Essays On The Future Of Environmental Health Research

This Dean’s Note is co-written by Professor George Annas.

A few weeks ago, we published an essay called “Aspirations and Strategies for Public Health.” Here we reproduce some of the arguments in that essay, in extended form, simply because many of the thoughts therein seem directly relevant to our ongoing School discussion.

We start with a fundamental premise. Public health is responsible for extraordinary achievements over the past century and could make similar critical contributions to health in this century; this track record of success would seem to make public health the logical choice to address new challenges to life and health in a changing world, including chronic diseases, increasing income disparities, the threat of bioterrorism, and climate change.

Our worry, though, and motivation for this article is that despite these successes, organized public health appears to be on the defensive. Efforts such as the burgeoning precision medicine agenda and the continuing war on cancer have captured the imagination of both federal funding agencies and the highest level of politics, including the President, diverting resources in the direction of individualized efforts at disease prediction through genomic approaches, and away from the structural efforts that aspire to the broader population-based impact that has long characterized public health action. Our societal preference for dazzling technology that leads to expensive treatments rather than relatively inexpensive prevention measures threatens to monopolize the direction of public health scholarship for decades to come, given that much public health scholarship arises from academic public health institutions that remain heavily dependent on federal funding agencies. Public health shares funding and infrastructure deficiencies with transportation, education, and virtually all other endeavors reliant on public funding and leadership, and investments in much of this infrastructure have been declining, or barely keeping pace with needs, for decades. In this context, every extra dollar spent on medical care comes at a high opportunity cost that degrades our environment.

Why is this the case?

The challenge to public health does not center on disagreements about the core goals of the field, which have always been, and remain, broad and aspirational. The World Health Organization, for example, defines public health (and its goals) as “all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases.” This definition is echoed by several others, including in the Institute of Medicine’s 1988 Report, The Future of Public Health,which defined public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy.” According to the American Public Health Association, “public health promotes and protects the health of people and the communities where they live, learn, work, and play.” These descriptions all take to heart public health’s focus on creating conditions that enable healthier populations, with a key emphasis on preventing disease.

We suggest, rather, that part of the challenge has been public health’s embrace of a shift towards operationalizing what we do without sufficient recognition of our aspirational, purpose-driven mission. A well-articulated set of “essential public health services” in three categories of function: assessment (regular surveillance of the health of communities), assurance (making services available to the public), and policy development (using scientific knowledge) represents what we do. As a core set of foundational activities, these remain valid and reasonable today. However, maintenance of core functions and activities cannot in and of itself constitute a forward-looking purpose; rather, it suggests doing more of what worked in the last century in a rapidly changing environment. The director of the Centers for Disease Control and Prevention, has, for example, suggested that public health should “expand its past successes to further reduce tobacco and alcohol use, control persistent infectious diseases, increase physical activity, improve nutrition, and reduce harms from injuries and other environmental risks.”

This agenda is, in our assessment, too narrow, and is responsible for public health losing ground to medical concerns in the national conversation. The bold goals articulated in the definitions of public health will never be met, or even taken seriously, if public health itself abandons or severely limits them. Tension between the bold roots of public health and its uncertain operational manifestation has allowed public health to recede in collective consciousness, as a burgeoning medical agenda has moved to the forefront. A lack of clarity about public health’s purpose has also muddied its actions and depressed its aspirations.

So what aspirations can invigorate what we already do well and nudge us into areas of innovation? We suggest two aspirations that are informed by our understanding of the state of the field, the challenges it faces, and the threats to public health we see facing us going forward.

First, public health continues to be about the conditions that make people healthy, and thus must unstintingly engage the social, political, and economic foundations that determine population health. Although creating the conditions that make people healthy is universally acknowledged as a central goal by most prominent definitions of the field, it remains perhaps the most difficult purpose for public health to seriously grapple with. The challenge is that the conditions that make people healthy often are outside what we have historically considered the remit of the health professions. For example, there is ample scholarship that has documented the core role of both income distribution and racial segregation as drivers of population health. A focus on the conditions that make populations healthy requires entanglement with issues that reflect political and social structures. Such an engagement is freighted with peril, both conceptually and operationally.

