Chicago, Illinois January 28, 2005 Check Against Delivery Thank you for such a warm welcome. I am very happy to be here with you today. It is exciting to be in a room full of people who are the heart of the health care system. It is clear that health care is important to people in the United States. According to a CNN poll, health care ranked as the third most important issue the president and Congress must deal with this year - on par with terrorism and after the economy and the war in Iraq. Fixing a health care system is a complex problem. There is no "one-size-fits-all" solution. But I want to share with you an approach that can help any system work better. Today, I want to talk about putting the "health" back into "health care". The idea of keeping people well so that we don't have to treat their illnesses has been around for a very long time. Before 2600 B.C., Huang Ti, the Yellow Emperor, said "To administer medicines to diseases which have already developed ... is comparable to the behaviour of those persons who begin to dig a well after they have become thirsty, and of those who begin to cast weapons after they have already engaged in battle." Today, I'd like to take you through a more recent history of this idea in the Canadian health care system. The father of medicare in Canada, Tommy Douglas, knew that it was important to get the insurance piece in place, and then get on with keeping people well. When speaking to the future of Canada's beloved social program, Tommy Douglas emphasized the importance of disease prevention and health promotion: "Let's not forget that the ultimate goal of Medicare must be to keep people well rather than just patching them up when they get sick. That means clinics. That means ... carrying on home nursing programs that are much more effective, making ... immunization available to everyone ... It means promoting physical fitness through sports and other activities. "All these programs should be designed to keep people well - because in the long run it's cheaper than the current practice of only treating them after they've become sick." Then there was Marc Lalonde, who was the Minister of Health and Welfare from 1972-1977. In 1974, he published a working document entitled A New Perspective on the Health of Canadians. This report changed how we think about health care. I highly recommend reading it, if you haven't already. You can find it on the Public Health Agency of Canada's Web site In this document, he laid out two objectives. One was reducing health risk and the other, improving access to care. He laid out five strategies to reach those objectives - strategies around health promotion, regulations, research, system efficiency and goal-setting. Marc Lalonde said that good health was the bedrock on which social programs were built. He said that the health care system is only one of the many ways of maintaining and improving health. Thirty years ago, with the Lalonde Report, Canada led the world in the development of a population health approach. We know now that poverty, violence, the environment, education, shelter, equity are as important to the health of Canadians as the repair shop or sickness care system. SARS reminded us of what Marc Lalonde told us to get on with a long time ago, in terms of a population health approach. As we in Canada debate the sustainability of our cherished health care system, we cannot underestimate the imperative of dealing aggressively with all determinants of health. Moving forward in time, in 1986, the Ottawa Charter for Health Promotion was developed and adopted by the International Conference on Health Promotion in Ottawa. The United States was one of the participating countries in the conference. Health promotion, as defined by the Ottawa Charter refers to the "process of enabling people to increase control over the determinants of health, to improve their health". The Ottawa Charter was at the forefront of the dialogue around healthy public policy. It recognized the prerequisites for health - the determinants like peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice and equity. As a result of the Ottawa Charter, the programs Healthy Cities and Towns in Quebec and Healthy Communities in the rest of Canada were launched in 1987, thus applying a healthy public policy approach to the municipal level. The local projects focus mainly on health and social problems, environmental issues and local economic development. Moving forward again, in April, 2001, Prime Minister Jean Chrétien formed the Commission on the Future of Health Care in Canada, which was led by Roy Romanow. The Commission released its final report called "Building on Values: The Future of Health Care in Canada," in November 2002. The Discussion Paper 8 from the Romanow Commission changed my life. This fabulous paper by Brenda Zimmerman and Sholom Glouberman talks about health and health care as a complex adaptive system. Another recommended read, if you're interested in solutions for health care systems. This one is one the Health Canada Web site. As you may know, complexity theory is a new way of dividing things into simple, complicated and complex problems. A simple problem is following a recipe. A complicated problem is physics, like getting a rocket to the moon. A complex problem is raising a child. I think that no one knows better than family physicians how complex the project of keeping people well really is. As Mencken said, "For every human problem, there is a neat, simple solution; and it is always wrong." A complex system also means that some health issues cut across government