Broadchurch

Broadchurch

A TV miniseries called Broadchurch drew much praise when it ran on the BBC last year. When I read the Guardian critic’s comments on it I made a note to watch for the DVD. It arrived recently at my friendly neighbourhood video rental place, so I rented the 3 DVDs on which it’s recorded and spent last weekend’s evenings watching it.  That’s about 8 hours of TV time, considerably more than I usually look at in a week.  It is a measure of the power of this drama that it held me glued to the screen for more than 4 hours on two successive evenings.

On the face of it, Broadchurch is a murder mystery, but I described it as a drama, which it emphatically is. It is set in the fictional small town of Broadchurch on the south coast of England, in Dorset. The town and its people are opened up and explored with detached compassion, their foibles and weaknesses exposed like peeling away layers of clothing until the naked soul is revealed in all its beauty and ugliness. An 11-year-old boy’s body is found on the beach near the base of a dangerous cliff, but the position of his body has been arranged and autopsy reveals that the cause of death was strangulation. A woman detective who thought she was about to become the local chief detective but is passed over for a more experienced but damaged man are in charge of the investigation, and their initially tense relationship is one of several sub-plots.  The investigation soon becomes convoluted with false leads and trails that point towards first one, then another suspect perpetrator. One false trail leads to the news agent for whom the murdered boy delivered newspapers, and leads ultimately to the suicide of this tragic figure. It would spoil one of the subplots to say more than this. The families of the murder victim, the woman detective, and other important characters are portrayed in three dimensions more believably than almost anything I’ve seen before on television. This drama is that rare event, television for intelligent grown-ups. Everyone who thinks they belong in this category should take the time – 8 hours, give or take a few minutes – to watch this drama.

It will haunt me for quite a while, and I predict that it will haunt you too.

Impressions of Japan in the 1990s

My grandson John Last junior's partner is moving soon from Istanbul to Tokyo, so I dusted off my 'Impressions of Japan' written about 20 years ago, and post these here. I wish we'd had longer there and more opportunities to revisit. I'm well aware that my impressions are sure to be misleading and wrong in many respects, so readers, please feel free to jump on me. If anyone cares to comment, whether to correct or contradict me, I promise to post whatever you say.

In 1991, Humio Tsunoda, MD, Professor and Head of the department of public health sciences at Morioka University and President of the Japanese Public Health Association (JPHA), invited me to visit Japan and give the keynote address at the annual congress of the JPHA, held that year in his home city of Morioka.

Our sojourn in Japan in October 1991 was brief and crowded so it would be easy for the memories to blend into a vague blur. The following account is based on letters written immediately after returning to Ottawa, with some additional thoughts after a visit to Nagoya in August 1993 and a short piece that I wrote for the American Journal of Preventive Medicine. This wasn’t our first visit to Japan. I had passed through twice on the way back to Canada from China, once in 1981 on my own when I flew in from Shanghai and had an overnight stay in Tokyo. In 1982, Wendy and I stayed in Tokyo for two days on our way back from Beijing. What I remember best from those short visits is rain, the choked highway from the airport into the city, the crowds, the neon signs, the outrageous cost of meals, the bewildering difficulty of finding our way around in the absence of street signs in a recognizable language (a problem I’ve had also in Shanghai, Beirut, Bangkok and a few other places). We didn’t know anyone in Japan at that time, and we felt alone and alien, and rather vulnerable, among huge, bustling crowds. 

It rains a lot in the beautiful islands that make up the nation of Japan, rather reminiscent of the British Isles. The resemblance is sustained if we compare Great Britain at the beginning of the first industrial revolution with Japan at the beginning of the next. Energetic competitive striving has led Japan, as it led Victorian Britain, to a position of economic supremacy among the nations. And since wealth advances health, the Japanese have an enviable record: the lowest infant mortality rate and the highest life expectancy in the world, achieved with modest expenditure of gross national product on health care. (Since I wrote this Japan has experienced a prolonged period of economic stagnation but I am told that this has had little or no impact on living standards or health status).