Conceptually it is inevitable that engagement with broader social and political issues tangles with societal values and political circumstances that are far less value-neutral than are efforts at population health maintenance such as disease surveillance. Operationally, engaging with issues such as racial segregation in housing and education requires clarity of advocacy by the public health professionals who must, to be effective, work in areas such as media, business, and academia as well as in the governmental public health infrastructure. This puts public health in the position of attempting to quarterback complex social change, motivated by an understanding that absent such change, very little is achievable that can sustain the health of populations in the long-term. This will require a boldness on the part of public health, as well as the reliance on agents of public health action, such as universities, that are less beholden to political dicta in establishing their budgets and their operating constraints. It also requires engaging with two powerful new organizational forms that have concentrated power and influence in ways that directly affect population health: the transnational corporation, and the nongovernmental organization. These organizations have their own agendas, and global public health will not be able to succeed without accounting for, and influencing, their actions. For example, NGOs, most notably Doctors without Borders, dominated the treatment of Ebola patients during the 2014 epidemic, and airline corporations determined whether air transportation services would continue to be available, in what countries, and on what terms.

Second, public health must balance overall improvement of population health with the achievement of health across groups and the narrowing of health gaps. This challenges public health on multiple levels. Although the roots of public health are in line with efforts to promote health among vulnerable and marginalized populations, we have achieved mass legitimacy through an unstinting focus on improving the health of the aggregate, making populations healthier. This has, perhaps not surprisingly, diminished our emphasis on the health of marginalized groups and our intellectual engagement with the real consequences of such effort. It is not too far a line to draw from an embrace of overall health improvement as our goal to an acceptance of health gaps as an inevitable consequence of immutable social structures. Health inequities, however, remain at the core of the conceptual underpinning of why we in public health do what we do, and the drivers of these inequities are the same drivers that have animated some of the difficult national conversations that have resurfaced in the past few years. It stands public health in enormously good stead to be at the forefront of this national conversation, creating a unique opportunity for us to engage in the foundational drivers of health, and to change a national conversation around health, in the service of our aspirations.

Given these aspirations for public health, what are the best strategies to meet them? We suggest four that offer a way forward.

First, the breadth of public health engagement we suggest necessitates relentless prioritization, engaging both intellectually and pragmatically with the core question of what matters most to the health of populations. And this question is time-specific and subject to change. As Sir Geoffrey Vickers put it in 1958: The “critical and ubiquitous question [is] what matters most now?” (emphasis added). This embeds intellectual, practical, and operational complexities. Intellectually, our scholarship is frequently ill-suited to identify what matters most and has for many decades been prolific at identifying causes of ill health without much serious engagement in questions of prioritization or relative weighting. This will require a rethink of how we do our intellectual work and how that work intersects with the actions of public health. Practically, the challenge in engaging what matters most lies in the mismatch between what we may be able to do and that which may indeed have the greatest impact. Unfortunately, we have, as a public health profession, for too long erred on the side of pragmatism, focusing on smaller scale efforts—principally around engagement of lifestyles and healthy behaviors—at the expense of larger efforts that target foundational drivers. Only by using a conceptual lens that scrutinizes and evaluates our actions for their salience and contributions towards the larger goals at hand are we likely to make much progress in meeting our goals.

