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DATE/DATE: November 5, 2007 8:30 a.m.
LOCATION/ENDROIT: Marriott Hotel, Ottawa

SUBJECT/SUJET: Keynote Address by Dr. David Butler-Jones, Chief Public Health Officer, Public Health Agency of Canada "A Perspective on Global Health" at the 14th Annual Canadian Conference on International Health.

Dr. David Butler-Jones: Thanks very much, Diane. And bonjour, bon dia, buenos dias, shalom, whatever hellos are from wherever you come from, please, please. Merci. C'est pour moi un grand plaisir d?tre ici aujourd'hui. It really is good to be here. One of the things I'll be talking about -- there's only so many things I can touch on in terms of this global village and the impacts that it has on health and the vulnerable.

I'm going to -- I'll start though with -- and so I'm not going to cover the whole watershed. I'm going to focus on a couple of areas. But I did want to start with a quote. And Canada has a long history in health and if you actually go back to the 17th century, actually much longer than that in terms of sort of Aboriginal healing and the understanding of the environment and the connection to health, etc. But Horatio Nelson actually was stationed in Quebec City one winter and he came back to England to say ?Health, the greatest of blessings I never truly knew until I saw fair Canada.? So there you go.

Je profite de l'occasion pour remercier tous ceux et celles qui sont parmi nous.

I just want to start with a -- sorry, I've already started but there you go. But in terms of the actual remarks around a short story. It's about how the starling came to North America. It's about 120 years ago Eugene Shefflin, he was a theatre lover and part of the Acclamation Society of North America and he wanted New Yorkers to experience every bird ever mentioned in the works of Shakespeare. And many of these of course were not native to North America. So he tried to introduce a few species and he repeatedly failed. But then he struck on one, the starling. So he brought about 100 birds and let them loose in New York Central Park.

Well-intentioned kind of things that people did then and now but, as it turned out, starlings are rather aggressive and very adaptable. The initial cohort of 100 has grown to about 200 million in North America. They force out smaller songbirds. Massive flocks are numbering in the hundreds of thousands, even millions and they devastate crops and leave a trail of waste that risks the health of both humans and buildings and it's here to stay.

Well, the point is I think that there are a number of things that can be taken from this experience. But particularly pertinent to this conference and what I'm talking about is the interconnectedness of everything we do between our actions, policies, environment and health outcomes here and abroad.

And let's not forget that within 200 years of Columbus arrival, 90 percent  90 percent  of the population of the Americas was wiped out by the importation of Eurasian diseases  the smallpoxes, the measles, the infuenza  that there was no counterpart for in the Americas.

And when we're thinking about vulnerable communities around the world, one of the fastest growing, at least people are finally starting to recognize this as a public health issue and that is the changing climate and the impact in communities and particularly in Canada's North. Now Northern communities are really looking at the melting of permafrost that would have, for example, destabilization of roads, buildings, pipelines and airports. The warming will change habits and traditional lifestyles and in the North this means changing patterns of game migration and the arrival of previously unseen parasites and viruses as well as the increased burdens on country meets of, for example, native species that once parasites would go through maybe one cycle a season in terms of their life cycle now go through two or three.

There's a Nigerian folk saying that says ?The day on which one starts out is not the time to start one's preparations.?

So in the North we're now seeing thunderstorms that used to be rare. Hunters have even been known now to have difficulty building their igloos because of the warmer temperatures, the hard snow pack.

And this is just one region. You look around the world and you see different, but all the same life-altering and potentially dangerous, impacts. Water supplies become less secure. Flooding increases in some areas, drought in others and alternating in the same place. We see changes in the migration patterns not just of human viruses but animal viruses and parasites as well. Agriculture around the world is being altered.

Livestock are exposed to new and different infections. New impacts on crops, on country meets, as I mentioned. And no surprise and no coincidence it is almost always, almost always the poorest populations of the poorest countries with the lowest level of social organization and support who are most vulnerable to the changes. What happens to those that can?t escape the consequences like rising heat or rising water? I remember flying into Bangladesh a few years ago and remarking at the amount of flooding and how houses were surrounded by water and I asked some of my colleagues about the flooding. What flooding? It was just monsoon. Anyways, different challenges.

So we saw that in a couple of the world's most prosperous nations, in the aftermath of Hurricane Katrina and in the devastating impact of the Paris heatwave in 2003. In Paris, thousands of vulnerable, isolated, disabled seniors died partly because of poor communication and a tragic lack of planning. In addition, many died because they refused to leave their pets behind and there was a policy for those evacuating them that they would not take pets and they'd rather stay behind with their pets and died as a result.

In New Orleans, people living in poverty and with disabilities were disproportionately affected and it's telling that almost a million people evacuated just a couple of weeks ago but this time in Southern California. They were getting the messages. It's interesting, the media, at least, talking about people having access to their acupuncture, musical performance, reflexology and yoga. Two different communities, same country.

