emphasize the importance of the greatest defence during any health emergency: simply, a healthy and resilient population. Almost all of those who died of SARS had underlying health problems. So it highlighted the need to strengthen the resilience of our communities to face not just infectious outbreaks, but all threats to health.

SARS was able to do what it did in large part because our public health system had been neglected over the years. Neglected, despite our fairly rich history in public health advancements, and in particular in health promotion.  Our 1974 landmark report from then-Health Minister Marc Lalonde got us thinking, as a country, about population health, and how good public health was so much more than just good health care.

Just over a decade after that report, Health Minister Jake Epp offered another, this one focused on broader determinants of health and approaches. It further highlighted the underlying reasons for poor health, and how it’s not just about the choices we make, but the conditions in which we live that guide those choices.

Those were pivotal reports for us. Added to that we had the Ottawa Charter for Health Promotion that came out of the WHO’s first international conference on health promotion, and a series of reports and committees through the 1990s that were all contributing to our base of knowledge and experience in the field.

But as I mentioned, it’s really in our nature to forget things when we’re not using them.

There is an old saying that when the Israelites remembered God, they prospered, but when they prospered, they forgot God.

And I raise that not as a religious matter… the point is that when we suffer and when we are in need, we struggle to find solutions. And once we’re back on our feet and prospering once more,  we tend to forget what it was that made us successful in the first place.

Establishing the Agency

And so SARS helped us to remember. It showed us that public health capacity and response was unequal across the country … our surge capacity was limited … the public health leadership wasn’t effectively there and decision lines weren’t always clear…and in many cases we were forgetting the basics of good public health.

Among many recommendations in a major report that reviewed Canada’s performance in the SARS outbreak was that an organization or agency was needed to lead on public health matters at the federal level – what many referred to as a CDC North.

And so in 2004, the Government of Canada established the Public Health Agency of Canada to,  among many other things, lead on public health issues at the federal level and to work at bringing together the numerous and often disparate and distant public health actors in the country.

In particular, to be value added to the system, to ensure we could bring the best possible expertise or resource to bear on a problem wherever it would arise.

At the same time, the position I now hold – Chief Public Health Officer of Canada – was created to serve at the Deputy Minister level, to advise the Minister, and lead the Public Health Agency.

But in a role which is unique in Canada, and perhaps internationally, the Chief Public Health Officer also communicates, independently of government, directly with Canadians on important public health matters, as needed and in an annual report on the state of public health, the first of which I’ve just released – I’ll talk more about that report in a moment.

Following soon after these moves, all of Canada’s Health Ministers – federal, provincial and territorial -- created the Pan-Canadian Public Health Network.

This was a new approach in Canada, and I want to spend some time talking about it because it’s been immensely valuable.

Public Health Network

The Public Health Network is a mechanism that was a new way for different levels of government and experts to work together to improve public health in Canada.

It’s a tool for improving collaboration across jurisdictions, for keeping us on the same page and working towards the same ends, mixing policy and practice.

It’s a means of helping us navigate the murky jurisdictional waters by bringing together all jurisdictions to the same table on the same public health issues. This is key, because as with Mexico’s states, Canada’s provinces have jurisdiction over most health service delivery.

A big part of the Network’s success has been in the simple fact that its structure embraces the basic notion that public health is all about the power of the collective. We all have individual parts to play, but like the team sport that it is, public health needs everyone to be playing them together.

I co-chair the Network’s council with the chief provincial health officer from British Columbia. The council includes a provincial deputy minister as well as senior public health officials from each of the jurisdictions. Under the council are a number of expert and technical committees that coordinate the full range of public health issues.

The Network then reports to the conference of Deputy Ministers where I sit, and then on to the conference of Ministers as needed.

This allows both cross-jurisdictional coordination on guidelines and programs while bringing forward policy and other advice to Ministers.

This assists us not only in the sharing of knowledge and the development of best practices, but also in terms of policy development.

The Network was created to deal both with coordinated action on a public health crisis and to address day-to-day health issues – such as obesity, chronic disease, injury, infectious diseases, and so on.   

As does the Agency, the Network deals with Federal-Provincial-Territorial coordination of population health assessment, surveillance, health promotion, disease and injury prevention, protection, and emergency preparedness and response.

It really is one of our most important success stories. Before SARS, that role was filled by what was, basically, a few advisory committees – which could, of course, only advise. With the Network, we’ve shifted from advising to doing.