In less than half a century, Japan moved from the upper ranks of developing nations to the topmost position in the league table of health indicators among industrially developed nations. How has this been accomplished? There is virtually universal coverage of the population for health insurance and social security through employment-related or other insurance modalities; maternal and child care are well-organized and comprehensive; but the way the health care system is organized and financed may not influence health levels as much as some other factors.   Japan is a highly urbanized industrial nation, with universal literacy, tremendous zeal for learning, and good, if often cramped, housing conditions. Education is highly valued in this nation of achievers. Probably, as in Kerala state in India, and Sri Lanka, the educational system is more directly responsible than the health care system for the impressive statistical picture shown by many health indicators.

All is not perfect of course. Low birth rates in the past two generations and in the present generation have changed the shape of the population profile dramatically. Early in the 21st century, more than 20 percent of the population are over 65 years of age. Therefore the need for facilities to care for the aged is increasing sharply, aggravated by declining family size and vanishing extended families. Other time bombs are ticking: Japanese men have among the world's highest rates of cigarette smoking, and the women are beginning to take up the habit, as well as inhaling their menfolk's sidestream smoke. So tobacco-related cancer and cardiovascular death rates are high and rising, and very little has been done to control the smoking epidemic.

Competitive striving and ancient traditions contribute to social attitudes towards suicide that are different from those in the west, although my hosts during the 1991 visit said that suicide is not a serious problem among children and young people who fail university entrance examinations.  Quite the contrary they said: like traditional dress, suicide as an honorable way to absolve social disgrace is dying out. [But suicide is a problem; it is common among young men, and is among the leading causes of death among men in their 40s and 50s, according to the 1990 Report of Health and Welfare Statistics for Japan]. My hosts also assured me that social and working relationships between men and women are moving towards those in western industrial democracies, although my own observations don’t bear this out. In 1991, women comprised a much smaller proportion, by my eyeball estimate probably fewer than 10%, of the audience at the annual conference of the Japanese Public Health Association, in contrast to 50% or more at annual conferences of the American Public Health Association; and the status of women has not changed much in recent years: an articulate young professional woman who had lived several years in California told me that her professional expertise goes unrecognized and unrewarded. Sawako Takikawa (Humio Tsunoda’s daughter) was one of less than 10 percent of women in her graduating medical class; she came at or near the top of her class throughout medical school whereas her husband, another gastroenterologist, just passed. Yet he has the prestigious post in the professorial unit in the medical school, while she works in a peripheral clinic 40 Km away. She believes that women have little or no potential for leadership roles in the medical profession in her country.

There are increasing difficulties in these crowded islands in finding places to dispose of garbage, to say nothing of toxic wastes. There is some dissonance between the loving concern that people have for their immediate environment and their disregard for environmental or ecological conditions in places more remote from where they live. This may help to account for the existence of unsightly industrial wastelands, and for the contributions that Japanese commercial and industrial interests have made to environmental depredation in such places as tropical rain forests and ocean fisheries.

My hosts asked me about the social and economic consequences of ‘colour-blind’ immigration policies that have produced multiracial and multicultural societies in nations such as the United States, the United Kingdom, France and Canada. After my keynote lecture to the Japanese Public Health Association, in which I had mentioned HIV/AIDS in the USA Black population, I had a rather chilling 2-hour conversation with a professor of medical history (who had translated Hippocrates from Greek and Galen from Latin into Japanese) and a professor of psychiatry who had worked in the USA for 20 years and spoke perfect English. They seemed, judging by their questions, to regard the prospect of diluting their own racial and cultural stock as a potential disaster of unimaginable dimensions. They have known only a culturally and racially homogenous society in Japan, and aspire to keep it that way. They have no interest in the benefits of miscegenation and cultural diversity, are worried only about the potential for social chaos and attendant costs. It remains to be seen whether Japan can remain aloof from the turbulent population mobility that characterizes most of the rest of the world in the late 20th and early 21st centuries. Only a tiny proportion of the people who inhabit the Japanese islands are not ethnically “pure” Japanese stock, and those who are have a status rather comparable to India’s Untouchables.  They work in menial jobs like garbage collection. We saw some cleaning carriages on bullet trains. Their appearance, clothing and unkempt hair marked them out as “different” and the body language of other Japanese who came close to them revealed the distain with which they are regarded. 

