Comment
Canada’s time to act
Beavers, ice hockey, maple syrup, Mounted Police,
peace-keeping. These things conjure Canada in the
minds of many. Others will add health to the list, for
Canada’s public health-care system is one of the oldest
and most celebrated in the world and because Canada
has ministered to global humanitarian, migration, and
medical crises for decades. While Canadian values of
solidarity, inclusivity, and diplomacy have found much
expression in matters of health, there are clear signs that
all of the world now “needs more Canada”.¹,²
For one of us (JC), being Canadian is a cherished
and inescapable aspect of identity and worldview. For
The Lancet’s international readers, Canada is probably
seen as a bright light in the dark climate of division
and fear that has given us Brexit, Trump, and the rise of
populism and political uncertainty across Europe. Here
we introduce The Lancet’s new Series on Canada3–8 that
traces the history of Canadian universal health coverage3
and global health leadership4 and calls for action on the
challenges and demands ahead.
It is impossible to overstate how important health
care is to Canadians and their national identity.
90% of Canadians view their health-care system as
a source of collective pride and security, and a key
attribute of being Canadian.3,9 One of Canada’s greatest
achievements internationally has been its human
capital exports in health: WHO’s first Director-General,
Brock Chisholm, and its most recent, Margaret Chan;
James Orbinski, who accepted the Nobel Peace Prize
for Médecins Sans Frontières while president in 1999,
and its current president Joanne Liu; Tim Evans at the
World Bank; and Rebecca Affolder, Bruce Aylward,
and Stephen Lewis in the UN system are but a
few Canadians in senior health positions advanc­
ing the Canadian example of multilateralism and
international citizenship.
That Canada’s identity rests on such cohesive values
defies some logic—it is an extraordinarily vast country:
second largest in land mass, bordered by three oceans,
covering six time zones and eight distinct climates,
with two official languages, 70 Indigenous languages,
and 617 First Nations. More than a fifth of the
36 million Canadians are foreign-born, almost twice the
proportion of Americans. Incredibly, Canada added 1%
of its population in 2016 through immigration.
www.thelancet.com Published online February 23, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30176-4 1
But it is Canada’s own special kind of nationalism— Published Online
February 23, 2018
fervent pride in its being polite, inclusive, cooperative, http://dx.doi.org/10.1016/
and emphatically non-American—that is its downfall S0140-6736(18)30176-4
when it comes to health. The country’s universal health See Online/Comment
http://dx.doi.org/10.1016/
system, Medicare, once held up as a model system, is well S0140-6736(18)30177-6,
overdue for reform and innovation. Its health leadership http://dx.doi.org/10.1016/
S0140-6736(18)30178-8,
globally, needed more than ever in a fractured world, http://dx.doi.org/10.1016/
cannot continue to be safe, steady, or slow. As the Series S0140-6736(18)30179-X, and
http://dx.doi.org/10.1016/
argues, the country’s trajectory on health has been too S0140-6736(18)30180-6
unstrategic, fragmented, and comfortable in its own See Online/Series
http://dx.doi.org/10.1016/
beliefs; it is at risk of resting on past laurels and of failing S0140-6736(18)30181-8 and
to realise its promise for the future. http://dx.doi.org/10.1016/
S0140-6736(18)30322-2
Regrettably, Canada’s progress and international
ascension are its First Nations’ loss. The Series papers3,4
highlight atrocious inequities associated with Indigenous
peoples’ health that suggest a developing world within
Canada’s borders. Unemployment and infant death
rates are twice the national average; the homicide rate is
eight times. A quarter of Indigenous peoples live below
the poverty line. The roots of these disparities lie in a
reprehensible past of colonialisation and forced assimilation
that Prime Minister Justin Trudeau recently called the
country’s “great shame”, promising reconciliation.7,8 It will
require the forgiveness and courage of Indigenous leaders
and communities to reconcile and forge ahead with the
governments of Canada and all Canadians.
Much of the current glow and expectation about
Canada’s leadership is due to Prime Minister Trudeau,
who assumed office in November, 2015, following
David Schloss/MacCreate/Getty Images
 Comment
almost 10 years of conservative government that took
the country down an unpalatable “Canada-first” path.
Trudeau’s progressive approach to global affairs has
been widely feted. That a world leader upon taking office
asserts himself a feminist, appoints equal numbers of
women and men to his cabinet (and 25% Indigenous
peoples and people of colour), and issues a foreign aid
policy requiring all investments to prioritise women’s
and girls’ rights and health8 is indeed extraordinary.
Trudeau‘s ways elevate the global discourse on gender,
rights, and health and deserve loud applause.