Where once public health issues had a tough time getting onto agendas at Ministers’ tables, they’re now regularly discussed by Ministers. Public health has been given a much stronger voice, as we’ve rediscovered public health as the first public good of government action on health.

As important as health insurance and health care are, they are no substitute -- and they would be an expensive one at that --  for good public health.

Public health also now has a seat at tables in sectors other than health -- for instance, the Chief Public Health Officer sits at the national security table with other Deputy Ministers.

That’s a change that has also occurred at the international level, where public health in Canada now has a single, unified voice to work towards strengthening partnerships and developing new avenues for collaboration.

PHAC International, Infectious Diseases, Working with Mexico

That was one of the most important, lasting lessons of SARS. An infectious disease in another country, whether a neighbour, or on the other side of the world, won’t stay someone else’s problem for long.

Without proper defences, and without sharing information, an infectious disease can be on our doorstep in the amount of time it takes a passenger jet to cover the distance.
Domestically we’ve been strengthening our tools for early detection, for disease surveillance, and for monitoring of infectious diseases. 

We have an agreement in principal with our provinces to share information during a public health emergency, and we’ll be formalizing it in the coming months.

We practise for emergencies, but occasionally we have the real thing. For example, just a couple of months ago we had an event on a train suggestive of a new, imported, serious infection.

Fortunately it wasn’t. But the important news is that three levels of jurisdiction came together quickly, effectively, and openly. 

We’re also in the process of developing formal agreements with all our provinces for sharing routine disease surveillance information. We don’t have a big problem getting it now, but agreements will reinforce this for the future.

We also have draft agreements on mutual aid and roles and responsibilities during a pandemic.

Also, as part of our pandemic plan for the health sector we’ve developed guidelines around public health measures such as quarantine, travel measures, school closures, and cancellation of public gatherings – all depending on what phase of the pandemic we’re in.
Internationally-speaking, we’ve been fortunate to be a part of a new level of desire for cooperation and partnership.

We’re partners with Mexico and others in the Global Health Security Initiative.

And we’re pleased to be a part of the recently-signed Declaration on Mutual Aid with Mexico and the US – essentially strengthening cross-border coordination and cooperation in times of emergency. It signals an openness, as neighbours, to work together and to help each other in case of emergency.

Both our countries are also partners in the International Association of National Public Health Institutes – IANPHI --  which has proven very worthwhile. It’s a forum beyond the traditional PAHO or WHO that brings together countries at all stages of development, to discuss public health issues and assist each other in setting up public health institutions.

State and provinces, as well as universities and NGOs all have important international activities and partnerships. It is, however, key that federal governments are able to portray a unified voice for a country on behalf of all its public health constituents.

For instance, the province of British Columbia is a subsignatory to a WHO agreement on physical activity because it has a very profound interest, and has taken unique actions within its own jurisdiction, on that file. But it is part of a national approach and remains important for the country to be able to speak with a clear and coherent voice on public health issues.

Leadership, coordination, reaching across sectors – the federal value added

Public health is though, 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’s still a series of local events.

But it’s important that no one level ever feel alone in dealing with public health problems, emergency or otherwise. In Canada, in an emergency each level of government provides a support for the other should problems escalate beyond their ability to manage or contain it.

The province gets involved when a problem escalates beyond the local ability to cope, or when the problem spills beyond local borders. The federal government gets involved in similar circumstances, when the province needs assistance coping or if the problem has exceeded provincial borders. 

The entire system needs to be connected from local, to regional, to state or provincial, to federal …  and then on to the international level – just like states and provinces must never feel like they are alone and isolated in dealing with issues, so must countries see that they are not alone.

At each stage, though, there must be added value offered, whether it is in specialized expertise, laboratory services, resources, teams, or coordination and connection.

Much of our progress in Canada has come thanks in large part to our willingness to reach beyond the traditional government health sector, and to embrace the contributions of civil society.

This has also brought value in the forms of added legitimacy to government decisions, and broadens our base of research and knowledge.

This has had a significant impact on our ability to make progress on a range of program and policy developments, from HIV/AIDS, to early childhood development, and one of our clearest and most measureable public health successes, tobacco reduction.

So while it remains the sole domain of the government to enact laws and regulations, in Canada we’ve had a far easier time finding success when embracing public health networks to the fullest extent possible across the breadth of society  --  from health professionals, to inspectors, to educators and academia, to community organizations and agencies, the voluntary sector, NGOs, international organizations, think-tanks, media, employers, private sector, and so on.