A chronological/geographical record of our travels in 1991 can be quite brief. We arrived in Tokyo on October 13, just after a typhoon had left much of the place under water. We were met by Sanae Oda, who had translated my keynote address on the “Future of Health and Public Health Services” into Japanese, and by two of Humio Tsunoda's children, both physicians (Ikuo, a male neurologist and Sawako, a female gastroenterologist). We stayed overnight in Tokyo and took the Shinkansen ("bullet") train next afternoon to Morioka, after a brief and damp expedition to a couple of Tokyo highlights, including lunch on the 53rd floor of one of the new high-rise towers with a spectacular view over the city. Ikuo left for his home base, and was replaced by Tsunoda's younger son Masashi, another physician, this one training in epidemiology, my specialty. We were accompanied by Sawako and Masashi on the Shinkansen which is nearly as fast as the TGVs in France, and quieter if anything, and they were our guides together or separately for the remainder of our stay in Japan. 

About to board Bullet train Tokyo to Morioka

With Dr Sawako Takikawa, Morioka, Oct 1991

We had a day's sightseeing in and around Morioka, including a dip in a hot pool (in the nude, but segregated by sexes). This gave my Japanese confreres the opportunity to flaunt their impressive genitals, demonstrating that they were very well endowed compared to me. I got the impression that this demonstration was a primary purpose of this visit. Next day I gave my talk on the Future of Health and Public Health Services to an audience of about 5000 without mishap; my slides appeared behind me as I spoke, in English on one screen, in Japanese translation on the other, and as I spoke, the Japanese translation of the text scrolled down on a third screen in the middle. I had a couple of other professional discussions of fairly mind-expanding dimensions (both included as the price of admission, so to say, at lavish banquets). This amounted to a total of about five or six hours of professional activity. My (our) reward for this was my air fare and about half of Wendy's, and total coverage of all our travel and living expenses for the entire stay. The travel included many taxi rides (one about 250 Km, costing about $300!) and all the conducted tours, which in Kyoto according to a brochure we saw, cost about $200 each, for a total of $800. I have never been treated with such reverence and respect (although years later our VIP treatment in Turkey in 2004 came very close). We felt like royalty as people bowed to us, and made what I consider to have been extravagantly effusive remarks about my achievements - all very good for my ego, and I trust that Wendy will join in praising me to the skies as everybody else was doing there. 

The 250-km taxi ride was to a Samurai village across the mountain range from Morioka, over a superbly engineered road with many tunnels (one over 2 km long). The Samurai village was very interesting and rather picturesque. One memory stands out. There was a museum devoted to the Japanese military campaigns in Manchuria, China and South-east Asia in the 1930s and 1940s, in which we could not read the captions but the photos unambiguously glorified the military triumphs. Then we came back to Tokyo by Shinkansen and on south to Kyoto, past Fujiyama, which we actually saw, its conical summit white with snow (a rare sighting, we were told, and we saw it again on the return journey; more often than not it is obscured by clouds and smog). 

Kyoto is a beautiful city with many lovely temples. We would have enjoyed a much longer stay there, but diligent and exhausting sightseeing under the demanding schedule set by Masashi Tsunoda covered a great deal in the limited time we had (he is a marathon runner, and a slight little man with the most voracious appetite we have ever seen; no doubt he burns enormous amounts of energy getting about at a cracking pace we had difficulty matching).

We had been advised of the custom of presenting a small gift to the host and to others who are hospitable, and we took a few little things, mainly rather grotty souvenirs of Ottawa. In return we were given most beautiful and costly gifts: indigo dyed table mats, a handsomely painted fan, and a lovely address book with a lacquer cover inlaid with gold leaf figures, among other items. We bought a lot of gifts too, and came home loaded down with loot, perhaps more than the amount legally allowed returning travellers, but not enough to make us feel like serious smugglers, especially when most of what we had were gifts we didn't actually pay for. 

Obviously one can't begin to generalize about a nation as complex as Japan on the basis of ten or so superficial days, even when these days are spent in the company of highly intelligent professional men and women. Their command of written English is excellent but many had neither heard it nor spoken it very often; their pronunciation was sometimes unintelligible and they had trouble also comprehending what we said, even when we spoke very slowly and clearly. So much of what I perceived is based mainly upon my observations. 