But Canadians and others are getting impatient,
worried that the Trudeau Government may be more
talk than action. As Tim Evans6 from the World Bank
in his Comment, and others, point out, Canada’s
foreign aid assistance is at a historic low.10,11 This raises
questions about Canada executing on its aspirations
and promises. The country’s annual CAN$4 billion aid
budget, 0·3% of gross domestic income, falls well short
of the international target of 0·7%. This lack of generosity
beggars belief for the tenth largest economy in the
world and for a country that by its own accounts has the
highest economic growth of any G7 country,11 and its
best economic outlook since 1974.12
This Lancet Series is our first ever for Canada, and we
believe it sets a standard for Canadian health leadership
moving forward. 2018 is a big year for Canada—the
country has just finished 12 months of celebrating
its 150th anniversary and accomplishments since
confederation. Now it’s time to get down to business.
Canada has assumed the G7 presidency for 2018 and
laid out a progressive agenda on economic growth,
gender equality, climate, and peace that is strikingly
relevant to health. It is also practically heroic in light
of the ugly rhetoric and foreign policy directions of
its bigger neighbour to the south. Given the political
uncertainties facing global leaders in Germany, France,
and the UK, the tone Canada is setting bodes well for the
country if it genuinely wishes to seize the opportunity
to advance liberal values and priorities globally. The key
will be concrete resources and action to match the tone.
For this Series we explicitly sought to reflect a
representation of Canada’s diversity—linguistic, cultural,
ethnic, and geographical. We are proud to have authors
from coast to coast, francophonie, and Indigenous
peoples, and equal numbers of women and men, and
of senior experts and rising stars. We also profile two
2 www.thelancet.com Published online February 23, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30176-4
trailblazing Canadians—Monique Bégin, the country’s
first female minister of health who was responsible
for legislating the universal health system in 1984,
and Cindy Blackstock, an Indigenous children’s health
advocate and civil rights heroine for the country.
Both Prime Minister Justin Trudeau and Minister of
Indigenous Services Jane Philpott have contributed
Comments that set out their visions and plans, and
they are here for readers to see and judge.7,8 We will hold
the Canadian Government to account for its promises
on health. Canada may be the wealthiest, happiest,
most stable, and most influential country in the world
right now. It needs to move forward on health more
boldly, more action-oriented, and with more financial
investment. But it must not advance by leaving its
Indigenous peoples farther behind. We care about Canada
because the world, more than ever, needs Canada’s
leadership on health. We’re counting on you, Canada.
*Jocalyn Clark, Richard Horton
The Lancet, London, UK EC2Y 5AS
jocalyn.clark@lancet.com
We declare no competing interests.
1 Zivitz N. Richard Branson calls Canada ”beacon of light”, slams Trump’s
“dangerous” trade stance. BNN, Nov 23, 2016. http://www.bnn.ca/richard-
branson-calls-canada-beacon-of-lightslams-trump-s-dangerous-trade-
stance-1.614843 (accessed Feb 1, 2018).
2 Darch M. President Obama is right: the world needs more Canada. HuffPost,
July 27, 2016. http://www.huffingtonpost.ca/michaeldarch/yes-president-
obama-the-w_b_11186428.html (accessed Feb 1, 2018).
3 Martin D, Miller AP, Quesnel-Vallée A, Caron NR, Vissandjée B, Marchildon GR.
Canada’s universal health-care system: achieving its potential. Lancet 2018;
published online Feb 23. http://dx.doi.org/10.1016/S0140-
6736(18)30181-8.
4 Nixon SA, Lee K, Bhutta ZA, et al. Canada’s global health role: supporting
equity and global citizenship as a middle power. Lancet 2018; published
online Feb 23. http://dx.doi.org/10.1016/ S0140-6736(18)30322-2.
5 Greenwood M, de Leeuw S, Lindsay L. Social contract for whom? Challenges
in health equity for Indigenous peoples in Canada. Lancet 2018; published
online Feb 23. http://dx.doi.org/10.1016/S0140-6736(18)30177-6.
6 Evans T. Canada and global health: accelerate leadership now. Lancet 2018;
published online Feb 23. http://dx.doi.org/10.1016/S0140-
6736(18)30178-8.
7 Philpott J. Canada’s efforts to ensure the health and wellbeing of Indigenous
peoples. Lancet 2018; published online Feb 23. http://dx.doi.org/10.1016/
S0140-6736(18)30179-X.
8 Trudeau J. Canada’s vision for global health and gender equality. Lancet 2018;
published online Feb 23. http://dx.doi.org/10.1016/S0140-
6736(18)30180-6.
9 Martin D. Better now: six ideas to transform Canadian health care.
Allen Lane, 2017.
10 Greenhill R, Mcquillan M. Global Canada. Global engagement gap.
Oct 6, 2015. https://www.opencanada.org/features/canadas-global-
engagement-gap/ (accessed Feb 1, 2018).
11 World Bank. World Development Indicators. 2018. http://databank.
worldbank.org/data/reports.aspx?Code=NY.GDP.MKTP.
CD&id=af3ce82b&report_name=Popular_indicators&populartype=series&isp
opular=y (accessed Feb 1, 2018).
12 Government of Canada. Progress for the middle class and fall economic
statement 2017. https://www.budget.gc.ca/fes-eea/2017/home-accueil-en.
html (accessed Feb 1, 2018).