More than as a simple provider of funds, giving that coordinating, overarching, cross-jurisdictional and cross-sectoral, national and international voice to public health is the kind of added value that a federal government -- and sometimes only a federal government -- can bring to the system.

More than that, it also makes sense on the fiscal level to have a federal government maintain certain capacities that can be shared with all jurisdictions.

The Public Health Agency maintains, for instance, a National Emergency Stockpile System. This is made up of small warehouses of emergency medical supplies and tools that can be deployed to support local health care and other services in an emergency.

We have Health Emergency Response Teams that can support local medical professionals in a health crisis.

We have National Collaborating Centres disseminating knowledge on variety of public health issues, from aboriginal health to health inequalities.

And the cornerstone of much of our infectious disease work is our Level 4 National Microbiology Laboratory.

These, and more, are all resources that make sense, at least in our circumstances, for the federal government to maintain. There are always investments in the public good, like these,  that should be shared from the national level.

Mexico’s Reforms, Successes in recent years

Now, my goal is certainly not to stand here and focus solely on what Canada has done and achieved. Our successes and failures will often be unique to our own culture, political circumstances, and our jurisdictional idiosyncrasies.

In my experience though, the situations we encounter and the wisdom we acquire is rarely unique to us, or even to our time.

So I’ve been interested in the reforms and progress made in Mexico over the last decade.

Reading your National Promotion and Prevention Strategy for Better Health, it’s easy to see we share many challenges and goals. Many issues, like growing inequalities in health, an increasingly sedentary population, and the rising burdens of obesity, diabetes and other chronic diseases, are faced in Canada as well.

On the other side of the equation, we share very similar long-term health and social goals that range from concentrating on promoting good health and sanitation, to preventing the preventable, building health and public health capacity across jurisdictions, reaching across sectors for solutions, investing in child development, and eliminating health inequalities.

While no country is perfect, and I know that you, like us, have a lot still to do, Mexico’s list of achievements in recent years is impressive.

You’ve reached the millennium development goal of reducing the number of homes without clean water by fifty percent, and will achieve the goal of reducing infant mortality by two-thirds by 2015 – thanks in large part to infectious disease control strategies.

Vaccine campaigns and actions to improve living conditions have proven successful in improving the prevention of many infectious diseases.

Your Seguro Médico para una Nueva Generación (health insurance for a new generation) is a model for other countries to follow – promoting health in children by nurturing physical and intellectual potential … reducing child mortality … reducing the burden of disease and disability…improving the health of families living at the lower end of the income scale.

These are all vitally important approaches given our understanding of how investments in early years pay such large dividends later in life. In the Canadian context, we figure every dollar we spend in the early years saves about $9 later on, in everything from health to welfare to justice costs.

Your preparedness for disasters has steadily improved, your epidemic surveillance systems are being strengthened, and your lab capacity is expanding.

In just a few short years, Mexico has gone from having millions of uninsured families facing economic catastrophe to being on the cusp of universal health care coverage.

I was reading an interesting article the other day on the burden of disease in this country, and the author talked about how important it was that Mexico was reporting disease burdens at the sub-national level. It reflects the reality of this country  - as well as my own - that in most cases it is the provincial and state jurisdictions that are directly responsible for health service delivery.

But local information alone, held locally, is not enough. It is most often when we put together and analyze that data nationally that we can better understand the pattern of disease and potential causes and solutions

And Mexico can move in this direction because of its investments in high-quality statistical systems. The bottom line is that it’s difficult to fix what we do not measure.

Inequalities, Health Promotion, CPHO’s Annual Report

But while Mexico’s health is generally improving, as in Canada, not all are benefiting from these improvements equally.

In the overall national picture, Mexico is in economic transition, which also means epidemiological change. And so Mexico has to deal with a double burden of disease – both the infectious disease threats of less developed nations as well as the diseases of affluence faced by more industrialized nations.

And a growing concern remains social and health inequalities.

The well-documented differences in socioeconomic status and health outcomes between, say, Mexico’s Southern states and Mexico City, or between Canada’s First Nations on reserve and suburban Toronto, are issues that don’t only affect individuals where they live. Health inequalities hold back an entire nation and prevent us from becoming as healthy and prosperous as possible.

