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Remarks for
Dr. David Butler-Jones, Chief Public Health Officer

at

Strengthening Canadian Communities:
National Showcase on Community Safety, Health and Well-being

“What Makes a Safe, Health Community?”

19:00, March 5, 2007
The Fairmont
Winnipeg, MB

It’s hard to believe how quickly time passes and things change.  This, I think, must be the most rapidly changing period in human history.  Each generation is facing new and complex challenges that can seemingly be overwhelming, and the consequences not always predictable.

We all remember Columbus. He traveled into the unknown, looking for India. He didn’t find it.

Rather, he found the wrong place -- the Americas -- but thinking he was elsewhere he named the people living here Indians, thus naming the wrong people.

He also introduced rather severe unanticipated problems. In the Americas at the time were cities far grander and better run than any in Europe, but within 200 years of his arrival some 90% of the population was wiped out, mostly by imported infectious diseases.

So Columbus set off and found the wrong place, named the wrong people, introduced terrible side effects, yet he became famous.  Go figure.

Is there any lesson in this?

I think it reflects some of the paradoxes and some of the challenges that we continue to face today.

Often when I speak, it is to a medical or public health audience … about public health issues. Usually people are interested in something about planning for pandemics or the next emerging disease. Or perhaps about the challenge of preventing chronic diseases, or how we respond to natural disasters or bio-terrorism.

So why me? A person most often associated with scary viruses, or threats of disease and pestilence as a dinner speaker. Good question. And, by the way, I don’t think it’s simply a surreptitious effort at weight control.

Perhaps it is in recognition of the fact that Public Health, as originally conceived, represents the organized efforts of society to improve health and well-being, and reduce inequalities in health.

On the health side of the equation, it is the first order of government business, the “public good” of protecting the public and improving well-being.  Much of the basic work is done by others, whether in ensuring adequate housing, employment and social policies, accessible education, clean water, safe food and sanitation -- but these are still of public health concern.

In particular, violence and crime are issues that concern those of the public health persuasion. It’s not so much in terms of the control of crime and violence, which is an expertise I certainly don’t have, though I know it is abundant in this room. Rather, it is the roots or seeds that underlie dysfunction in society. And, what are possible societal measures that reduce those risks.

Much as we talk in health promotion about “making the healthier choices, the easier choices,” we can also ask what are the things that can be done to reduce the risks or incidence of crime or societal dysfunction, that could then make for safer communities, and reduce the burden on the police and courts.

In a similar way we think of the prevention of disease as not only benefiting the health of individuals and communities, but also reducing the burden on hospitals and treatment.

There is a dramatic context to all this.

Technological, economic and social changes are occurring at an unprecedented rate. We are the healthiest generation ever, in our part of the world. Yet, in many parts of the world this is far from true. 

Children in Afghanistan have little better chance of survival than in the 1700s.

When I was in Kosovo after the war there, they would have as many cases of meningitis in one week as we see here over the space of five years.

In several countries in Africa the combination of HIV/AIDS and other diseases now means life expectancy is little better than it was during the Bronze Age. 

And every day some 35,000 children die in the world from a very basic preventable combination of infection and malnutrition.

On the more developed side of the world, life expectancy for Russian men is now in the 50s, while women’s life expectancy has not dropped.  Interesting commentary on the importance of sense of purpose and role, as many men have lost their position or employment, turning to alcohol and other things, while women continue to have purpose in the care of their families.

Here at home many have said that with the rapid increase in obesity in young people, that this generation currently in childhood will be the first ever to experience poorer health than their parents.

We used to count on our family and neighbours.  But to what extent is that still true? Do we know them? Families and social connections are scattered over great distances.

This can be a good thing as it broadens our own sense of community and the wider world. But if there’s a crisis or an emergency, what good is the guardian of our children if they live 2000 miles away and there are no planes flying?

As I said, many things are changing rapidly. For example, with the growth of technology and economies, and with widened gaps between the “haves and have nots,” any disease can now travel the world in less time than it takes to go from being exposed to becoming ill. Thus, by the time we recognize a new disease or outbreak it could be in several countries already.

People around the world are moving to cities and out of the countryside – it’s not just here in the Prairies. Cultural influences from around the world both enriches and threatens what many have taken for granted. Yet for all we’ve come to know and with all the marvelous advances we’ve made, the basics still matter. It is all connected, and we forget the essential lessons to our peril.

