Canada 2010: what should global health expect?
Authors: Richard Horton
Journal: The Lancet (2009)

For South Africa in 2010, it is the World Cup. For Canada, it is the G8—on Jan 1, 2010, Canada takes over the G8 presidency. As the predicaments facing the world's leading economies grow ever more complex, Canada's global leadership has never been more keenly needed. Over the next 15 months, Canada has an opportunity to make a decisive impact on global health Canada could learn a great deal from Japan's example. Japan occupied the G8 presidency in 2008. The country's foreign policy team, together with national health leaders, prepared early. In 2007, Japan's foreign minister signalled his commitment to international health through human security.1Koumura M Global health and Japan's foreign policy.Lancet. 2007; 370: 1983-1985Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar The government proceeded to create an academic collaboration to propose action on health systems.2Reich MR Takemi K Roberts MJ Hsiao WC Global action on health systems: a proposal for the Toyako G8 Summit.Lancet. 2008; 371: 865-869Summary Full Text Full Text PDF PubMed Scopus (89) Google Scholar That proposal fed directly into the G8 meeting itself3Takemi K Jimba M Ishii S Katsuma Y Nakamura Y Human security approach for global health.Lancet. 2008; 372: 13-14Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar and led to a post-G8 process that identified key policy areas for priority action: the health workforce, financing, and information.4Reich MR Takemi K G8 and strengthening of health systems: follow-up to the Toyako Summit.Lancet. 2009; 373: 508-515Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar An attempt was made at a collaborative handover with Italy in 2009,5Kurokawa K Banno Y Hara S Kondo J Italian G8 Summit: a critical juncture for global health.Lancet. 2009; 373: 526-527Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar but internal Italian political distractions—the personal life of Silvio Burlusconi—made 2009 something of a dead year in G8 history.6Missoni E Tediosi F Pacileo G Borgonovi E G8 Summit 2009: what approach will Italy take to health?.Lancet. 2009; 374: 9-10Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar It is now time for Canada to restart the G8 engine. Prime Minister Stephen Harper has already signalled four priorities: the global economy, climate change, development, and democratic governance. But Canada's health community has so far been silent publicly on what Canada's priorities should be. Canada has many natural advantages to shape its international policy—world-class universities with global ambitions, a history of international policy influence (eg, the 1974 Lalonde report, which redrew the boundaries of health), front-rank scientists and intellectuals who have redefined what is possible in health,7Montaner JSG Hogg R Wood E et al.The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic.Lancet. 2006; 368: 531-536Summary Full Text Full Text PDF PubMed Scopus (427) Google Scholar, 8Schrecker T Labonté R De Vogli R Globalisation and health: the need for a global vision.Lancet. 2008; 372: 1670-1676Summary Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 9Jha P Avoidable global cancer deaths and total deaths from smoking.Nat Rev Cancer. 2009; 9: 655-664Crossref PubMed Scopus (401) Google Scholar and increasing overseas development assistance. The most prominent anomaly Canada has to address is the failure of the international institutional and donor architecture to address in any comprehensive and coherent way the catastrophic failure in progress towards the Millennium Development Goals (MDGs).10Horton R What will it take to stop maternal deaths?.Lancet. 2009; (published online Sept 23.)https://doi.org/10.1016/S0140-6736(09)61669-XSummary Full Text Full Text PDF Scopus (19) Google Scholar Integrating funding for maternal, newborn, and child health into the Global Fund for AIDS, Tuberculosis and Malaria and the US President's Emergency Plan for AIDS Relief is urgently needed if MDG targets are to be met in 2015. But beyond rebalancing existing programmes, Canada's unique experience as a nation could lead it to make important contributions in five further dimensions of global health. First, health systems. Canada's health service benefits from relatively low health disparities, high levels of public solidarity, and a strong commitment to equity. Universal coverage is now top of the global health agenda.11Garrett L Chowdhury AMR Pablos-Méndez A All for universal health coverage.Lancet. 2009; (published online Aug 20.)https://doi.org/10.1016/S0140-6736(09)61503-8Summary Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 12WHO Maximising Positive Synergies Collaborative GroupAn assessment of interactions between global health initiatives and country health systems.Lancet. 2009; 373: 2137-2169Summary Full Text Full Text PDF PubMed Scopus (426) Google Scholar Canada must deepen and broaden G8 commitments to health-systems strengthening. Second, climate change. This issue is already a Canadian priority. But the health aspects of global warming are largely invisible. The Lancet-UCL Commission on the health effects of climate change13Costello A Abbas M Allen A et al.Lancet-UCL Institute for Global Health Commission: managing the health effects of climate change.Lancet. 2009; 373: 1693-1733Summary Full Text Full Text PDF PubMed Scopus (1928) Google Scholar argued that global warming is the biggest threat to health in the 21st century. This view has been backed by doctors' leaders.14Jay M Marmot MG Health and climate change.Lancet. 