Health promotion, along with disease prevention, health protection, and building capacity, is one of our main pillars of activity at the Public Health Agency of Canada. It is, without a doubt, one of the most difficult areas of public health to convey the importance of -- but at the same time, it is one of the most important and most inspiring, and goes to the root and origins of public health as the “organized efforts of society to improve health and wellbeing and to reduce inequalities in health.”

It is fundamental to public health, and challenges our populations to recognize the interconnections between physical health, mental health, and between social, environmental, political, and economic conditions.

Last  year Canada was fortunate to host the 19th International Union on Health Promotion and Education Conference. And in closing remarks, I told the assembly that health promotion thinking must be core to public health and must be reflected in all we do.

Moreover, if government public health agencies and institutions at all levels aren’t actively engaged in health promotion and seeking to create the conditions and opportunities for all our people to have the chance to be truly and fully healthy… well, if we’re not doing it, then who will?

In this vein, just a few short weeks ago I released my first annual Report on the State of Public Health in Canada – I am required by law to do so once a year, and it’s a means of communicating important public health issues to both our elected officials and directly to the public.

Health inequalities present an immense challenge to the overall success of our country and, reflecting on the historical roots of public health, I chose to focus this first report on them.

And one thing I’ve tried to make very clear in the report is that while it’s easy to get caught up in averages – like how healthy we are, on average, or how educated or wealthy we are on average – those averages actually mask very important details. We need to look at the people we’ve left behind in the race for progress…those with little income, no shelter, living on the streets, those who are isolated, illiterate, or who have no food security. 

We are, I believe, as a nation only as healthy as the least healthy among us.

And while it is, of course, important that we address issues of income, we need to go farther than that -- It’s not just about economic poverty, and it’s not just about money. Poverty is a constellation of deprivations. We need to understand and address the whole range of social determinants of health.

I look at Mexico’s Opportunities Program, and something as simple as offering assistance to mothers and families to improve nutrition and education is a nice combination of programming, because it goes beyond just giving money, to engaging in effective opportunities for health.

Beyond the basics, we know that having a sense of influence over our future, a sense of control and hope, and of having connections in the community – those we care about and who care about us -- represent the difference between ok health and great health and wellbeing. These are the kinds of transformative ideas that, if we address them properly, can make a significant difference in health inequalities.

Eliminating the gaps that are growing between us has to be the choice and action of whole  societies, though;   a choice as to what kind of society we wish to create: one that ignores underlying causes and tries to fix individual problems then as they appear, like so many fingers in a dam… or one that understands that by levelling the playing field and raising the status of the most disadvantaged we truly make inroads into preventing not just health problems, but a host of other social problems.

My report doesn’t seek to be prescriptive, but rather to point out actions happening across Canada and internationally that we can emulate and adapt elsewhere, and also to spur thinking about new ideas to encourage dialogue on what we aspire to, and how together we might get there.

But it is clear that the way forward for us exists in the combination of a few things.

Fostering collective leadership and will by building recognition of the importance of public health, reducing inequalities and exploring potential solutions…

For example, reducing the impact of child poverty through a variety of income policies, childhood learning and development, and targeted interventions to low-income families…

And, simply, strengthening and supporting communities and community activities – helping the people on the ground, closest to the problems, where all sectors converge.

As in the past, our success in conquering health inequalities is going to rely on our continued ability to reach beyond just the health sector and beyond federal jurisdiction. All sectors, from health to transportation to finance to housing and more, every jurisdiction, community organizations, non-governmental organizations, and individuals…we all have a part to play.

For example:

In Canada one hundred years ago, there were no public pensions, and senior citizens were more likely to be economically disadvantaged than other citizens.

The federal Old Age Security pension came about in the 50s… the Canada and Quebec pension plans followed in the 60s…added to that were the income-tested Guaranteed Income Supplement, the Spouse’s Allowance, the Widowed Spouse’s Allowance, provincial and territorial income supplements over the years.

And through all this, as our public pension system matured, we’ve moved from having one of the highest rates of income-disadvantaged seniors among industrialized nations to one of the lowest.

Another example is taking place right now in downtown Vancouver. Not long ago Vancouver declared a public health emergency in its downtown Eastside neighbourhood – drugs, violence, prostitution, epidemic HIV infection rates… an unstable environment had been created over time and residents felt unsafe, defeated even.

But by engaging in a tripartite agreement between the municipal, provincial, and federal governments that combined government expertise and services with the work of residents, community groups, and businesses, Vancouver has been able to start turning things around.

