CHECK AGAINST DELIVERY

Remarks for a talk by Dr. David Butler-Jones, Chief Public Health Officer at the University of Toronto

• INTRODUCTION
• IT’S ALL CONNECTED
• WHY I GOT INTO IT
• PUBLIC HEALTH CHALLENGES - TODAY AND TOMORROW
• MOVING FORWARD
• CONCLUSION

INTRODUCTION

Thanks very much.

It’s always a homecoming for me when I’m back in the Toronto area. I was born here, grew up here, most of my formal education was right here at the U of T – including my residency training in community medicine, and I’ve worked here.

So for me to be able to come back here and meet and chat with the next generation family doctors, or Medical Officers of Health, or Chief Public Health Officers is quite a precious opportunity.

I want to leave plenty of time to take questions, but first, I’d like to speak a little bit about my thoughts on public health – where we are, where we’re going, some of the challenges we face.

And I want to share a bit about how I’ve fit in that world, my experiences as Dr. Dave Butler-Jones, and as the country’s first Chief Public Health Officer. Maybe I can help you gain some insight into what’s out there for you as health professionals, the experiences that await you, and maybe even help you look through some interesting, and perhaps unexpected, doorways into your many possible futures.

IT’S ALL CONNECTED

I often find that a good starting point for talks like this is a particular line by British Prime Minister Benjamin D’Israeli:  “the health of the public is the foundation upon which rests the happiness of the people and the welfare of the state.”

And what that quote does well – as well today as it did over 100 years ago when he first said it -- is make the point that public health is all about creating a solid foundation on which we build all of those things we truly value as a society – our physical, mental, and social health, our happiness, our success and prosperity.

In looking at it this way we see how truly connected everything is. The basics matter, and everything’s connected.

Say I’m a kid from the poorest part of town, and I have little hope for a future, school doesn’t seem relevant, and we have no after school programs. The gang members seem to be the only ones who respect me. To be initiated I need to steal a car. Not everyone would…but, well, why wouldn’t I?

And why is it that the hardest hit in a hurricane are the poorest, or the hardest hit in a heat wave the oldest and most isolated?

Why do some aboriginal reserves have  much higher suicide rates than the rest of the population, while others have lower rates?

Our happiness, economy, success, environment … how we look after the basics …  how we look after each other.  All of it is intimately connected to our health outcomes, and to our success as a community, country, and planet.

Or to look at these connections another way:  as a country, we’re preoccupied with wait times for orthopaedic hip and knee surgeries.

But if not for the polio vaccine, we wouldn’t worry about those line-ups. Every orthopaedic surgeon we could ever hope to train would be consumed with dealing with polio. Those hips and knees would never be priorities.

And if not for obesity, we wouldn’t have those hip and knee wait lists – most of those surgeries are related to the excess weight we carry.

And to bring it full circle, if not for war and poverty in certain regions, we would’ve already eradicated polio from the face of the earth.

It’s all connected.  It’s even said that every breath we take contains particles once exhaled by everyone who’s ever lived, anywhere.

WHY I GOT INTO IT

Now, just because we’re aware of these connections doesn’t always make the job easier.  It’s hard to argue against the virtue of making sure everyone has clothes on their backs, shelter, access to good food, a good education.

It’s easy to make the point, but sometimes difficult to make real headway. We still sometimes face an uphill battle in terms of getting everyone to see and appreciate the value of prevention and promotion, and the public health way of approaching problems.

A good example of this was the debate over the HPV vaccine that erupted last year. Admittedly, it was a bit mystifying to see the number of people who would argue: “we have cervical screening, we don’t need to immunize, we just need to do a better job of finding those cancers.”

Well, first, I’ve yet to meet a woman who is eager for the opportunity to deal with cancer and a hysterectomy.

And for many young women, by the time they’re either at risk, or have already developed a cancer, they’re lost to the system – maybe they’re in the sex trade, or drug addicted, or whatever --  they’re not getting screened.

Vaccines happen to be one of our greatest, most effective, and most cost-effective public health measures.

But these kinds of preventive measures still sometimes face opposition never faced by diagnostic and treatment measures.

In an extreme example: a hundred years ago, not far from here in Montreal, mobs stoned and set ablaze houses of the civic health officer and public vaccinator when smallpox vaccinations were made mandatory.  Thankfully I haven’t encountered that specific level of opposition…

But the public health advocate needs to be ready to face a sometimes surprising reluctance to accept the tremendous value and potential of avoiding illness altogether, and of asking those basic questions: what are the causes of ill health, what are the obstacles to good health, and how do we overcome them?

So, what made me want to be a part of this?

Working in health is a tremendous privilege. We’re involved with humanity at its greatest and weakest moments, and in the most profound of personal events.