2009; 374: 961-962Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 15Lim V Stubbs JW Nahar N et al.Politicians must heed health effects of climate change.Lancet. 2009; 374: 973Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar Health advocates in Canada need to press this point on their politicians as additional evidence for concerted action. Third, peace through health. Canada has been the leading nation bar none to develop the concept of peace dividends through policies on health.16MacQueen G Santa-Barbara J Neufeld V Yusuf S Horton R Health and peace: time for a new discipline.Lancet. 2001; 357: 1460-1461Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 17Neufeld V Yusuf S The McMaster-Lancet health and peace conferences.Lancet. 2004; 364: 311-312Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 18Santa-Barbara J MacQueen G Peace through health: key concepts.Lancet. 2004; 364: 384-386Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar This idea has catalysed governments to embrace health as a vital force in foreign policy.19Ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa, and ThailandOslo Ministerial Declaration—global health: a pressing foreign policy issue of our time.Lancet. 2007; 369: 1373-1378Summary Full Text Full Text PDF PubMed Scopus (148) Google Scholar As suffering escalates in zones of conflict such as Afghanistan,20Panter-Brick C Eggerman M Gonzalez V Safdar S Violence, suffering, and mental health in Afghanistan: a school-based survey.Lancet. 2009; 374: 807-816Summary Full Text Full Text PDF PubMed Scopus (181) Google Scholar embedding health in political thinking is critical to promote peace and reconstruction. Fourth, indigenous health. Some Canadian writers, such as John Ralston Saul, argue that Canada is more Aboriginal than European.21Saul JR A fair country. Viking, Toronto, Canada2008Google Scholar In A Fair Country, Saul suggests that Canada's inclusiveness and egalitarianism stem from these indigenous roots and that if Canada is to free the full creative energy of future generations, it must embrace its indigenous past. With 400 million indigenous people living in disrupted, exploited, and marginalised circumstances today, Canada's voice—as a country with an important indigenous population—has the potential to command respect and influence.22Gracey M King M Indigenous health 1: determinants and disease patterns.Lancet. 2009; 374: 65-75Summary Full Text Full Text PDF PubMed Scopus (900) Google Scholar, 23King M Smith A Gracey M Indigenous health 2: the underlying causes of the health gap.Lancet. 2009; 374: 76-85Summary Full Text Full Text PDF PubMed Scopus (953) Google Scholar The recent Commission on Social Determinants of Health emphasised the importance of inclusion and empowerment for indigenous peoples in governmental policy making.24Commission on Social Determinants of HealthClosing the gap in a generation. WHO, 2008Google Scholar And finally, global evidence and ethics. As the birthplace of evidence-based medicine, Canada's health community should have a strong voice about the way health metrics are used to shape global health policies. To be fair, Canada's health community has called for increased Canadian awareness, involvement, and funding in international health.25Neufeld V MacLeod S Tugwell P et al.The rich-poor gap in global health research: challenges for Canada.CAMJ. 2001; 164: 1158-1159PubMed Google Scholar, 26Ruggiero ED Zarowsky C Frank J et al.Coordinating Canada's research response to global health challenges.Can J Public Health. 2006; 97: 29-31PubMed Google Scholar, 27Nixon SA Critical public health ethics and Canada's role in global health.Can J Public Health. 2006; 97: 32-34PubMed Google Scholar These calls need to be channelled into a more coherent response. Perhaps it is time for a CHANGE—A Canadian Health Action Network for Global Equity. The creation of such a coalition of Canadian academic and institutional health interests could contribute significantly to Canada's G8 agenda. A CHANGE could also offer a mechanism for sustained follow-up and continuity—between different political parties and as the G8 chair rotates between nations. Canada's evolution as a nation through the lens of health reveals a deepening commitment to global affairs. In the 19th century Canadian doctors and public health officials reached out beyond Canada's borders to attract health workers to help build a national health system. The country's planners broadened the reach of Canada's health system westwards. Health leaders identified the crucial importance of reliable information to shape the progress of Canada's development. Severe acute respiratory syndrome illustrated the powerful fact that no nation can be immune from the global forces of disease. And Canada's political leadership now recognises that the institutions that govern the world today need to become more democratic and representative. A long-forgotten but exemplary Canadian public health leader, Charles Hodgetts, once wrote about "health as a foundation of Government".28Hodgetts CA Department of Health for Canada.Lancet. 1919; 1: 767Abstract Scopus (1) Google Scholar This is as true today in a global context as it was in Canada a century ago. It is up to the Canadian health community to seize the opportunity that 2010 now offers. A version of this Comment was presented at the University of British Columbia, Vancouver, BC, Canada, on Sept 10, 2009. I owe thanks to many Canadian colleagues who offered views on the arguments presented here.