We’re seeing lower death rates due to alcohol and drug use, HIV-AIDS, and suicide…we’re seeing greater access to health services through the opening of four new health clinics in the community…we have expanded addiction services, and an after-hours youth crisis response program…there’s more employment for street youth in the city’s hotel industry, a mobile after-hours centre for sex workers to escape violence and abuse – essentially, a healthier community is slowly being built by embracing the contributions of every level of government and every sector of society.

In 2005, the agreement was renewed for another five years and similar urban development arrangements are being sought in several other cities.

We’ve also seen success with the federally –funded Community Action Program for Children which supports community groups and coalitions in offering programs that help the health and development of children living in high-risk conditions. The key to this program is in the recognition that communities have the unique ability to respond to children’s needs, and so we place an emphasis on building partnerships and community capacity to deliver these kinds of programs.

And one final example if you will – The Eskasoni Primary Care Project. A community of nearly 3000 Mi’kmaq people – one of Canada’s aboriginal First Nations – wanted to manage its own health care services.

A steering committee made up of the local Eskasoni band council, the provincial health department, the federal health department, and a local university oversaw the project.

The results? A new health centre was built. Record-keeping was streamlined. Better quality care, lower costs, more accessible services, higher satisfaction. 96% of pregnancies are followed from pre- to post- natal care within the community. Physician-referrals to nutritionists and health educators to help manage diabetes have increased by 850%.

So those are just some snapshots of the kinds of successes we’ve had when we bring together jurisdictions with the communities we’re trying to help. Is it always easy? Of course not. Rarely, actually. But when we get it right, it’s more than worth the effort.

PHAC in the future – where do we go now?

The release of my annual report came on the heels of the Public Health Agency’s first-ever Strategic Plan,  and together, those symbolized a coming of age for our Agency. At almost four years old, we’re not really “new” any more. So where do we go from here?

Public health is never static. It’s constantly evolving with the public itself.  Japanese artist Okakura KakuzoOkakura Kakuzo said “the art of life lies in a constant readjustment to our surroundings” – and that has to be how we approach public health management and delivery.

In the year ahead the Public Health Agency of Canada is undergoing a variety of internal exercises geared towards ensuring our human resources, our spending, our program direction – everything we do– is all supporting our priorities as an Agency, our government’s priorities, and the needs of the Canadian public.

We’re also constantly working to not just build our internal capacity and our capacity across our regional offices throughout the country, but also to help build public health capacity outside of the Agency and throughout the Canadian system – it’s one of our reasons for existing.  

To help us achieve that end we’ve recently launched the Canadian Public Health Service. This is basically a program where we recruit public health expertise into the Public Health Agency but deploy them to jurisdictions and areas where they’re needed. It’s just one way that we’re trying to help the provinces and regions build their public health capacity.

We’re also moving ahead with new public engagement initiatives to bring the population more into the decision-making process. Risk communications teaches us that the public will be more keen to accept decisions they’ve had a hand in. And public health history teaches us, of course, that people have greater health outcomes when they’re able to exert some influence over their own affairs and futures.

So we’re in the midst of developing a new public involvement framework that is about respecting the public and bringing them into the fold to inform future public health decisions.

All our actions going forward are about refocusing ourselves, realigning our resources, remaining relevant in the midst of changing public and government priorities, and doing the best work we can as effectively and efficiently as possible to protect and promote the health of the public.

Conclusion

Thank you once again for having me here. There’s a Latin proverb that says always let a person light their fire from yours -- mutual exchanges and discussions have tremendous value as we learn from each other, I believe, for both countries involved and I’ll be bringing what I’ve learned here back to Canada.

I know Mexico’s current administration is very much a results-oriented one that seeks accountability in spending and assurances that programs and activities are getting full value for taxpayer funds. The current federal administration in Canada is similar in that respect. And so I’m eager to see how you go about evaluating the progress of your plans and goals. Measuring the effectiveness of our social investments over the years has not been a strength in Canada, so your experiences going forward will be instructive to us.   

I’ll close with two quotes from the poet Henry Van Dyke.

The first is that “there is a loftier ambition than merely to stand high in the world. It is to stoop down and lift mankind a little higher.”

The second is the observation that “the woods would be very silent if the only birds who sang were those that sang best.”

We all have a part to play. I often refer to public health as a team sport. Many types of expertise and perspectives, and many nations, make for our success.

Merci, muchas gracias.