jurisdictions, which can lead to a gridlock. In 2003, we learned about this gridlock; we learned that diseases know no borders; we learned that we needed to look at better ways to share information. In October 2003, the National Advisory Committee on SARS and Public Health put out a report called Learning from SARS: The Renewal of Public Health in Canada. This report coined the four "c's" from SARS: collaboration, cooperation, communication and the clarity of who does what when, in an emergency. The report is a very important blueprint for not only infectious disease but also chronic disease, injury prevention and emergency preparedness. Based on the recommendations of the report, we've created the Public Health Agency of Canada and appointed a Chief Public Health Officer. And, if it hadn't been for SARS, I probably wouldn't have my job as Minister of State for Public Health. As I said, SARS was a huge wake-up call to what Canadians have lovingly called the "tyranny of the acute," - the focus on the sickness care system, the repair shop model, and the under investment in the upstream realities of our shared goal of keeping Canadians well. SARS has provided us an opportunity for transformative change, for a real renaissance in the understanding of the importance of population and public health and the peril of taking it for granted. I know how important it is not to take these things for granted. Before I ran for public office, I was a family physician. When I think about public health and how it relates to being a family physician, I think of the four principles of family medicine: The patient-doctor relationship and the needs of our patients are central to all we do. We are skilled clinicians providing and coordinating a broad range of evidence-based health care for individuals and families throughout their lives. We are community-based physicians responding to patient and community needs in our offices, hospitals, patients' homes, and other community settings. We are a resource to our practice populations promoting health to prevent illness, providing and explaining health information, collaborating and facilitating access to other caregivers, and advocating for patients throughout the health care system. So as well as being skilled and having good doctor-patient relationships, family doctors are also expected to have a relationship with the community and population. In 1994, I wrote the toughest letter I ever remember writing - a letter to my patients explaining that I was going to run for public office. I remember the patients saying they're going to lose a good doctor. And I remember explaining that I thought I had to go and do this in order for it to be possible to be a good doctor, that if the system was falling down around us, there had to be a voice from the trenches at the table where the decisions were made. When I was asked to do my job by the Prime Minister on December 11th last year, I said "Now, you know this just can't be about infectious disease," and I thought here's this man asking me to be in his Cabinet and I'm already arguing with him. But SARS taught us not to take public health for granted - that it is important to reverse the other epidemics of obesity, heart disease, diabetes and cancer. I don't expect you to just take my word for it that public health is important. The fact is, there is hard evidence showing that investments in public health save lives and money. According to the World Health Organization, chronic diseases cost Canadians $80 billion a year. Over 90% of type 2 diabetes and 80% of heart disease could be avoided with good nutrition, regular exercise, quitting smoking and stress management. According to the Chronic Disease Prevention Alliance of Canada, up to 70% of all chronic diseases can be prevented. As of 1998, the total cost of illness in Canada was over $159 billion - and 67% of that was spent on chronic diseases. Finally, our Chief Public Health Officer, Dr. David Butler-Jones, says that it is a moral imperative to help prevent injury and disease-if we can prevent a broken hip or a heart attack because we funded injury and disease prevention programs and health promotion programs, then we are on the right track. We can say that we "get it". First, with the meeting of the prime minister, the provincial premiers and the territorial leaders in September 2004 we were actually able to see the that different levels of Canadian government "get it." We were worried they were going to take prevention/promotion off the agenda because they were two hours behind. Then, when we heard those provincial premiers and territorial leaders talk about everything from immunization to obesity to trans fats to rails for seniors so they don't fall, we understood that the leaders in Canada get it. They wrote in their news release that better health for Canadians will include a Pan-Canadian Public Health Strategy. This will address risk behaviours like lack of exercise and unhealthy diet - and look at integrated disease strategies. Work will also be done through initiatives like Healthy Schools. Then, the Speech from the Throne then built upon the September meeting. (The Speech from the Throne is a document laying out the broad agenda for the government). The top levels of government finally understand that prevention will help the sustainability of the health care system. All levels of Canadian government realize that public health efforts on health promotion, disease and injury prevention are critical to achieving better health outcomes for Canadians. To illustrate the kind of shift in thinking needed for an upstream