Throughout his 30-plus-year career, Dr. David Butler-Jones has been an agent of transformative change. Having recently announced his retirement as the founding director of Public Health Agency of Canada, he recalled for IANPHI World how the Public Health Agency of Canada evolved and lessons learned.
What circumstances led to the creation of the Public Health Agency of Canada?
In the early 2000s I co-chaired Canada’s national review of public health capacity, commissioned by provincial and federal Deputy Ministers who realized that public health had been neglected during the 90s due to budget constraints and the focus on hospital deficits. Among the many findings we confirmed were that the system was coping, though barely, and that it couldn’t manage more than one crisis at a time or anything too big or too long. When the report came out a year and a half later, all Deputy Ministers had changed since the report was commissioned. Focused again on acute care, they shelved it.
Then in spring of 2003, SARS hit. It wasn’t a good scene: healthcare workers responded courageously, but still people lost trust in the system. Affected hospitals had huge challenges, communications were poor and information was shared selectively, and different officials were saying different things or changing messages.
The constellation of many different issues ultimately led to both economic and social costs on top of the direct tragedy for those affected.
Following the outbreak, the National Advisory Committee on SARS and Public Health reviewed the SARS experience and findings of other groups, and made a number of recommendations. Health charities and professional organizations came together to develop six basic recommendations that were also broadly accepted. The two key ones, in addition to the need for additional resources and capacity focused on public health (not just infectious diseases), were that Canada needed a separate department focused on public health (at the time it was just one of the functions of the Ministry of Health), and that we needed a chief public health officer with some independence from the government and the ability and credibility to speak on matters of public health. The Public Health Agency of Canada became a department when I took on the position of Canada’s first NPHI director in September 2004.
What were your responsibilities as chief public health officer?
My first job was to build the agency, in part from elements in Health Canada (the Ministry of Health). We developed the Public Health Network (PHN) Council that brought together the senior provincial, territorial and federal officials in public health. Underneath is an expert committee structure to facilitate collective work on issues that jurisdictions have in common. The PHN reports to the Conference of Federal-Provincial-Territorial (FPT) Deputy Ministers which I sit on, which then reports to the Conference of Ministers. In Canada my position of chief public health officer is a dual role. As deputy minister, I am responsible for policy, communications, and finance for my department, as are deputies in other departments. As chief medical officer, I am responsible for managing public health issues and speaking publicly. From the outset we had to build credibility and demonstrate utility and a clear sense of where we were going and what we were trying to accomplish. For the first few years, I was a bit of a traveling salesman -- speaking, meeting, working with colleagues in the provincial, territorial, federal, and international levels as well as with professional groups about the Public Health Network and our collective vision for public health.
What were the keys tasks of the new agency?
My view at the outset was that there were three things we will ultimately be known for having succeeded or not.
First is our ability to prepare for and respond to public health emergencies.
Second is to bring health promotion into the 21st century, linking our understanding and application of social determinants and one health (animal, human, environment and economy).
The third is support for public health practice. Public health is ultimately local. It may be a thousand localities at the same time, but the point is that at each level of governance we need to provide added value so that every locality has access to the tools, ideas, and expertise needed to connect and effect public health. So whether it’s our best practices portals or other tools and programs that we continue to build across the spectrum of public health, whether for traditional public health functions, educators, policy makers or community workers, they can be useful on many fronts.
Even though more people die from chronic diseases and infections than during pandemics, outbreaks or natural disasters, we knew that if we didn’t plan well to handle public health emergencies, we wouldn’t have much credibility for anything else we did. We needed some basis of trust. We had to make sure that people knew each other at all levels, so we didn’t have to introduce ourselves in the middle of a crisis. We needed plans in place so we could focus energy on the crises. That meant having everything from pandemic plans in each jurisdiction to a secured domestic supply of vaccines sufficient for the whole population if need be, stockpiles of antivirals that could be deployed quickly, back-up ventilators and a whole host of other things.
We’ve been promoting and continuing to develop what we call “one health,” which links animal and human health, the environment, and the economy so we don’t miss those key intersects that are important if we’re actually going to shape a better future and respond effectively to outbreaks.
How did Canada handle the H1N1 pandemic in 2011?
We focused on communication of basic risk issues—what we knew, what we didn’t know, how we were going to address those gaps, and, as important, what people could do to protect themselves or their loved ones. Sometimes those were very simple things. During the H1N1 outbreak, we were told that people could tell the Canadians in international airports because they were coughing or sneezing in their sleeves rather than their hands. Public buildings and even small shops had signs encouraging proper hygiene including available hand sanitizers. Interestingly, we saw very few community foodborne illness outbreaks or other infections in hospitals.
During the pandemic the Public Health Network served as our focus for coordinating the Canadian response. In addition, the Conference of FPT Deputy Ministers met at times weekly to get rapid policy decisions as needed and to form a deputies' committee of all key federal departments to ensure a coordinated federal response. I was part of both committees as well as being federal co-chair of the PHN Council.