There is an old saying that “when the Israelites remembered God, they prospered. And when prospered they forgot God.”  This is not solely a religious issue, but an observation that when, as a people, as a society, we figure out what works, we do well. Unfortunately when we do well we seem to forget what got us here.

I think we all seek similar things, whatever our politics, culture or religion.

We want children to grow up loved and cared for, wise and independent.

We want to be able to influence our destiny, and to make a contribution.

We want a solid foundation for healthy communities, where everyone has the opportunity to be happy and healthy. 

Benjamin Disraeli, 19^th century Prime Minister in Britain during the early days of public health, had many good things to say. One which you might remember is “there are lies, damn lies and statistics.” Hence, the importance of understanding not only numbers but their context.

But the one I want to focus on is “the health of the public is the foundation upon which rests the happiness of the people and the welfare of the state.”

He said that about a century and a half ago, in the days of great Cholera and Smallpox epidemics, and he’s as right today as he was then. The key isn’t in simple illness and treatment, it’s not even about prevention alone -- it’s about the recognition of the connectedness between what we do, how we organize, how we address issues and a healthy people and vibrant economy. It’s about the connections between health, poverty in all it’s dimensions, inequality, the environment and violence or crime. We need to ensure our social foundations are strong enough to support the rest of the system. It’s all connected, and we are all connected.

I think there’s a slow, small sea change occurring, as people are increasingly recognizing the issues and connections that go in to making us healthy and prosperous. If we just look through the newspapers over the last few weeks, we can see articles covering issues from how to better integrate schools into our communities, to the importance of good ventilation to learning, to how some Ottawa area schools are considering cutting back on special needs programming.

These may look like minor low profile issues but they’re all part of the basic things that go into determining how healthy we are, and potentially our crime and violence rates as well.

In the early days of HIV/AIDS people would ask me: “when should we start teaching our children about AIDS prevention?” And what I told them was you start when they’re infants.  Now, I’d usually get some stunned looks as people would misunderstand me, and wonder if I was suggesting teaching infants how to put on a condom. Of course not.

But what I meant was simply that the important, lasting lessons we want to teach, about anything, need to start early in life, even if it’s just a matter of setting good examples.  For instance, when we laugh and say how cute it is when a toddler takes a toy from another, we have taught a powerful lesson. And if it continues, how will that toddler react when they are a teenager and someone tells them: “I’d rather not have sex.”

At one level they are little things, little things that go into helping our children learn better and stay in school. Little things that demonstrate we are a caring society that looks out for others and do

our best to minimize the number of people left behind. Little things that say to kids as they’re growing up that they are valued and as such should value and respect others.

We know that kids with a full tummy learn better.

We know that having daily physical activity in school, even though it takes away from class time, means kids perform better academically.

We know, and many of us remember, how important extra curricular activities were to keeping up our interest in going to school. How many kids stayed in school because of the choir, or orchestra, or drama, or sports, or one of the clubs? And teachers that really seemed to care about us and that we succeed.

And yet what are some of the first things to go when school budgets are tight?

I remember a few years ago, living in Regina, and at different times our van was stolen and house broken into. Anyone who’s experienced theft and vandalism can relate to the feelings, and frustration. It’s not about the material things so much as the sense of intrusion, the loss of family jewellery, and things with a history whose worth is not in their economic cost but in the memories of loved ones lost, the sheer hassle of documenting, and cleaning and figuring out what was lost.

Yet there is a part of me that understands -- if I came from a home where no one cared, I didn’t have much hope for any better future, school did not have much to offer and what support I got came from gang members. Why wouldn’t I steal cars? 

This is not to excuse the theft, or to make excuses for those who do these things. It is wrong -- and daily, most people in similar difficult circumstances choose not steal or commit violence. My only point is that to change the trajectory we have to understand the influences on the path and find ways to address them early on.

So are after school programs with positive adult role models, and culturally sensitive classes, or involvement of community elders in teaching traditions part of the solution to youth crime?

Everything’s connected, and the basics do matter.