focus on health care here is a selection from my 20 Questions to Save Medicare ... Health Care, to me, means: A. Best possible repair shop B. Keeping people well, improving their health status I would rather: A. Train more orthopaedic surgeons B. Spend money on a communication strategy to prevent broken hips by asking seniors to remove their scatter rugs, not to put their newspaper on the floor and to wear rubber-soled shoes I think doctors should be rewarded for: A. The number of patients they can push through in a day B. Keeping patients well, the results they achieve in immunization rates, mammograms, helping patients stop smoking I'd rather my tax dollars went to: A. Clean air B. More puffers and respirators Another tool I've been using to help get people engaged around healthy public policy is my public health tree. I could do a rock video on the evolution of this tree in terms of the amount of help I've had in changing it to reflect people's realities about what's going on for them. Victor Ling, the famous cancer researcher, told me my root system wasn't big enough - my tree was going to fall over. I had a fabulous conversation with the chief medical officers of health for this country who want it now to be an evergreen. And growing up on Georgian Bay where the west wind shapes the pine, I think I also want a very brisk west wind out here that is healthy public policy and good macroeconomics. The tree is very much a part of getting some sort of coherent public policy - it puts a health lens across all government departments and helps all jurisdictions understand that they've got a role to play in keeping people well. The roots of my tree have all of the determinants that you well know in terms of poverty, violence, the environment, shelter, equity and education. It then depends what population forest you get born into, and we have certainly seen that if you get born into the First Nations or Métis or Inuit forest that you can have worse health outcomes. I'm trying to figure out how we can put that particular forest in neon. If we cannot close the gap on the health status of our First Nations and Inuit and Métis people that we will have failed. Closing that gap becomes a very important goal. I really want to underline that poverty is one of the main determinants of health. A joint Canada/United States Survey of Health in 2002/03 showed, that "In both countries, individuals with the lowest incomes reported poorer health and higher rates of severe mobility limitations, as well as higher levels of smoking and obesity compared with those in higher income groups." We then come up to ground where there's self-esteem and secure personal and cultural identity. And then up into the choices piece around sexual health, smoking, physical activity, healthy eating, alcohol and drugs and then out into the branches of the individual disease strategies. In terms of self-esteem, when you look at the indicators around healthy active kids, you see that mental health is part of that. From self-esteem and physical activity comes a whole piece around social inclusion and belonging. Health outcomes are reflected in the branches and leaves on the tree. They are chronic diseases like type 2 diabetes, heart attacks and strokes, or cancer. They are also addictions, mental health problems and preventable injuries. For people who have the right determinants going for them, and who avoid the risks and make the right health choices, the outcomes can be Olympic medals or at least a personal best in running a marathon. We need an integrated strategy, from self-esteem on up. The eating, smoking, drugs, exercise, mental health lead to diabetes, cancer, cardiac, Olympic medals if you want. All of these things will come out of the top of a decent integrated strategy for keeping people well. I'm talking about a healthy public policy that takes into account determinants of health. A healthy public policy that is evidence-based. Given the scope and complexity of the challenge, and the need for action in many areas, we need the best available information to make good policy decisions. And that's where research comes in. Citizen Engagement is important in shaping healthy public policy. With a strong common purpose, local wisdom, local knowledge, we can get the job done. I hope you go from this Seminar today with a better understanding of Canadian public health policy. If you do, then I'll know that I am doing my job as a Minister. Benjamin Disraeli, who was the prime minister of England in 1868 and 1874-80 said that public health is the foundation for "the happiness of the people and the power of the country. The care of the public health is the first duty of a statesman." In closing I want to use the fabulous quote from the Wanless Report in the UK. This report was very important for me because Gordon Brown - the Chancellor of the Exchequer in Tony Blair's government - asked Derek Wanless, who was a former president of the NatWest Bank, to write it. And the report ended up underlining what it is we want to do. It's hugely important in that it understands economically that two and two makes five. Derek Wanless opens the report with a quote by Dr. Elizabeth Blackwell, who was the first woman to graduate from medical school - Geneva Medical College at Geneva, New York in 1849. She observed over a century ago, that "We are not tinkers who merely patch and mend what is broken... We must be watchmen, guardians of the life and health of our generation, so that stronger and more able generations may come after." I wish you the best of luck with this very important issue. Thank you.