By sharing our reagents with provincial labs we were able to get confirmed results within a couple of days on potentially infected people. Because of that coordinated effort, Canada had almost half the population immunized well before Christmas. While we had the occasional case in the new year, for the first time in history we effectively stopped and changed the course of a pandemic.
Our partnerships internationally with the World Health Organization (WHO) and IANPHI as well as the Global Health Security Action Group allowed sharing of knowledge and information that assisted each other in understanding what was going on elsewhere and applying learning more broadly.
If we hadn’t been as focused as we were, if we hadn’t been as successful in treating serious cases with antivirals that minimized the spread of those strains, if the virus had not been so responsive to antivirals and the vaccine, if the world capacity had been as it was in 1918, it would have been a very different picture.
We have strains of the 2009 virus that kill ferrets (best animal model for human disease) in the lab faster and nastier than the 1918 virus.
Looking back, what are some of the things you are proudest of since the Public Health Agency of Canada was created?
We just had our ninth anniversary, and it’s been ten years since SARS. We’ve checked off the boxes that we set out to do for each of the recommendations from reviews of SARS and events since. We’ve made some remarkable progress—positive legislation enshrining the role of the agency and of the director as having an independent voice as needed on matters of public health. We have established our reputation domestically and internationally, in being a good partner and bringing added value.
We are seen as one of the key players in thought and action towards addressing the social determinants of health and a One Health approach.
We have also built some unique capacities in tools for detecting and managing outbreaks in Canada and internationally.
Our Global Public Health Intelligence Network at one point provided a majority of reports to WHO on outbreaks in member countries. And in retrospect when we were piloting it, we probably picked up SARS in late fall prior to its breaking out of China. So the potential is great if you can pick up on outbreaks early; countries can actually get assistance, so you may have only hundreds of cases rather than thousands or tens of thousands and a better chance of heading off outbreaks earlier.
Our portable lab system doesn’t require external power or water and has the capacity to do diagnostics on Level 4 pathogens in the field. It fits in a few crates that can be flown on a small plane into just about anywhere in the world. We’ve used it in support of WHO and other countries in the mountains of the Congo with Ebola outbreaks, and Rift Valley fever in East Africa, and at the Beijing and Vancouver Olympics among others.
You were a founding member of IANPHI and on its Executive Board. What does IANPHI bring to the table?
I’m deeply committed to IANPHI. It brings together heads of key national organizations responsible for public health around the world so its members can build those relationships and share information. IANPHI was hugely beneficial during the H1N1 outbreak because of our connections in IANPHI.
For example, knowing colleagues in other countries before a crisis hit allowed us to have the kind of conversations we need with a measure of trust gained only through knowing each other, to allow us to collectively address things more effectively.
The world has fundamentally changed. Forty years ago, there were WHO and the U.S. Centers for Disease Control and Prevention (CDC) and other countries with varied abilities. Now there’s substantial capacity in many countries. In any country may be found the potential leadership or expertise that can benefit others, not just those that are larger better resourced or higher income.
The question is how do we tap into those capacities? The IANPHI Secretariat’s ability to help facilitate those connections is going to be a key strength of IANPHI in the future, a benefit to member organizations, and a clear rationale for being part of it.
As a complementary organization to the work of WHO, there’s no better forum than IANPHI to bring together the experience and technical expertise of NPHIs to meet the policy and practical challenges that we all face to varying degrees. IANPHI is one of those organizations in my view that, if it didn’t exist you’d want to create it. I think it’s absolutely essential.
What lessons learned would you like to share with other IANPHI members?
Have a clear sense of what you want to accomplish, and keep it practical and value-added. Today the Public Health Agency of Canada is the lead federal department for six functions of public health (population health assessment, disease and injury prevention, health promotion, surveillance, emergency preparedness and response, and health protection). Other NPHIs may have different mandates or structures, but we are all working towards improving the health and well-being of the population.
It’s about partnerships and relationships. Fundamental to that is respect. If we don’t understand where others are coming from, the responsibilities they have, and what they are trying to accomplish, then we have very little chance of influencing them. If we can find ways to help them do what they want to do, to help them reach their objectives, it’s amazing what you can accomplish.
These positions we hold offer a tremendous privilege to be engaged in such important work that can make a positive difference in people’s lives.
I have always found it best to gather around me people with different views and expertise who are comfortable with telling me not necessarily what I want to hear, but rather what I need to hear. And I have been privileged in some small way to be part of all that.
I'm not a caretaker. I like to build and develop, to transform and change.
David played an active and thoughtful role in shaping IANPHI. He understood the value and potential of NPHIs and their collective organization, IANPHI, and regularly suggested ways for IANPHI to operate in a more strategic and effective manner.