Second, we must actively engage the mechanisms that explain how core foundational structures produce population health. Therefore, while core social conditions—including, for example, the widespread availability of cheap, calorie-dense, nutrient–poor food—is undoubtedly the core driver of the obesity epidemic, health behaviors including eating patterns mediate the relationship between the corporate practices that establish food availability and obesity in populations. We ignore health behaviors at our peril. Nonetheless, public health cannot effectively engage eating behaviors without recognizing their place in a causal cascade. Eating behaviors do matter, but they matter only insofar as food choices proffer a range of options that ill serve the ends of health promotion. It is, however, easier to tackle the mediating mechanisms than it is to tackle the foundational determinants, in no small part because we think that the former fall within the scope of public health action, and that while we pay definitional attention to the latter, our action on it is limited. Therefore, this challenge centers on breadth of engagement, from the foundational through the mechanistic. It argues that we need to adopt a perspective that seeks balance, navigating the import of understanding and intervening on mechanistic processes, without losing sight of the core foundational drivers that will determine the sustainability of any progress. This thinking also applies to public health’s engagements with areas such as genomic medicine in terms of both scholarship and practice. It suggests that public health would do well to be a part of a conversation that engages the genomic research agenda and its potential, while recognizing it as one rather small piece of a much more complicated production of health of populations in which the environment, lifestyles, and even the microbiome are likely more important than genomics in determining health. Put another way, “personalized medicine” is not public health.

Third, the vision of public health as a government-mandated and financed activity has already been supplemented, if not replaced, by a wide recognition that public health is multi-sectorial and that we need to engage actors across government, academia, industry, and not-for-profit sectors, among others, to achieve the goals of public health. It is not as well recognized that these multiple sectors will engage around the goals of public health only if we create a narrative of the importance of public health that fluently replaces a current health narrative that centers on improving clinical care. Public health must be at the forefront of generating and sustaining a broad national and global conversation around centrality of population health to all our well-being. This will require substantial engagement in education both of our patterns across sectors and of a broader public that must see the goals of public health as consequent and important drivers of decisions across these sectors. It also requires the elevation of health in public consciousness and the recognition that individual health is glass ceilinged without an improvement in the health of the collective. Teachable moments such as the Ebola outbreak represent an opportunity to shift the public discussion towards emphasizing the foundational efforts that must be taken to create a world where Ebola outbreaks are prevented or quickly contained, rather than a world where we have tertiary hospitals and new pharmaceuticals to treat people who contract Ebola when large-scale outbreaks happen.

Fourth, public health needs its own ethics to help guide practice. The fact that much of public health is directed by the state—and often defines the relationship between the state and the individual—suggests that human rights, as articulated in the Universal Declaration of Human Rights, provides a solid ethical framework for public health practice. In practice, many in public health have already adopted human rights as the primary guide for their work. This is because not only do human rights proclaim a “right to health” for all people, they also provide a wide array of state obligations to “respect, protect, and fulfill” the rights of people in ways that promote population health. The World Health Organization has adopted the “health and human rights” principles, and, like the goals of public health itself, the challenge is not to define them but to apply them. Jonathan Mann, the first head of the WHO’s world AIDS program, suggested the “health and human rights” paradigm for public health at the beginning of the HIV/AIDS epidemic, when he quickly discovered that those with the disease were often severely discriminated against and lost jobs, housing, and even families as a result. His legacy, as Rebecca Cook and Bernard Dickens have suggested, is “his focus on how social inequality, economic powerlessness, social exclusion, and denial of human dignity condition preventable disease, disability, and premature death.” The universal scope of public health is matched only by that of human rights and, because of its core focus on human dignity and nondiscrimination, its inherent partner, social justice.

The potential of public health to continue to improve the health of populations is being challenged and undermined by multiple factors, including an overemphasis on curative medicine and increasing the length of life regardless of quality of life. The medical agenda is clear. A lack of clarity about the purpose of public health has made us less effective than we could be. We suggest that identifying two core aspirations and four strategies for public health can help shape our resolve towards public health achievement in the remainder of the 21st century.

I hope everyone has a terrific week. Until next week.

Warm regards,


Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Twitter: @sandrogalea

Previous Dean’s Notes are archived at:

Related Profiles:

Improving the Health of Future Generations: The Canadian Institutes of Health Research Institute of Aboriginal Peoples’ Health

Jeff Reading, PhD and Earl Nowgesic, RN MHSc

Jeff Reading is with the Canadian Institutes of Health Research, Institute of Aboriginal Peoples Health, and the Department of Public Health Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario.