Broadly, what do we know determines the health of a population? Well if you think about them most are pretty obvious.  Things like: peace (not living in the midst of war or a violent community); a stable ecosystem,;adequate and safe food; a roof over our heads; literacy and access to an education that allows us to participate in the economy and grow ourselves; sustainable resources; healthy child development in a loving environment with lots of stimulation to encourage the growing mind and body; working conditions that don’t undermine our health; -being able to make choices, and how healthy those choices are; our ability to cope with stressful situations; adequate income to purchase the necessities of life and to participate in society; social status such that we feel a valued member of community; access to essential health services; having a sense of opportunity and influence on our future; and  a strong family or social support network.

And what are some of the determinants when we think of rates of crime?

Well, funny thing, they’re not so different. Things like poverty, parenting issues, family violence, substance abuse, poor schooling, unemployment, social exclusion, inappropriate peer association, poor academic achievement, employment, literacy, low self esteem, housing, etc.

The similarities are seemingly obvious.  They’re not in any particular order of importance, and while I could give several examples for all of them, I’m sure you can all think of your own.

I do however want to say something more about the last two of what I listed as health determinants. Beyond ensuring the essentials of life, these are the two that I’ve come to believe are the common thread that runs through so many of the others: having a sense of opportunity and influence on our future; and  a strong family or social support network.

While there is no question in my mind of the importance of access to education, employment, shelter and all the others, what really are transformative factors that move us as individuals from okay to great, from not sick to healthy, from coasting through life to being one of the great ones:  caring for others and knowing we are loved and cared for, and having a sense that we have some control and influence over our life and future … these are critical.

For example when we compare those with the least connections to others, to those with many connections, we find they are more than twice as likely to die at any age. A not too subtle difference. 

But what do you do?

Some are simple, some less so. It is about building on small successes, thinking comprehensively, making the connections and in spite of the challenges not letting discouragement overwhelm.

It is no one level of government, no one group, no one sector, which can address all of these factors and determinants in isolation. Addressing the determinants of health, and preventing crime through social development requires a comprehensive, multi-sectoral, whole-of-society approach.

And it does take all of us. As Henry van Dyke once said: “Use what talents you possess, for the woods would be very silent, if the only birds who sang were those that sang best.”

I’ve always said that public health is a team sport.  Crime prevention through social development is no different. It’s about bringing together different groups with the same long-term goals, and breaking down silos so that we’re all working from the same playbook.

I grew up in Ontario. There we talked about silos. Then I moved to Saskatchewan and we talked about stovepipes. To my knowledge, the latter is for exhausting noxious gases, while the former is great for storing stuff – but leave it too long, and it rots.

We really shouldn’t be aspiring to either.

We have all traditionally had issues with silos that create artificial barriers to cooperative and concerted action. I think we are finally making some progress, in starting to shed those traditions as we learn that together we really are more effective.

From my experience, particularly in the field of emergency preparedness and response, we’ve made a lot of progress over the last few years in tearing down our silos.  But some of these lessons came at a cost.

The SARS outbreak was a big turning point for us.  Some things worked very well. Health professionals and others were heroic under terrible stress – some at great personal cost. Nationally and internationally, we worked well, and in concert, to quickly identify the virus and develop a test, and then to be absolutely open about sharing that information – there was an incredible recognition of working in the interest of the public good, without consideration for borders.

But other things didn’t go as smoothly. The outbreak highlighted some of our health system’s weaknesses. Public health capacity and response was different across the country … our surge capacity was limited … the public health leadership wasn’t there and decision lines weren’t always clear.

So Canada established the Public Health Agency of Canada to, among many other things, lead on public health issues at the federal level, and work at bringing together and supporting Public Health in Canada to work together to address whatever challenges we face. In particular to be value added in the system, to ensure we can bring the best possible expertise or resource to bear on a problem wherever it arises.

And Canada’s Health Ministers created the Public Health Network – a mechanism that is, in effect, a new way for different levels of government and experts to work together to improve public health in Canada. It assists not only in the sharing of knowledge and the development of best practices, but also in terms of policy development.

Much of its effectiveness comes from its connectedness. The Network’s Council reports to the Deputy Ministers of health, where I sit, and then on to the Council of Ministers. It’s a forum for people to come together, to raise issues, to lay plans, and to make connections. 