There is considerable dissonance in Japanese life, society and customs: spectacular technological wizardry provides glimpses of what the 21st century might be like, and the architecture of new buildings is often exciting and aesthetically pleasing - but Tokyo is a mish-mash of non-planning, one of the ugliest cities I have ever seen, and the beautiful countryside to which the Japanese are obviously devoted, is blighted by hideous industrial waste-lands reminiscent of the worst that New Jersey, the Ruhr Valley or the north Midlands of England can offer. The ancient shrines are cared for, though many are not all that ancient because of a tradition and widespread custom of destroying and replacing them - and their destruction by fire or earthquake when they are not deliberately demolished. A curtain of inscrutability seems to prevent communication about some basic values that we hold dear, and in some other respects, for example the status of women, their values clearly differ from ours. There seems to be a ruthlessness in their business and professional transactions which exceeds the bounds of courtesy as we understand it, and they tend to take credit where it is not due. For instance, my gracious host, a charming and civilized man, did not translate my talk, Sanae Oda did; but he and every other professional man at the banquet firmly seemed to believe that he did, and he was accepting compliments from all his colleagues for its excellence; Sanae Oda commented wryly to me that women have no status even in modern Japan, where very few hold prominent professional positions. Japanese women have achieved high positions in several UN agencies. But some observations at the Japanese Public Health Association’s banquet were revealing.  The “entertainment” included an eating competition, in which six eminent public health specialists seated at a table on the stage scoffed down bowls of noodles; the winner was the man to ate the largest number of bowls in the shortest time. They were waited on by a bevy of attractive young women in revealing, very tight dresses; and more young women moved among the gathering that was overwhelmingly male. It was rather reminiscent of a frat house party, a rather sickening demonstration of male chauvinism and supremacy. It was also hardly a good example of healthy behaviour by a gathering of public health professionals! 

A few times I saw evidence of a resurgence of militarism. In several of the museums we visited, for instance on the upper floors of the museum houses in the Samurai village, there are lovingly tended memorabilia and photographs of the Japanese war against Russia (which maybe is justifiable) and of the more recent and far less excusable war against China. The old Rising Sun flag, supposedly as extinct as the Nazi swastika, is flown or displayed here and there, and the statues of military heroes in the parks in Tokyo include several of the generals and admirals of the second world war; the first time we saw one of these it had a display of rising sun flags around its base, though this had gone when we had a closer look at the same statue on our last day in Tokyo. Was it removed by official edict or because the flags, made of paper, had become soggy and bedraggled after heavy rains?

They have the best health performance in the world, judged by infant mortality rates and life expectancy; they have a comprehensive social security system, a superb network of transport and communications by rail and road (though it doesn't stop Tokyo strangling and choking in its own automobiles and of course the peak hour subway crowds are legendary). I got the impression that medicine is not a very high status profession, though it is hard to be sure about this, and when I asked, my questions seemed not to be understood. Medical research of course is outstanding, judged by citations and representation in the leading peer-reviewed journals. Yet when I gave them a keynote lecture made up largely of derivative material, they were overly impressed by its scholarly content - and I am confident that here I know whereof I speak, because I discussed it in depth with two Japanese colleagues of long standing, the man who translated the Dictionary of Epidemiology and Kunio Aoki, my fellow IEA Council member, as well as with Humio Tsunoda and several of his colleagues. I can summarize this part of my impressions with the observation that the approach to biomedical science at least, if not to science in general, is rather uncritically enthusiastic, which is certainly dissonant with their scientific record and achievements since the late 19th century.  There is dissonance too in their occupational health standards, but this is too technical a subject to go into in this account. This situation resembles the dissonance between their devotion to their own immediate environment and their disregard for other people's environments - again, a familiar theme. 

Much that I’ve read about Japan since those visits in the 1990s reinforces my impression that the alien aspects of its culture and its variant of modern western civilization are too complex for any casual visitor like me to comprehend. Like India, like China, it would take a lifetime of living among Japanese people to understand what makes the country tick. Unfortunately my lifetime was mostly behind me by the time I began visiting Japan, first just in transit for a few days on the way back from China in the early 1980s, then two short visits in the 1990s.  This was not nearly enough to make meaningful generalizations.  