But to be completely honest, public health was actually the last place I saw myself. My passion was clinical medicine -- the mystery of diagnosis fascinated me. I loved the level of care and support I’d be in a position to give to others.

But it’s funny how you don’t always end up where you expected.

I can’t really point to just one thing, but there were some fairly important issues and realizations that played large parts in my eventual desire to devote myself to public health.

At least for my part, I think you can only spend so much time in an ER without wondering if -- more than just giving patients good care and treatment -- if  there’s a little more you can do to keep people out of the emergency room in the first place.

I had a patient once, who had been suffering from mental health issues. A single mother, she faced an uncertain future, had little community support, few social connections to fall back on, no employment, little education. And after providing the best care we could, I still had to ask: are we sending her right back into the conditions, into the environment, that had so contributed to her inability to be healthy?

How much more could we do for her by looking deeper than the problem, to the causes… and deeper than that, to what Sir Michael Marmot refers to as the causes of the causes.

So it’s a bit of a calling that affects us all in different ways.

The hope is that wherever we wind up, we are in some way contributing to building stronger communities. And it’s truly important that we all recognize that we have something to contribute, and what that is.

I’ve a friend, Nasim. He’s a medical doctor, as is his wife. 

And while Nasim could be anywhere in the world, he has chosen to stay in Bangladesh, to help the people of his country, to see his kids grow up knowing their culture. He’s happy knowing he can make a difference, not matter how big or small, in the well-being of his country.

I’ve been fortunate to spend time in many different places, and to see a variety of approaches and contributions.

I was involved in a project in Kosovo after the war.  One aspect was the rebuilding of a maternity hospital in Pristina, a building with hardly a window intact, with sewage running down the walls from leaking pipes, where babies other than the healthiest had a mortality rate over 25%.  In one week in Kosovo - one week - they would have as many cases of meningitis as we would see in Canada for the same population over five years.  In Canada, a handful of cases would spark a media frenzy and mass immunization. 

And following on the pre-war tradition, the Communist bureaucratic approach and efficiencies, cases were definitely still being reported to the capital, the focus being on getting the numbers right and not so much on preventing new cases.  Interesting.

Two weeks ago, I was in Chile.  They’re very conscious of how the various influences on health or determinants interrelate and how solutions go beyond any one sector or level of government.  In a middle income country, their average income is about a half of what it is for us in Canada.  They’ve approached child health with the resources that they have by a mix of targeted programs to support the poorest and general programs for all first pregnancies up to the age of two.  So as a result of that, they’ve had a dramatic improvement in infant mortality.

Cuba is also an interesting country that I’ve spent some time in, and for many reasons -- not just the least of which is that with 5% of the wealth per person of the United States, they have an infant mortality rate and a life expectancy virtually the same.  Now, I’m not arguing for the Cuban system as a whole, but what they do is they get the basics right.  Everyone is connected to a local doctor, a nurse, standard care protocols ensure that few fall through the cracks.  More complex problems are referred to the polyclinics where the specialists come to the regional centers and if need be, they can move on to regional hospitals and more sophisticated hospitals.  The point is that with a strong emphasis on prevention and primary care, it reduces the numbers that need for sophisticated and more complex therapies and so they’re able to actually deliver them. 

Close to home, when I was in Saskatchewan, we were faced with very high rates of Hepatitis A in the northern and rural areas – particular in northern reserves.

The real cause? Generally, housing issues, sanitation, crowding. But it was difficult to make significant progress on resolving those issues. So our solution was to work to get every kid immunized against Hep A.

It wasn’t the perfect solution, but at least kids were no longer getting sick and dying from Hepatitis.

One of the best things I think we were able to achieve in that province and this is back in the 90s, was actually helping ensure continued benefits to low income families. So if a parent would be able to successfully come off welfare, and get a job, they wouldn’t lose the dental and drug plans for their kids. Because the way it was, they would get a job and lose those benefits… which are a disincentive to work.

So I consider myself lucky to have seen different solutions in different parts of the world… it’s been invaluable to witness the kinds of differences we’re able to make.

Some of you are already doing these kinds of things, and some of you are on your way, and we need all of your contributions.

I’m often asked: “what do we need in public health in Canada? What kind of people do we need to be training and hiring? What expertise do we need to acquire?”

And I think it’s just easier to ask: “what expertise don’t we need?” There’s certainly no shortage of challenges facing us.

PUBLIC HEALTH CHALLENGES - - TODAY AND TOMORROW

Most of the challenges we’re facing today are just the tips in a field of icebergs.

Thanks to rising obesity rates -- what some call the new tobacco -- we’re faced with the very real possibility that the current generation of children may actually be the first to have a lower life expectancy than their parents. Imagine what a step backwards that would represent.

Not only is the prevalence growing, it’s spreading. It’s no longer an issue restricted to industrialized nations. The obesity epidemic is starting to affect developing nations, where it sometimes even coexists with malnutrition.