Requests for reprints should be sent to Jeff Reading, PhD, Department of Public Health Sciences, 100 College St, Room 207-B, Faculty of Medicine, University of Toronto, Toronto, Ontario M5G 1L5 (e-mail: ac.otnorotu@gnidaer.j).

Author information ►Article notes ►Copyright and License information ►

Accepted May 24, 2002.

Copyright © American Journal of Public Health 2002

Am J Public Health. 2002 September; 92(9): 1396–1400.

This article has been cited by other articles in PMC.


In the past and in the present, research studies and media reports have focused on pathology and dysfunction in aboriginal communities and have often failed to present a true and complete picture of the aboriginal experience. The Canadian Institutes of Health Research Institute of Aboriginal Peoples’ Health is a national strategic research initiative led by both the aboriginal and research communities. This initiative aims to improve aboriginal health information, develop research capacity, better translate research into practice, and inform public health policy with the goal of improving the health of indigenous peoples.

INDIGENOUS PEOPLES around the globe endure profound disparities in health. In developed countries, the health profile of indigenous peoples is most commonly associated with noncommunicable chronic diseases and lifestyle-related health issues such as type 2 diabetes mellitus (Figure 1▶),1,2 tobacco use (Figure 2▶),3 substance use, and violence.4


—Age- and gender-specific and age-adjusted prevalence (%) of type 2 diabetes mellitus among First Nations and Inuit people and the Canadian population as a whole.


—Rates of smoking (%) among First Nations and Inuit people and the Canadian population as a whole, by age.


In response to a growing public health burden, the idea for creating a research institute devoted solely to aboriginal health had its genesis in September 1999. A group of leading Canadian health researchers, aboriginal and nonaboriginal, urged the federal government to consider a specialized research funding agency dedicated to aboriginal health research and capacity building. The group firmly believed this approach would contribute significantly to the overall health and well-being of aboriginal people and hasten the elimination of disparities between aboriginal and nonaboriginal populations. The researchers also envisioned a cadre of expert and emerging researchers who would form a Canada-wide network that would strengthen information gathering and sharing, leading to heightened awareness and improved health among aboriginal populations.

The objective of the Canadian Institutes of Health Research (CIHR) is “to excel, according to internationally accepted standards of scientific excellence in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products and a strengthened Canadian health care system.”5 CIHR was presented with the group’s recommendations and subsequently launched the Institute of Aboriginal Peoples’ Health (CIHR-IAPH) in early 2000.

Consistent with the overall CIHR mandate, CIHR-IAPH promotes holistic and crossdisciplinary health exploration embracing the 4 pillars of health research—biomedical, clinical, health systems and services, and social, cultural, and environmental factors—as they affect the health of aboriginal populations. Health research that has a positive impact on the mental, physical, emotional, and spiritual health of aboriginal people at all life stages is promoted by CIHR-IAPH.


CIHR-IAPH will strive to improve the health of First Nations, Inuit, and Métis people by supporting innovative research programs based on scientific excellence and collaboration with the aboriginal community. The institute will play a lead role in building research capacity in the First Nations, Inuit, and Métis communities and will support partnerships and alliances between aboriginal communities and nonaboriginal health research organizations at the local, regional, national, and international levels. Critical to the accomplishment of our goals is the recognition that we will support health research that respects aboriginal cultures, while generating new knowledge to improve the health and well-being of aboriginal people both in Canada and abroad.


  • Present health research results to aboriginal people in a way that is accessible, appropriate, and easily understood

  • Maintain ethical standards by adhering consistently to prescribed values and principles

  • Act in an honest, fair, and just manner

  • Aim to include aboriginal people in all health research activities

  • Share new knowledge with all research partners

  • Conduct all activities and business in a transparent manner


CIHR-IAPH supports research that addresses the special health needs of aboriginal people across Canada. The 4 strategic research priorities to be pursued over a 5-year period, beginning in 2002, are as follows:

  1. To forge partnerships and share knowledge. Develop and nurture aboriginal health research partnerships with aboriginal and nonaboriginal organizations in the public and private sectors at all levels—local, regional, national, and international.