(The above account was written in the early 1990s, revised and expanded after my visit to the IEA meeting in Nagoya in 1993 and lightly touched up again more recently. I'm sure it is inaccurate and my generalizations are unjustifiable so I will welcome suggested amendments and corrections).

Mitigation of climate change

The latest report from the Intergovernmental Panel on Climate Change (IPCC) deals with mitigation of climate change. In a nutshell, it calls for immediate action to break our addiction to carbon-based fossil fuels. If we do not wean ourselves off of these sources of energy and switch as rapidly as possible to renewable sources of energy the world’s average ambient temperature will soon surpass the predicted 2^o C rise and rapidly reach a very dangerous 4^o C increase by the end of the 21^st century. Such a rapid increase in global average temperatures would disrupt many of the earth’s essential life support systems. Rapid warming of the world’s oceans and seas is accompanied by acidification as more carbonic acid is created from dissolved CO₂; the pH is declining to levels that are lethal to corals and consequently vitally important marine ecosystems are endangered. Many coral reefs are already dead or dying, along with phytoplankton and zooplankton at the base of marine food chains. Terrestrial ecosystems and agriculture in the world’s great grain growing regions are threatened by rapidly increasing volatility and unpredictability of seasons, with greatly increased frequency of violent climatic extremes of hot and cold weather, severe storms, floods and droughts. This is a real and present danger to food security. Melting and thawing of glaciers in polar and alpine regions and thermal expansion of seawater as it warms will raise sea levels by at least a meter by the end of the 21^st century; accompanying storm surges will make life precarious for all who live close to present sea level. At least half a billion people, perhaps more, will become climate refugees, will have to move, severely straining all resources in the places to which they move.

These are not predictions of what to expect at some vague future time; these events are happening now. They will continue, and get much worse, unless we break our addiction to carbon-based fossil fuels, coal and oil. If we want essential life-supporting ecosystems to recover and sustain the human population, we must switch to renewable, sustainable energy sources, solar, wind, tidal, geothermal. The oil and coal industries are resisting fiercely, paying advertisers and pseudo-scientists to obfuscate the evidence, spreading lies and buying governments that will do their bidding, allow them huge tax benefits, even pay them obscenely large subsidies as they continue to destroy the earth, our only home.

For details, see http://www.ipcc.ch/report/ar5/wg3/

(Fifth Assessment Report; Working Group III: Mitigation of Climate Change)

All thoughtful people should read the Summary for Policy-makers and those who are scientifically trained should read the reports.

Intimacy

It's 3 1/2 years now since Wendy died. I miss her presence as much as ever, sometimes more so. I can't count the ways I miss her, but I was reminded of one way today. Occasionally we used to indulge in scurrilous gossipy remarks about people we knew, people in our family, or our friends, acquaintances and neighbours. These remarks would be about conversations, or observations, or events, or sometimes all. We would never have dared to say to their faces any of the remarks we made to each other about family members, friends or neighbours, but it was one of the minor pleasures of life to be able to say these things to each other, secure in the certainty that what we said would go no further. I had an experience today that falls in this category and a fleeting thought, "I must share this with Wendy!" Then reality set in, Wendy's not here now to share this priceless gem. On reflection, our scurrilous conversations, brief though they always were, rank high on the scale of things that made our marriage so pleasurable, catty comments. They might have ranked in the top 5 pleasures of our marriage.  Sometimes this was pillow talk, sometimes it gave us a brief talking point as we did the dishes or the weekly hunt and gather expedition to our friendly neighbourhood supermarket. It was just one kind of intimacy between us, part of the bonding process perhaps, and it was immensely pleasurable. I miss those occasional conversations and it saddens me that there is no one now with whom I can share the sort of unkind, scurrilous, scandalous comments I'm describing. If I believed in an afterlife I'd be jotting down notes to remind myself of some observations, some episodes I'd relish talking about with Wendy when we meet again in the hereafter. But I know, of course, there is no such thing as an afterlife, so there's not much point in making notes. These aren't items of note that I want to record for posterity in my memoirs.