So obesity rates are rising … rates of type II diabetes are rising …  the population is aging… And we’re seeing an increasing economic burden of chronic disease.

At last count, the total indirect and direct costs of all chronic disease in Canada was over $100 billion dollars.

Now, according to Disraeli, as well as Mark Twain, there are exactly three types of lies:  Lies ….   Damned Lies ….  and Statistics.

Their dislike for the stats notwithstanding, these are incredible numbers that underscore the magnitude of the challenges ahead of us.

Beyond chronic diseases, if we look to our environment, the challenges aren’t less daunting.

The UN’s International Panel on Climate Change has reported that if things don’t change, we could see global temperatures warm by a further 1 to 2 degrees by the 2020s.

The effects of that small an increase would potentially include a higher proportion of humanity facing heat waves, floods, droughts … and an estimated 20-30% of known species facing an increased danger of extinction.

Overall, the list of impacts that the panel expects from predicted warming across the 21st century reads somewhat apocalyptically: from considerable impacts to ecosystems across the planet, to serious consequences on the most vulnerable populations and the industries on which they rely – those that tend to be in coastal and river flood plains, and tend to be more reliant on climate- and weather- sensitive resources …

Personal health will be put more at risk from severe weather events… we’ll see increases in malnutrition… increased diarrhoeal diseases…increased frequency of cardio-respiratory diseases due to higher concentrations of ground-level ozone in urban areas … and the altered spatial distribution of some infectious diseases.

It’s not even all bad – in some areas, food production may actually improve … in the short term. Though in others, food production will fall.  Some areas in Africa may actually be assisted by climate change in their war against malaria. But it’s clear the bad will outweigh the good – especially in developing countries.

In our own North, the risk of permafrost melting brings the possibility of destabilized roads, buildings, pipelines, airports.

Warming will change habits and traditional lifestyles…game migration will change … previously unseen parasites and viruses can appear.

Thunderstorms are rare in the North, but climate change is making them more frequent. Hunters are now known to have difficulty building igloos because the snow is packing tighter.

That’s just one region. Around the world we’re already seeing flooding increases, drought increases, changing human migration, human virus migration, and animal virus migration. There are increased burdens on country meats – for example, as native species now face parasites for more cycles over the course of a season.

And it’s almost always – almost always – the poorest populations of the poorest countries with the lowest level of social organization and support who are the most vulnerable.

What happens to those who can’t escape the consequences of rising heat or rising water?

But it isn’t just a rich or poor issue. We need to understand the changes happening all around us. We need to be committed to addressing the basics of health to build healthy, resilient communities, at home, and everywhere.

Those basics do matter, and everything is connected.

- Health Inequalities & The CPHO’s Report -

A unique requirement of this Chief Public Health Officer position is that I report to Parliament once a year on the State of Public Health in Canada.

The first of those reports will be out later this year.

I chose to focus on health inequalities this first time out --  on our understanding of them, and how we can overcome them. It’s about those basics, and those connections. And it’s one of the biggest health challenges we face, and will continue to face.

To a certain degree, that theme was an easy choice.  In Canada, we often like to tell ourselves we’re the healthiest people in the world – and in many ways we’re up there.

But I would argue that a society is only as healthy as the least healthy among us.

We can’t rate how healthy we are simply by looking at the healthiest, richest, or most educated few. And we can’t just focus on averages – they mask important differences between the least and most healthy.

We have to consider those that progress is leaving behind.

Overall, we report generally good mental and physical health in Canada. We’re living longer. And over the past 100 years we’ve made great strides in improving the health of the population.

But not all health trends are on the upswing, and not all of us are benefiting to the same degree.

Some groups in this country have higher rates of infant mortality than others, higher rates of injury, disease, and addiction. Some are more obese and overweight.

In short, some groups of Canadians are not living as long, or as well as others.

It’s probably not shocking to this group that the poorest, or least educated, have worse health outcomes.

But I think it would be very shocking to some outside of the health community to know that, again, this isn’t simply an issue of rich versus poor. Any step down from the highest level of education, or highest level of income, carries with it a reduced life expectancy.

How surprising would it be to an upper middle class family to find out that, as a group, across society, they’re not actually doing as well as those with just a bit more income?

I mentioned Michael Marmot earlier. He famously provides an illustration of this very point. If you take a subway from the poor, black downtown areas of Washington, and travel 12 miles out into the rich, white suburbs, life expectancy rises for every mile you travel.

Our health is incremental, and every step up, as a population, is based on a number of social factors.

And it’s such a difficult state of affairs to comprehend in a country like this. Things don’t have to be this way, and there are things we can do. There are ways to reduce these social differences in health, to help people live in conditions and environments in which healthy choices are the easiest choices, and in which we all have that chance, that opportunity, to be healthy.