  2. To respect aboriginal cultures. Maintain open, 2-way communication with CIHR to influence policy development on ethical standards, peer review processes, and knowledge translation systems that respect aboriginal cultures.

  3. To build capacity. Build aboriginal health research capacity, especially among university graduate students studying aboriginal health.

  4. To resolve critical health issues. Fund initiatives that address urgent or emerging health issues affecting aboriginal people.

CIHR-IAPH has already funded a series of exemplary aboriginal health research projects. The following projects were undertaken between January 2001 and March 2002.

Enhancing Survey Research Methods—Centre for Aboriginal Health

The Centre for Aboriginal Health will improve health survey activity in First Nation, Métis, and Inuit communities by producing high-quality, comparable, statistically valid, and culturally relevant data. Longitudinal data will be compiled to track changes in health over time.

Improving Access to Appropriate Health Services for Marginalized Groups

Members of marginalized groups may have limited access to, or feel constrained in accessing, appropriate health services. This research project involves a team of researchers who are exploring innovative ways to enhance access to health services for people on the fringes of society. Research results will inform policy, program, and management decisions relating to improved access to appropriate health services for identifiable marginalized groups.

Aboriginal Capacity and Developmental Research Environments (ACADRE)

A key CIHR-IAPH goal is to build capacity by developing researchers and providing continued support for scientific careers in aboriginal health research. The groundbreaking ACADRE program was launched on October 11, 2001, with up to Can $12 million in funding for the first 4 ACADRE centers over the next 6 years. These 4 centers are the initial links in what will become a network of centers across Canada responsible not only for developing the next generation of aboriginal health researchers, but also for focusing research efforts on determinants of health in aboriginal communities.

As they grow into their new roles, the 4 ACADRE centers will become more involved with the global aboriginal health research network and share their expertise with others around the world. Their joint goals are to promote information sharing on best practices in research methodology, develop resourceful partnerships, support ethical conduct, encourage community engagement, advance knowledge translation, and build research capacity through training and experience. Increasingly, they will initiate and participate in international exchange programs for researchers and research students involved in indigenous peoples’ health.

Centre for Aboriginal Health Research, Winnipeg, Manitoba.

The Centre for Aboriginal Health Research, affiliated with the University of Manitoba, was the first center to receive ACADRE funding. Its efforts will be concentrated in areas where the University of Manitoba has already established excellence in aboriginal health. Primary research themes include population health, health services, child health and development, and ethical issues in aboriginal health research. A secondary objective is to develop a research environment that encourages aboriginal students to pursue careers in health research. Health science career camps and undergraduate internships in health research are program ideas in the offing.

National Aboriginal Health Research Training Program, Edmonton, Alberta.

The Edmonton ACADRE center was set up to create a collaborative and interactive network of mentors in aboriginal health research training, bringing together resources from academia and aboriginal communities. This program will concentrate on research in 3 areas: (1) chronic health issues such as diabetes and heart and lung diseases; (2) child health, including fetal alcohol syndrome and fetal alcohol effects, nutrition, and acute illness; and (3) addiction, mental health, and suicide.

Indigenous Peoples’ Health Research Centre, Regina, Saskatchewan.

This research program is led by the Saskatchewan Indian Federated College, in partnership with the Universities of Regina and Saskatchewan. It takes a holistic approach, focusing on 4 areas: (1) chronic disease, nutrition, and lifestyle; (2) indigenous or traditional healing methods for addictions, including fetal alcohol syndrome, and mental health; (3) health delivery and control, including ethics, community development, and governance; and (4) environmental health.

Anisnawbe Kekendazone, Ottawa, Ontario.

Community Information and Epidemiological Technologies Canada and the Institute of Population Health at the University of Ottawa were also awarded a 3-year ACADRE grant. The center they established, Anisnawbe Kekendazone, will train aboriginal researchers by offering them opportunities to participate in high-profile indigenous research projects in Canada and around the world. Initial health research priorities at this facility are perinatal health, youth at risk and resilience, and knowledge translation (communicating health research knowledge to aboriginal communities in a way that is readily understood).