It's a benchmark of true intimacy that we were able to have these totally uninhibited conversations in which nothing, absolutely nothing was off limits. We were lucky I suppose that we fell into this custom quite by accident very early in our married life together. We lost the ability to have these intimate dialogues during that two-year stormy period I described in another chapter of these memoirs (see post of June 28, 2013). Thank goodness we recovered it, and recovered or discovered so much else besides, that enabled us to forge unbreakable bonds that united us for well over fifty years. Probably it's this aspect of intimate bonding that enables a loving couple to withstand or shrug off many of the stresses and strains that lead to the break up of less secure unions. 

Wendy's birthday, October 14, 2001 

Core values of public health

In 2010 I spoke on "Equitable public health engagement" in a session targeting health problems of First Nations at the Centennial Conference of the Canadian Public Health Association in Toronto. Here is the text of my remarks.  I left out the paragraph on Osler's Aequanimitas to save a few moments and allow a little more discussion time. Otherwise I said pretty much what's written here.  Is it worth while to clean up this text, generalize beyond First Nations,  and publish it somewhere?

 Core Values of Public Health

My favorite image signifying the meaning of public health is a picture of rescuers at the scene of an earthquake, a life-threatening disaster. People, usually strangers, do all they can to help other people whose lives are in danger. They tear at the rubble with their bare hands in case there may be somebody alive buried beneath it. It is a vivid demonstration that we are hard-wired with something akin to an instinct to come to the aid of others who need help.

That’s what public health is about: coming to the aid of people who need help. Nowadays the aid is mostly unobtrusive and those who benefit are unaware that they needed and have received help. Public health practice saves countless lives by ensuring that water and food are safe, infants are immunized against communicable diseases, and other routine public health measures are rigorously followed.  Dramatic life-saving actions are very rarely necessary in public health practice but we are ready to activate these at short notice, for instance in the event of an outbreak of a highly contagious disease caused by an imported case of haemorrhagic fever – perhaps the nearest public health emergency comparable in dramatic impact to an earthquake measuring 6 or more on the Richter scale.

I spent much time and effort compiling a Dictionary of Public Health, defining the concepts, methods, and procedures that collectively comprise the science, practice and art of public health. The purpose of public health can be summed up in the phrase: coming to the aid of people who need help. That may mean all people everywhere, as with safe drinking water (residents on many reservations for aboriginal Canadians do not have this necessity for healthy life). Or it may mean any other population subgroup, some easily identified and easily reached, others vaguely delineated and hard to reach, some elusive, and needing urgent help. Today we are considering one group, First Nations, especially children and youth. Other groups who often need help are single-parent mother-led families, particularly their infants and children; isolated elderly people living alone in a former family home; street people with mental disorders; prison inmates. Only rarely are any of these groups adequately represented at strategic pubic health planning discussions.

At meetings where environmental problems are being considered, some groups may be over-represented. Industrialists, mine owners, developers, and their spokesmen, sometimes speak loudly, act aggressively, drown out or try to suppress dissent. In some countries they have been known to silence dissent or opposition e.g. to oil exploration and mining, by brutal means, up to and including murder.

In coming to the aid of people who need help, public health professional workers don’t distinguish one group or class of people from another. We don’t discriminate on the basis of age, sex, race, income, occupation or any other identifying characteristic. That’s what ‘equity’ means: all are considered equally. There is no such thing as some being more equal than others, like the pigs in George Orwell’s Animal Farm.

What are the philosophical foundations of public health? Consider its core values, the moral basis of public health. The 1940s UK social administrator Geoffrey Vickers described the historical progress of public health as ‘redefining the unacceptable.’ This is a core value of public health. The pioneers of the sanitary revolution in the late 19^th and early 20^th century knew enough about the causes of disease to recognize that it was unacceptable to cough and spit indiscriminately, to prepare food in a filthy kitchen, to provide polluted municipal water supplies, to allow owners of mines and factories to employ little children. By the 1990s public health workers and many others knew it was unacceptable to smoke without permission in somebody else’s home, on an airplane or in a crowded elevator or bus; to drive a car while impaired by alcohol or drugs, to carry infant and child passengers in a car without correctly fitted safety seat restraints.  Soon I hope it will be unacceptable for any person or corporation to pollute the land, sea, or air, or to emit combusted carbon products into the atmosphere. It is unacceptable to ignore distress signals like suicide of young native people, nutritional deficiency diseases among isolated old people, drug and substance abuse by homeless street people, and other less obvious signs of the persisting inequities in modern Canadian society.