Of course it isn't simply just a rich or poor issue as we know that some countries have been more effective than others in mitigating the impacts of poverty. It, however, remains an issue. We must ensure we understand the changes happening in the world and are committed to addressing the basics of health in building healthy, resilient communities.

It's interesting that Jean-Jacques Rousseau in the 1700s was able to say without any challenge, without any contradiction, ?Half the children die before their eighth year. This is nature's law. Why try to prevent it?? Well, we spent a couple of centuries trying to do that and, after all, in his day life expectancy really at about 40 hadn't changed much since the Bronze Age. And in Canada in 1900, just over a hundred years ago, one out of five babies died. Infant mortality was one in five. And by the end of that century it was less than one in a hundred. Yet life expectancy at birth due to a combination of HIV/AIDS, poverty, destabilization, other diseases, in some parts of Africa is back in the 40s like the Bronze Age.

I'm going to give you another little quote. See if you can -- while I'm saying it, see if you can figure out where it's from and when. ?Remember that the sanctity of life in the hill villages of Afghanistan among the winter snows is as inviolable in the eye of almighty God as can be your own.? This from William Gladstone who was prime minister in Britain in the 1800s talking about the great gain in the British versus Russian influence in that region of the world. And today in Afghanistan, at least recently, two out of five children would not make the age of five ? pretty close to the 1700s.

But rather and so I think it's important that rather than just focusing on soldiers deaths, as tragic as they are and they are tragic, that we do spend more time focusing on what the Canadian International Development Agency, IDRC, the World Health, UNICEF, etc. are doing as children are being immunized. Health care workers are being trained. Food and other essentials are being distributed as infrastructure is rebuilt though sometimes to be destroyed once again and access to education, all of these are the stories that I think should be much more prominent and much more of our focus. Yet even then, even then, the focus of the media largely is on how not every dollar gets to exactly where we expect it to go.

I can't imagine what we would say in Canada after 150 years of colonization, war and poverty, how effective we would be in Canada at getting every dollar to exactly where it needs to go. I think we need to have a better understanding of the complexity and the relationships here.

Now, if not for polio vaccine shifting gears a little bit  if not for polio vaccine we would not be worried about hip and knee replacements in Canada because all the orthopedic surgeons in the world that could ever be trained would be focusing on the effects of polio in children. And if not for obesity, we would not have lineups because the vast majority is related to most of us having gained weight and the impact of that on our joints.

And if not for wars and poverty and destabilization we would already have wiped out polio in the whole world as we did for smallpox. Today there are only four regions left in the globe in which polio is endemic. One of the largest is in Kandahar province and in March of this year CIDA committed five million to fight this with the goal of immunizing seven million children and Canada is working with NATO in the Kandahar region to try and address these issues collectively and to make Kandahar one of the next polio-free regions.

Now in the 19th century, another British prime minister said that the health of the public is the foundation upon which rests the happiness of the people and the welfare of the state. I think it's as relevant today as it was 150 years ago though sometimes we forget. And sometimes we fall into a trap where we create a false dichotomy between domestic and foreign security and health. When it comes to health, security vulnerable populations the problems faced by one part of the world are almost immediately felt by its neighbors and then on and on and on.

For us here in Canada SARS was a big wake-up call, how a disease can progress on one side of the world and how it is dealt with locally, nationally and by the international community all became very significant to us.

From the other side of the globe, it didn't take long for one region's problem to directly become our own. The air we breathe, every molecule that we breathe was once breathed by someone else for centuries and millennia and it's funny to think -- I mean I always find it amazing to think that, you know, that breath I took part of it might have been taken by Caesar or whoever you want, right? And some of them not nice people though I'm not sure what class Caesar would go in, at least Julius.

The one thing about Julius, if you ever read his memoirs sorry, sidebar  if you ever read his memoirs he always talks about these great battles and having two casualties. Well, that's because he puts all the allies up front, right? The Romans stayed behind and all the Nubians and everybody else was in the front lines but those didn't count as casualties because they weren't Roman. So, anyways.

And it's not, I mean it really is not just an infectious disease issue. And increasingly globalized world urbanization, media, infections, I mean the whole economies, I mean everything else it's almost impossible to think of how we can separate these issues whether it's around contaminated products or lead in toys or fast foods or shared pollution. It's all connected.

So while we share risks though, it's also encouraging that we're now increasingly sharing some responsibilities and solutions. Like the increasing efforts, the momentum we're seeing to reduce the global burden of chronic disease though sometimes it feels like a pretty uphill battle. And the impact not just on -- because you're seeing, for example, in developing countries this dichotomy of people with not enough to eat and people who are grossly obese in the same communities.

And the impact is not just on individual lives but on whole societies and economies and there are some things like the global strategy on non communicable diseases, the global strategy on diet, physical activity and health and the WHO Framework Convention on Tobacco Control which are positive items. The fact that agencies like ourselves, CDC and others around the world have come together in an international organization of heads of public health, national public health institutes, that never occurred until two years ago. And so we can actually start to address and interestingly Gates is providing funding to this organization to ensure that poor countries can be active and participate and work around the development of institutes as well.