And it’s a network that doesn’t just include government, but experts in the field that can advise and guide on concrete work that needs to be done. Where once public health issues had a tough time cracking agendas at the Ministers’ table, they’re now regular agenda items.  And for the first time in history Health Ministers of the G8 and other countries met a year ago to find better ways to work across countries in addressing public health issues, from pandemics and the increasing burden of chronic disease, to health inequalities. So we have made progress in finding ways to bring together different groups and different levels of government.

This kind of population approach to health and to crime is indeed a big challenge for all of us, but an important one.  Success on both of our parts can be measured in lives improved, and saved. 

Or, if we want to look at the economics of the situation, they can be just as convincing:

The economic burden of crime in Canada has been measured at around $60 billion annually.

The economic burden of chronic disease in Canada comes in at around $70 billion annually.

It’s said that it costs about seven times as much to incarcerate for a crime, as it does to prevent that crime through social development.

A diabetic incurs medical costs that are two to three times higher than that of a person without.

So much of this is preventable. There are large returns to be made on upstream investments when we focus on proactive approaches.

It’s not just about reacting to laws that are broken, just like it’s not just about treating illness.

We need more cops on the streets, and more doctors in offices and hospitals, but that’s not the only, or necessarily best solution.

What’s required is balance between the proactive and reactive, and the recognition of the importance of social policy and programs, services that address the basics like housing, family benefits and education. This gets to the core of public health and crime prevention. Better to prevent the crime, or prevent the sickness in the first place, than dealing with it after the fact.

Small things? Maybe not?

I just want to leave you with a few more practical examples. I’m sure each of you have many of your own as we continue to build the connections.

Let’s return to the determinant that relates to control over one’s future. We know, sadly, that in many parts of Canada, the youth suicide rate on reserves can be many times above the provincial average. Chandler and Lalonde compared different BC reserves to try to understand why there were such large differences in suicide rate. 
 
What this study found was that if a certain combination of factors was present, suicides virtually disappeared. 

The things that made the measurable difference were: how involved the individuals and communities were in their surroundings, and how much control they had over their futures. Basically, it was about opportunity. Things like self-government and participation in land claims. And just as importantly, if the community itself was involved in its cultural facilities, in police and fire services, and in delivering education and health services.

Communities that had all of these factors averaged no suicides while those communities with none of the factors had suicide rates several times the provincial average. It wasn’t about suicide prevention counsellors, as important as they may be. It was about functional communities and people’s influence and control over their lives and future. That research has now been expanded to look at other health issues and factors. Interesting stuff.

A couple of examples from Saskatchewan:  

We know families on assistance can have a phone. Unfortunately, someone comes along and runs up a long distance bill that the family cannot afford. So no more phone. It is possible to have a long distance cap put on to allow incoming and local outgoing calls. Unfortunately that required a $200 deposit which most could not afford.  So still no phone. Sasktel was convinced to waive the deposit and suddenly there were thousands of phones in households that previously couldn’t afford it. Imagine the difference in reducing isolation, being able to participate more actively in society and the increased ease for health, social workers or others to make contact, let alone the value of a phone in an emergency.

Most people, I find, given the choice, would prefer to work and participate. However, what is the incentive to work if doing so adds little or nothing to your income, but you lose prescription and dental benefits for your kids?
 
Not a very rational choice.

So Saskatchewan decided to provide health and social benefits to low income families to reduce that barrier to work. And what we find is not only more people working, with all of the benefits to self-esteem and the economy, but it also makes a positive difference to how they use the health system. Probably the most important policy implemented to improve health in Saskatchewan in the last decade.

Small things –perhaps-- but all important to the health of the public, and, I believe, also an important part of our approach to crime prevention and safe communities.  

It is all connected, and small things done effectively and consistently can add up to a great deal.

So hopefully this evening I’ve offered up a little food for thought and just a few of the many examples of how individually and collectively we can make a difference.

The playwright Henrik Ibsen once said that “a community is like a ship; everyone ought to be prepared to take the helm.” That’s what it takes. None of us can do it alone.  Meetings like this are important steps in that process.

To close then, I’d like to leave you with the words of a prairie kid from the province next door --  I believe they ring true whatever our profession, culture, religion or politics.

I’m sure Tommy Douglas said this more than once:

“Courage my friends, it’s not too late to make the world a better place.”

Thank you.