National Network for Aboriginal Mental Health Research

The innovative National Network for Aboriginal Mental Health Research, launched in November 2001, is cofunded by CIHR-IAPH and the CIHR Institute of Neurosciences, Mental Health and Addiction. The network addresses critical mental health needs of aboriginal people in rural and urban settings. It will train new researchers and will provide research consultation services for and in collaboration with aboriginal communities. Possible areas of mental health research include alcohol and drug addictions, volatile substance abuse, compulsive behaviors, suicide, abuse of prescription drugs, and sexual abuse.

Graduate Student Support

A significant portion of CIHR-IAPH funds go toward capacity building by supporting and nurturing graduate students pursuing careers in aboriginal health research. In March 2001, CIHR-IAPH hosted a gathering at the University of British Columbia at which 24 graduate students from across the country discussed capacity building and support, peer review and ethics, and knowledge translation and communications. They also shared their research with the group and voiced concerns over a number of issues, such as the need for more support from CIHR-IAPH, ethical research protocols, and a lack of networking opportunities. After that event, many more graduate students identified themselves to CIHR-IAPH. As a result, 60 participants attended the second such gathering, which was held in Ottawa in March 2002 in conjunction with the CIHR-IAPH advisory board meeting (photo on page 1399).


CIHR-IAPH posted several requests for applications on research topics that were linked to at least 1 of the institute’s 4 priorities, including a focus on child and youth health, diabetes and stress, fetal alcohol syndrome and effects, HIV/AIDS, improving access to appropriate health services for marginalized groups, preventable injuries and accidents, and innovative projects. The focus of the request for applications for “innovative projects” is on social and culture-based studies that aim to improve health (e.g., studies on traditional medicine, midwifery, or the link between indigenous knowledge and health).


Health disparities between aboriginal people and the general population in Canada are strikingly similar to those experienced by indigenous people in other developed, postcolonial countries with minority indigenous populations, including Native Americans, Alaska Natives, and Native Hawaiians. Canada can learn much from research conducted outside its borders. Thus, CIHR-IAPH has contacted several aboriginal health research organizations around the world, with impressive results.

A memorandum of understanding was signed in 2002 by chief executive officers of the Canadian Institutes of Health Research, the National Health and Medical Research Council of Australia, and the Health Research Council of New Zealand to cooperate on health research for indigenous populations.

On January 31, 2002, the Health Secretariat of the United Mexican States and CIHR signed a letter of intent to develop “health research, research training, clinical training, and knowledge translation based on equality, reciprocity, and mutual benefit.” Areas of potential collaboration agreed upon include environmental health, genetics and genomics, needs of indigenous people and vulnerable populations, health policy development, health services, financing, and electronic forms of knowledge transfer.


Some participants in the CIHR-IAPH institute advisory board meeting and graduate student conference held in Ottawa in March 2002. Indigenous health researcher–practitioners from 5 countries are represented, underscoring the institute’s...


Perhaps the most important partnership of all is with aboriginal communities and individuals. CIHR-IAPH will ensure that aboriginal people are full partners in research, not merely informants and respondents. In the past, research has not always helped aboriginal communities, because it failed to address urgent health concerns and because there was little or no aboriginal ownership of research projects.

Increasingly, aboriginal communities are incorporating the principles of ownership, control, access, and possession into health research activities affecting them. These principles support valid and reliable research processes and products, which are based on aboriginal community needs and priorities and relevance within the context of aboriginal self-determination. Furthermore, these principles promote broader understanding and ways of knowing that include a more holistic approach, drawing heavily upon community-based, participatory research methods.


Making research relevant to people is the cornerstone on which CIHR-IAPH stands; therefore, knowledge translation is essential. The term refers to the exchange, synthesis, and ethical application of knowledge by researchers and users. The goal is to accelerate the benefits of aboriginal health research, such as more effective services and products, a stronger health care system for indigenous people, and improved overall health.