Now the involvement of Canada I think has been particularly significant whether it's around pandemic, avian and human pandemic planning or the Commission on Social Determinants or the Age Friendly Cities Initiative, we're in the middle of it and I'm quite proud to say so.

The last one I want to talk a little bit about because Age Friendly Cities is a recent endeavour with the WHO and it represents I think a very useful model framework for approaching large public health issues. It resulted in a set of guidelines developed in partnership with cities and inhabitants themselves for making communities more age friendly, whether health services are accessible, what state of the environment, surroundings in, access to employment, transportation, etc. And all with the goal of helping build conditions for healthier communities to thrive. The difference between communities that the same conditions that thrive and those that don't so that they are more prosperous and resilient. Communities that are then resistant in the face of outbreaks and public health crises and that are better capable of responding and rebuilding as well as in maintaining health in the first place. And while it targets older persons, it is titled Age Friendly Cities, not Aged Friendly Cities as the principles I think apply to the benefit of all and it really is an international, multi-sectoral, multi-jurisdictional endeavour.
Now I'm just going to wind down now so we leave lots of time for dialogue later but sometimes it seems absolutely overwhelming when you think of the issues of poverty, of social justice of just economic conditions, of the environment and everything else it seems almost impossible. How can an individual or a small group or whatever impact on that?

And 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.? And so how do we get at these grains of sand at the same time being cognizant of and working towards the bigger picture?

Well, one of the things that I found helpful for myself and both as individuals and as organizations is something I call PACEM which is not by coincidence peace in Latin. And it's an acronym for the first is partnership, working with others, crossing individual artificial boundaries, working together, finding coalitions, building coalitions around issues as we come together to do the things together that we can do better than we can do individually.

The A is for advocacy, that is how we bring our expertise and understanding. Many of the social changes, many of the important work that's taking place in the Americas and elsewhere has come from people who recognize in their daily work the impact of conditions whether it's housing or water or whether it's poverty or education and the impact of that and bring that expertise and evidence to bear on the development of social policy.

Thirdly is cheerleading. One of the worst things that I can do as a physician is when all these good things are happening in the community and then I say to my patient you're better of smoking. Immediately I'm duped. Being part of, the same with the work that we do, the fighting, I can't imagine -- I used to talk about how in public health nobody -- we're so busy shooting at ourselves that nobody else had to as we argued over nuance or language or which professional will do what, etc. Not very helpful. So sometimes it's just better to stand back and say that's pretty cool.

Enabling. These are the things that we actually do within our organizations or ourselves to make the conditions. Do we have a healthy workplace Do we have accessible Do we have kind of working conditions that are amenable to people of different social conditions, etc. We're not very good at that but how we engage, how we work are ways that we can actually, if we think about it, do something about and how we develop policies within and without government and in organizations.

And, finally, there's mitigation. And that's basically what the health system traditionally does well which is whatever the situation we pick up the pieces and try to put it back together. A good example of that, as we all know, that inadequate housing, sanitation, crowding is why in many parts of the North and in rural Saskatchewan we have very high rates of hepatitis-A. No surprise. The solution is to fix the housing. Well, it hasn't happened yet. Maybe some of the new investments will certainly help with that but in the meantime every decade or so we'd have a major outbreak in Saskatchewan of hepatitis-A, a lot of people -- a lot of kids in hospital. By the time they're 15 or at least 20 virtually every kid in small rural communities on reserves would have had hepatitis-A. And a few of them have died, a lot of them been sick.

But there was a vaccine. And so we immunized all of these communities and essentially wiped out hepatitis-A in those communities so at least the kids don't get sick and die of that. So that's something that the health system does very well. Important work. Doesn't mean we stop working on those underlying conditions. Same as water management. We chlorinate the water or treat the water so we don't all get sick and die from typhoid and cholera. The solution is having better quality water in the first place but at least we can reduce the impact of the bad water on people.

So there are ways and those are just a few examples but ways we can think and you have your own ways I'm sure to think about how we take pieces of this towards the whole that we want to address because sometimes it does seem insurmountable.

So we need to understand and work to fulfill our roles and appreciate I think the interconnectedness between our actions, our policies, health outcomes, social changes, economics and on.

There is -- I'm going to close with an Ojibway saying. ?Sometimes I go about in pity for myself and all the while a great wind is bearing me across the sky.? It is important work that we do. We are not alone. It is good company that we keep. Have a great conference. Merci. (Applause.)

Moderator: Thank you very much, Bill. How's that for a challenge? I know Bill could have gone on and we would have been happy for another half hour or so but he is in a workshop following this session so for those of you who want to hear more, please look up that workshop.

I want to thank all our three speakers who contributed tremendously today to really shaping our agenda for the day but for the opening of the conference and really touched all the key issues that we wanted and put the major challenges right in front of you.