Some of you might be familiar with the work Chandler and Lalonde did on First Nations reserves in BC.

They found that on many reserves that had little control over their own affairs – political, social, and cultural – that teen suicide was sometimes several times higher than in the rest of the population.

But on those reserves where the band had a measure of control over its own affairs, where the community delivered some of its own social programs, where the people were involved in fire services, policing, education, and where land claims had been resolved. Well, the teen suicide rate plummeted, virtually to zero.

And what this illustrates is how beyond those basics – past the basic Maslow hierarchy – once you’ve got a roof over your head, a job, enough income to put food on the table and clothes on your back… beyond those things, one of the most important determinants of our health is that sense of control over your own future. The sense that you are affecting how things work around you, and how your personal destiny unfolds.

Equal to that in importance, I would add, are the social connections we each maintain. It’s been shown that those with the most social connections are the healthiest. Looking out for people, having people look out for you, loving, being loved…these are very important, and often overlooked, determinants of our health.

MOVING FORWARD

We’ve some momentum building in the country, and around the world, on understanding and addressing these social determinants.

The Public Health Agency of Canada has been very pleased to support the work of the World Health Organization’s Commission on the Social Determinants of Health, which is going to be reporting later this year.

We also have a Senate Sub-Committee Reporting later this year on a similar topic, but within Canada, and focusing on maternal and child health.

We also have a new Mental Health Commission, which I think is vital to promoting the idea that complete health includes mental health, and that truly healthy conditions and environments are those that promote positive mental health.

We’re seeing new public health bodies being established around the country -- not just nationally with the Public Health Agency of Canada, but in the provinces, including here in Ontario.

And really, much of the great work being done is happening right in communities across the country. When we’re dealing with social issues, the best work is often done by those closest to the problems.  

Individual projects and programs are doing everything from helping kids get nutritious breakfasts, to mobile health clinics bringing care to immigrant women who might not otherwise have access.

From the Public Health Agency’s national perspective -- while we have a lot of roles, from promoting health, to preventing chronic disease, to combating infectious diseases, to responding to disasters, and more -- I think one of our most important functions is to support these community level programs and to advocate on their behalf.

Collectively, all of these issues I’ve been talking about form a massive challenge, and it can sometimes be overwhelming. Climate change, an aging population, the growing burden of chronic disease, emerging infectious diseases, the possibility of a pandemic, the impact of social conditions ….

 
There’s an old Arabian saying, that “it’s not the road ahead that wears you out… it’s the grain of sand in your shoe.” In public health we try to maintain that difficult balance of working towards the big picture, keeping an eye on that road ahead, while at the same time working to get at that grain of sand.

And something helpful I’ve found to help keep the focus, as an individual, but also organizationally, is an acronym – PACEM – which is, not coincidentally, Latin for peace. It stands for partner, advocate, cheerlead, enable, and mitigate.

Partnership is about working with others, crossing individual artificial boundaries, building and nurturing coalitions around issues – doing things together better than we can do for ourselves.

Advocacy – that’s how we bring our expertise, evidence, and understanding to bear on the development of social policy.

We cheerlead by supporting, and by getting out of the way when something good is happening.

Enabling – these are the things that we actually do within our organizations, or ourselves, to help create the right conditions for health.

And mitigation. That’s basically about those things that the health system has traditionally been good at dealing with – picking up the pieces when something goes wrong and putting it back together. 

Just a few ways to think of our roles. It’s so important to understand and work to fulfill our roles and appreciate the interconnectedness between what we do.

I think the last few years have seen some really positive progress in public health.

In the future I’m hoping we’ll continue down that road, on which we increasingly think not just about how to fix and cure, but about how to prevent and avoid injury and illness, always looking closer and closer at the causes of the causes. We can never avoid all sickness… but it’s always better to try.

CONCLUSION

If you think about it: getting every kid a good start; seeing every kid finish high school; if we can see fewer people worried about food on the table and clothes on their back; or if literacy is brought to such a level that every adult has the ability to read and understand what the labels on their prescription bottles say.  Things like this pay huge dividends for society in countless ways. Once we can take care of these basics, imagine where we’d be as a country.

I’ll close with two things John F. Kennedy said that I think wraps this all up nicely: “the problems of the world cannot possibly solved by skeptics or cynics whose horizons are limited by the obvious realities. We need men [and women] who can dream of things that never were.”

He also said: “few will have the greatness to bend history itself, but each of us can work to change a small portion of events and then the total of all those acts will be written in the history of this generation.”

As health professionals, public health professionals, educators -- and beyond us in this room and this profession, simply everyone -- we all have a role to play and we all determine our health by the kind of society we choose to create.

Thanks so much for having me here. I wish you all great success in your studies and wherever your careers take you.