In public health practice we are proactive, not reactive, seeking and solving potential problems, not just waiting for problems to happen. That’s why we have immunization programs to prevent outbreaks of polio, measles, diphtheria and the like, and why these programs should be mandatory. It’s why we purify municipal water supplies, close unhygienic restaurants, why we campaign against tobacco smoking and substance abuse. It is why we have sex education classes in school, and family planning clinics accessible to teen-age girls whether or not their parents approve or know that their daughters are coming to the clinic; and why we oppose patriarchal and authoritarian attempts to restrict access by school girls to education about sex and sexuality and access to contraception (and if this fails and an undesirable pregnancy occurs, access to safe, legal abortion).

Sometimes we are not proactive enough. There are subgroups in every population who need our help but do not seek it for one reason or another. Some equate public health services with authority figures that for one reason or another they dislike, are averse to, or distrust. Some marginalized people feel stigmatized for instance by their appearance or their shabby clothing, and avoid waiting rooms in clinics because of shame or reluctance to be seen by and, they fear, overtly or covertly criticized by others they might encounter there. Some have a problem understanding the language used by public health professionals. E is for extra effort as well as for equity, to ensure that these people receive public health services of the best possible quality.

An important consideration in equitable public health engagement is the baggage that the public health worker brings to her or his interaction with individuals and groups that need help. Ideally public health workers should be impartial, objective. They should always be ready to provide the only therapy administered by ear – words of comfort.

          They should possess what William Osler described and discussed in Aequanimitas, the capacity to evaluate and resolve complex problems without becoming emotionally involved with the people who are the victims of the problem (or others who may be causing them). Yet the role and function of the public health professional includes being an advocate for the persons or groups afflicted with the problem. Striking a balance between impartiality and advocacy can be very difficult!

Among Canada’s attractive features is multiculturalism. It has some potentially harmful features; but its strengths and inherent goodness outweigh these. I mention it only to offer a cautionary word. The cultural roots of a public health professional must never influence her or his interaction with clients or population groups who happen to have different cultural backgrounds. First and foremost we are Canadians. We may be hyphenated Canadians, but the qualities embodied in that hyphenated word are irrelevant in our professional interactions. This is a necessary statement, but it is not sufficient. Public health professionals have a responsibility to know and to understand enough about the culture of the population groups with whom they work so that they do no harm by inappropriate kinds of interaction.

Inequitable public health engagement is commonplace, even in nations that pride themselves on their equity, their fairness. In Canada we proclaim our tolerance and the excellence of our democracy but our body politic is so manifestly, so blatantly inequitable, the playing-field so obviously uneven, that it amazes me when our political representatives, our elected “leaders” boast about the excellence of all things Canadian, implying that it’s so perfect it can’t be improved.

In March 2010, disturbing news reports emerged about the shockingly high incidence and prevalence of tuberculosis among First Nations and Inuit Canadians – among the highest in the world. The flames of infection with tuberculosis are fanned by deplorable living conditions, by poverty, overcrowding, poor nutrition, and by ignorance, alcohol and substance abuse. If we needed any further warning signals of inequitable public health engagement with these underprivileged members of the Canadian population, the morbidity and mortality statistics for tuberculosis have provided them! This is more than a public health issue; it is a public policy issue. In 2008, prime minister Stephen Harper issued an apology on behalf of Canada for past injustices associated with the residential schools policy perpetrated against the descendants of the original inhabitants of Canada. As Barack Obama said in another context, that apology was “just words.” To have any meaning, the words must be matched with action, and no action has been forthcoming to remediate the deplorable living conditions of the descendants from the original inhabitants of our country. As the Nobel Peace Laureate Amartya Sen pointed out in The Idea of Justice, social justice is a powerful determinant of health. It follows that victims of social injustice will be unhealthy; the morbidity and mortality statistics of tuberculosis eloquently and accusingly illustrate this harsh reality, as do many other health indicators. Canadian public health has been an abject failure in not advocating effectively to correct this injustice. The next generation of public health leaders must do better than my generation to correct these inequities.