Remarks for
Dr. David Butler-Jones

Chief Public Health Officer of Canada
at the Global Indigenous STOP-TB Expert Meeting

November 13, 2008 Toronto, Ontario

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I want to thank the elders for their wisdom and their prayers this morning, as well as for the leadership all that are present here, for your interest and commitment to these issues, not just today but as we go forward, and for all the work that's brought us to this point.

I'm very happy to have had the opportunity to spend the morning here.

I can say, on behalf of the Public Health Agency of Canada and our federal partner, Health Canada, that we're pleased to support the goals of the Global Stop-TB partnership and this meeting.

There is an illusion that tuberculosis is a disease of the past. And while it is true that we have made some remarkable progress since the 1920s when it was the largest killer of young adults in Canada, we are far from finished. Whether we are focussed on an International or domestic context, it will require greater attention than it often gets.

Now Sir William Osler, who was a professor at McGill and at Hopkins in the U.S. in the last century, and probably one of the great physicians, would say that “to prevent disease, to relieve suffering and to heal the sick, this is our work.” 

And I would say that that order was not by accident. I think it
has been, and will continue to be that the ability to prevent disease and injury and illness, to actually manage suffering of peoples and, finally, to heal, is key. 

But if all we do is focus on healing, we will miss much of what we can accomplish.

By way of background, let me say that the Public Health Agency of Canada was created just over four years ago as a Department reporting to Canada's Minister of Health, partly in response to weaknesses in our public health system exposed most notably by the SARS outbreak of 2003.

But even more broadly, we needed a body at the national level that could provide some public health leadership, and work with governments, different sectors, and communities to improve public health and public health capacity across the country.  

The position of Chief Public Health Officer, which I have the privilege to hold, was created at the same time to report to the Minister, advise the federal Government on health issues, and to speak to Canadians and organizations on important public health matters.

And so this meeting is an opportunity for me, to engage with everyone here on the impact of tuberculosis in Canada's aboriginal communities, and around the world.

But I'm reminded at the same time of a caution from Stephen Leacock, who was a Canadian economist, a professor at McGill, but also a keen observer on the human condition (and some of us would call him a humourist).  And he would say that “Success is 10 percent inspiration and 90 percent perspiration.”

And I can say that the Government of Canada is committed to this issue, and the Public Health Agency and Health Canada are working very closely to reduce TB in Canada.

For our part, at the Public Health Agency, our recent 5-year Strategic Plan articulates our commitment to working closely with Aboriginal organizations on issues relating to the social determinants of health, and to work to address through partnerships and action the underlying factors that give rise to health problems – including, of course, TB.

We're also working with other federal departments, provinces and territories, and non-governmental organizations through the Canadian Tuberculosis Committee to discuss strategies for improving TB prevention and control at the national, provincial and territorial levels.

That Committee established the Aboriginal TB Scientific Subcommittee to provide scientific, evidence-based and expert advice on TB prevention and control in Aboriginal populations in Canada.

The Public Health Agency of Canada and Health Canada are working with provinces, territories professional organizations and other groups to reduce the Canadian reported TB rate to 3.6 per 100,000 population by 2015, in keeping with the World Health Organization's tuberculosis reduction targets … and, ultimately, to eradicate TB by 2050.

Nationally, there has been some progress in reaching that goal.

Through the Canadian Tuberculosis Reporting System and the Canadian Tuberculosis Laboratory Technical Network, the Public Health Agency gathers surveillance data that appears in annual reports on Tuberculosis in Canada.  This surveillance and data collection has been one of our strengths.

Good information we know is important because if we can measure something, it's easier not only to get more appropriate focus in addressing it, but also to assess whether we are being effective.

So there has been some progress. But we all know that we have a very long way to go.

Tuberculosis has a much longer story than many people realize. It's an ancient disease that has shaped human history dating back thousands of years. And on the surface, it looks as though advancements in treatment, sanitation and living and working conditions since the industrial revolution have all helped most of the industrialized world to, dramatically reduce it's impact. 

Certainly if we look at the average numbers in high-income countries, they are generally stable or slowly decreasing.  

However as we know all too well, not only does TB continue to be prevalent in the developing world, if we look deeper into the statistics within our own borders, it's quite clear that not everyone has benefited equally from public health and medical advancements over the years.

We have groups of Canadians with higher child mortality rates than others. Some have lower life expectancies, or different rates of obesity and diabetes.  

And, of course, some groups in this country have far higher rates of TB infection. First Nations in Canada have rates many times higher than the general population. And Inuit have rates even many times higher than that.

So why?

