For the record ============== * Wayne Kondro * © 2008 Canadian Medical Association ## Public health primer Canada's first annual report on the state of public health raised nary a political ripple as Chief Public Health Officer of Canada Dr. David Butler-Jones sketched the socio-economic factors that underlie inequalities in health status among Canadians. The report provides a basic primer on the health effects of such socio-economic and personal factors as income, employment, environment, housing, education, nutrition, access to medical services and behaviours such as smoking, drinking, drug use and unsafe sexual practices such as “early initiation, infrequent use of condoms and multiple partners.” It also briefly sketches international and regional initiatives aimed at redressing such inequalities, including national strategies in Great Britain and Norway, as well as requirements in Quebec and British Columbia that all government measures be subject to some form of health impact assessment. Butler-Jones deliberately took a descriptive rather than prescriptive approach to his first public health report since he was appointed chief public health officer and the Public Health Agency of Canada was created by Order in Council on Sept. 24, 2004. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/179/3/227/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/179/3/227/F1) Nearly 4 years after being appointed Chief Public Health Officer of Canada, Dr. David Butler-Jones has unveiled his first legislatively mandated report on the state of public health. Image by: Public Health Agency of Canada “I wanted to set the context,” he says. “It's to outline what we know and some options to move forward and to engage a dialogue, and particularly a dialogue that is not simply, ‚well, government will fix this.' We all have a role to play.” Butler-Jones added that the medical community's contribution could best be encapsulated the acronym PACEM (peace, in Latin), for “partnership (working in groups), advocacy, cheerleading (vocal support for the efforts of others), enabling (such as organization of health care facilities and employment practices) and mitigation.” “Part of the reason I'm not really prescriptive is every community and every level of government kind of has to figure out for themselves what works in their context,” Butler-Jones says. In a similar vein, the report urged that any efforts to redress health inequalities pay “attention” to 5 priority areas: * “social investments, particularly investments in families with children living in poverty and in early child development programs; * community capacity through direction involvement in solutions, enhanced cross-sectoral co-operation, better defined stakeholder roles and increased measuring of outcomes; * intersectoral action through integrated, coherent policies and joint actions among parties within and outside of the formal health sector at all levels; * knowledge infrastructure through a better understanding of subpopulations, the pathways through which socio-economic factors interact to create health inequalities, how best practices from other jurisdictions can be adapted to improve Canadian efforts and through more advanced measurement of the outcomes of the various interventions undertaken; and * leadership at the public health, health and cross-sectoral levels.” ## Pharma R&D spending remains in doldrums Pharmaceutical industry spending on research & development (R&D) in Canada continues to lag well below the 10% of sales level promised when drug patent protection was extended in 1987, while Canadian spending on patented drugs rose 3% to $12.3 billion in 2007, according to the latest report of the Patented Medicines Prices Review Board. Although R&D outlays recovered slightly in 2007 after declining in 2006, the overall R&D-to-Sales ratio of patented drugmakers was 8.3% as total R&D expenditures among 82 reporting companies, including federal grants, was $1.325 billion on revenues of $15.991 billion. The report indicates there's been little change in the overall nature of R&D expenditures, with clinical trials continuing to represent the bulk of industry spending, even though they were not originally intended to be included in the promised 10% of sales target, (*CMAJ* 2006;175[4]:344). The report indicates that in 2007, industry spent roughly $259 million on basic research, as opposed to clinical trials, drug regulation submissions and availability studies. The 3% growth rate in sales of patented drugs in 2007 was the lowest recorded since 1994. The report indicates that is largely a function of expiring patents and the fact that the industry has introduced far fewer so-called “blockbuster” products in the current decade. “Sales of patented drugs are still dominated by products introduced in the second half of the 1990s: in 2007 products introduced before 2000 accounted for sales of $7.0 billion, compared to $5.4 billion for products introduced in 2000 or later.” Some 13% (156 of 1178) of existing patented drugs sold for human use in Canada are now either under review, under investigation or the subject of a hearing for exceeding the highest price of the same product in France, Germany, Italy, Sweden, Switzerland, the United Kingdom and the United States.