All applications requesting CIHR-IAPH research funding must explain how research results will be disseminated and communicated in ways that are meaningful and beneficial to aboriginal organizations, communities, and individuals.


In Canada, indigenous peoples recognize that their legitimate aspirations to achieve selfdetermination are linked to the health of their families, community members, and nations.6 The principle of selfdetermination underscores the idea that health and well-being are achieved through success in a myriad of interconnected and developmental activities and that success is possible only within the context of selfdetermination. It is also recognized that equal human rights are achieved, in part, through autonomous and independent institutional development in pursuit of community self-determination.

Recently, the United Nations Permanent Forum on Indigenous Issues affirmed the importance of health information, including research: “For health equity approaches to be successful, systematic health and demographic information on all marginalized and disadvantaged groups, including indigenous and tribal peoples, is needed. At the same time, the increasing calls of indigenous and tribal peoples to be centrally involved in decisions affecting their health have to be heeded.”4

In a recent memorandum of understanding,7 Health Canada of the government of Canada and the Department of Health and Human Services of the government of the United States recognized

Our common objective to raise the health status of First Nation and Inuit people in Canada and American Indians and Alaska Natives in the United States; Our common interest in improving our approaches to health issues with First Nation and Inuit people in Canada and American Indians and Alaska Natives in the United States by identifying and reinforcing best practices; and Reaffirming our common interest in the sharing of knowledge and learning experiences, which will serve to strengthen our individual approaches to issues within the context of the respective countries.

Article 5 of the memorandum includes the plan of work, which states:

  • The Participants intend to develop a Plan of Work describing specific activities to be carried out under this Memorandum of Understanding. The Plan of Work may include but is not limited to:

  • Training in health data and financial management systems to better assist patient care needs;

  • Exchanging information on telemedicine and tele-health capabilities;

  • Collaborating on studies on chronic diseases of high prevalence in indigenous populations;

  • Cooperating on mechanisms to support indigenous populations in the hemisphere;

  • Providing guidance in working with universities and other nongovernmental organizations; and

  • Sharing of information on approaches to health care reform and the support of innovative approaches to health care delivery.

Clearly, a significant opportunity exists for meaningful transborder cooperation and collaboration between the national health research agencies of Canada and the United States. The creation of CIHR-IAPH as part of the Canadian health research enterprise is a recognition both of the contribution that an advanced research agenda can make to improve the public health burden borne by indigenous peoples and of the potential contributions that different “ways of knowing” could make to improving public health.


1. Reading J, Elias B, McDonald G. Early onset of type 2 diabetes among First Nations in Canada. Can J Diabetes Care. 2000;24(Suppl 2):44–48.

2. Young TK, Reading J, Elias B, O’Neil J. (2000) Type 2 diabetes mellitus in Canada’s First Nations: status of an epidemic in progress. CMAJ. 2000;163:561–566. [PMC free article][PubMed]

3. Reading J. The Tobacco Report. In: First Nations and Inuit Regional Health Survey National Report 1999. St Regis, Quebec: National Steering Committee of the First Nations and Inuit Regional Health Survey; 1999:87–135.

4. United Nations Economic and Social Council. Review of Activities of the United Nations system relating to indigenous peoples: an interactive discussion. E/CN.19/2002/2/Add.8. Available (in PDF format) at: Accessed July 12, 2002.

5. Bill C-13, §4, C-6, RSC 2000.

6. Matthew Coon Come, Grand Chief, Assembly of First Nations. Open letter to the United Nations Permanent Forum On Indigenous Issues. May 13 2002. Available at: Accessed July 12, 2002.

7. Secretary Thompson signs agreement with Canada on indigenous health during 55th World Health Assembly, Geneva, Switzerland. May 14, 2002. Available at: Accessed July 10, 2002.

Articles from American Journal of Public Health are provided here courtesy of American Public Health Association

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