Well, what goes into making us healthy?  We're all impacted by our physical make-up… but it's also our housing, adequacy of income, our education, relationships, culture, experience, access to health services, our geography…and just as important as all the rest,  the opportunities we have in life, our level of influence over our futures, and the social connections we have - all those things go into making us physically healthy, but also mentally, spiritually, economically, emotionally, and culturally healthy as well.

In June of this year I released my first annual Report on the State of Public Health in Canada  - it's one way the Chief Public Health Officer is able, and expected, to profile public health issues with the Government and public alike.

And at the heart of that report is the very simple idea that our society is only as healthy as the least healthy among us.

Health problems affecting groups within a population will inevitably affect the entire population.  If one group is held back, we're holding back the entire country. We're all in this together.

The bottom line is that there is an all-important interface between infectious diseases – as well as  chronic diseases and injury for that matter - and the social conditions in which we live. So this isn't just about TB, and it's not just a health issue.

Just as TB is largely a disease of living conditions, our response to TB can't just be about responding directly to an infectious disease with treatment and medication – although that's a very, very important part of it.

It's got to be about how we collectively address the many diverse issues that at the moment create the right conditions for the disease to grow and spread: from crowded, poorly ventilated housing to access to early diagnosis and care.

It's also not an either-or equation. We need to be addressing the problem in its entirety.

Ultimately, I do think that one of the big questions we're all here to ask is less about a specific disease, and more about how do we all work together -  across sectors, communities, levels, jurisdictions, and internationally as well – to make sure everyone has the basics they need to be as healthy as possible.

Seeing to those basics doesn't just take us closer to conquering TB, but advances us on a host of other public health issues, including reducing other chronic and infectious diseases.

Now, I acknowledge that in this country we have had a history of addressing TB in aboriginal communities that has, to understate matters, not always been positive. I won't minimize the impact of the cultural memories of people being taken away from their communities to be isolated in  sanatoriums.

At the same time, we need to find ways to move to a new future, to bring down barriers to diagnosis and treatment, and to accurate disease surveillance.

Getting beyond the barriers may not be an easy process. But it's one that involves us, as governments and in health, and as other sectors, engaging both aboriginal and non-aboriginal organizations and individual communities -  working with all to find the best possible solutions.

That also means recognizing that public health efforts simply work better when we embrace expertise and traditional knowledge within the community, and when we help build community capacity where it's needed.

Now I remember a conversation with a mayor, one of the mayors of a large community in Brazil talking about how the frustration that they had with building a school in one of the favelas and how very quickly the school would become a wreck.  But they never actually engaged the
community.  They never actually asked the community, or involved them in the design of the school, or the placement of the school, or the activities that  might occur in the school.  So, again, it was an imposition from the outside.  So is it any wonder that the community could not embrace it, no matter how well-meaning that was?

Continuing to find the best ways to partner within the community, and working to integrate local knowledge of people and culture is absolutely essential if we're to not just increase the number of people being tested and accessing treatment, but also if we're to really get to the source of health issues.

We can't simply be treating a disease and sending people right back to the conditions that led to the problems in the first place.

I want to conclude on the point that just like the issues that give rise to TB infection are more than just medical, so does TB affect more than just the body.

As has been so eloquently articulated throughout this meeting, TB tends to attack everything from the spirit, to the community, to economic development.

As far back as the Greeks, tuberculosis was referred to as consumption because it seemed to actually consume a body from within. It can have that same impact on populations.

It's a disease that marks much deeper problems that we can only get at by continuing to work together.

We all have a role to play in creating the physical, economic, social and cultural conditions that are the foundation of good health, for one and all.

I want to thank the many different groups that have come together for this meeting. The AFN, ITK, MNC, WHO, UN - the many others who took part in planning this meeting … and everyone from the Public Health Agency, Health Canada, and CIDA that have been involved.

I applaud the leadership of the AFN, ITK, and others shown here at this meeting and through the Global Indigenous Stop TB Initiative.

And lastly, I'll add that we've taken a wonderful step forward in recent weeks with the appointment of Canada's very first Inuk Federal Minister. Health Minister Leona Aglukkaq brings her experience in government and in health and social services to this portfolio, and I know we all look forward to working with her as we move forward.

Thank you for having me, and I wish all of us great success in the discussions during the rest of this meeting. I look forward to the Action Plan resulting from these deliberations.

I've often said that public health is a team sport.  It takes each of us together to bring together expertise, wisdom and understanding of communities and our political and economic processes.  So, as Henry van Dyke would say, “Use what talents you possess, for the woods would be very silent if the only birds who sang were those who sang best.”

Finally, there's an Ojibway saying - Ojibway is one of the First Nations of Canada — and it goes like this:  “Sometimes I go about in pity for myself and all the while a great wind is bearing me across the sky.” We are all essential and we are supported by each other. It's my privilege to play a small part. 

Thank you.