Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 6 - Evidence

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 3:47 p.m. to examine the state of the health care system in Canada.

Senator Marjory LeBreton (Deputy Chairman) in the Chair.

[English]

The Deputy Chairman: Honourable senators, our session today is the continuation of phase two of our hearings on our health care study which is intended to identify current and future challenges for the health care system. Today we will be examining disease trends.

There are concerns that new diseases and increasingly prevalent illnesses may significantly impact on the current and future costs of health care. However, many of the causes of disease, disabilities and early death are preventable. It has been suggested that increasing efforts in the area of health promotion and disease prevention, with particular focus on Canadians with low incomes and low levels of education, must remain key areas in public policy if we are to improve overall health status and contain health care costs. Our witnesses today are here to help us better understand the issue of disease trends and its potential impact on the publicly funded health care system.

Today, honourable senators, we have Dr. Christina Mills with the Centre for Chronic Disease Prevention and Control at Health Canada. The Centre for Chronic Disease Prevention and Control works to assess and detect chronic disease threats, provides strategic information on risk assessment, and collaborates with others to develop programs which unite the practices of population health, public health, and preventative health care in order to reduce the burden of current and emerging chronic diseases.

Dr. Paul Gully is the Acting Director General at the Centre for Infectious Disease Prevention and Control at Health Canada. This centre provides research on infectious diseases directed at the identification and quantification of risks, and assesses proposed prevention and control strategy.

Dr. David MacLean is the department head at Community Health and Epidemiology, Clinical Research Centre, Faculty of Medicine at Dalhousie University.

I will ask our witnesses to make their presentations, after which we will turn the floor over to senators for questioning. Senators, Dr. Mills must leave a little earlier than the other witnesses, so when you are thinking of your questions, please consider the ones you may want to address to her first. I turn the floor over to our witnesses.

[Translation]

Dr. Christina Mills, Director General, Centre for Chronic Disease Prevention and Control -- Population and Public Health Branch: I wish to thank you for inviting me to share with you some data on the burden of chronic diseases and injuries in Canada, and a prospect of the possibility of avoiding a portion of the future estimated burden.

[English]

I shall briefly describe the burden of chronic diseases and injuries today, the estimated future burden, and then allude to prospects for substantially altering that future burden to prevention and health promotion efforts.

Chronic diseases and injuries are very complex issues. They affect all Canadians, but the burden is unevenly distributed regionally, ethnically, socio-economically, by age, sex and many other dimensions. For example, diabetes is increasing overall in Canada but dramatically higher and more rapidly in Aboriginal populations.

Many major conditions share common risk factors, and many risk factors influence multiple disease and injury outcomes. Conditions will rank differently depending on the indicator that we choose to monitor. In general, we lack good data for indicators reflecting personal suffering, quality of life, disability and productivity costs. These indicators exist -- quality-adjusted life years, and so forth -- but we do not routinely collect the data to be able to calculate them. They require special studies. The strategies to address these issues need to be equally complex to reflect the complexities of multiple causes, settings and populations.

More than half of Canadians report having some chronic condition, according to the 1998-99 National Population Health Survey. That is more than 16 million Canadians. The most prevalent ones -- allergies, arthritis, back problems, high blood pressure, asthma -- are not typically those associated with the highest mortality or premature mortality, but nevertheless they pose a significant burden in suffering, disability, and cost to the health system.

The graphic illustrates some of the complexity of these issues. Potential years of life lost -- or PYLL -- indicates relative prematurity of death from different causes. Conditions that kill younger people primarily will rank higher when we are looking at PYLL because they cancel out more years of potential life. This slide shows how the ranking will differ by sex and age group for the top three causes overall. You can see that, in youth, injuries are by far the highest cause. In older years, cancer and heart disease overtake injuries in rank.

The next slide is from the economic burden of illness study which I believe you have had presented to you previously, and copies are available to you if you have not yet received them. Two-thirds of the economic burden of illness in Canada is explained by the top five causes: cardiovascular disease, musculo-skeletal disorders, cancer, injuries and respiratory diseases. If you add the next two causes, a full three-quarters of the burden is explained. Hospital costs are the largest contributor, at 52 per cent. If current trends continue, drugs, which are now in second place as a contributor to costs, will eventually overtake hospital costs.

The estimated future burden of disease has both avoidable and unavoidable components, and the slide labelled "lung cancer mortality counts" illustrates this. The bottom line reflects the evolving rate patterns. If we maintained our current age and sex structure and size of population, that line would show how the numbers of cases of lung cancer in women in Canada would increase to 2010. The top two lines that you see reflect the change in the population size and the age structure, the aging of the baby boom, and show how those numbers of cases will increase due to factors that the health care system cannot influence.

Our only chance to slow or reverse the rate of increase is to invest in effective upstream prevention. It is quite well recognized now that failure to prepare for an increased burden due to the aging population is a threat to the sustainability of our health care system, but it is not widely recognized that our failure to invest upstream is an equally great, and perhaps even greater, threat to sustainability. The last part of my remarks will deal with prospects for upstream interventions.

The next slide shows a theoretical reduction in coronary events that might be possible given various kinds of risk interventions we could undertake: influencing diet, smoking, exercise and body mass index. If we were to act now, by 2016 we would be able to see the pattern. Depending on the intervention and the effectiveness of the intervention, the net effect would be shown in this at the end of the slide in 2016. Unfortunately, most people living today have accumulated a lot of risk, and we will not see the full benefits of interventions to reduce those primary risk factors until much longer than that. There will be some early pay-off for things like injury prevention and for conditions like respiratory diseases and acute myocardial infarction which do respond faster to smoking cessation. However, even for those conditions where the pay-off is longer, cancer, for example, the pay-off for primary prevention will be significant.

Eighty-five per cent of Canadians over 65 have at least one modifiable risk factor for cardiovascular disease, and almost two-thirds of Canadians overall have at least one factor for cardiovascular disease. Two-thirds of Canadian lead sedentary lifestyles, and over half are above a healthy weight. There is strong clustering of risk factors, especially in adolescents. Diet, physical activity, smoking and risky sexual behaviour tend to cluster together, so we need strategies that address a spectrum of risk factors, and that address those risk factors in the patterns in which they cluster.

There is considerable variation across Canada in how the various provinces are doing in control of these risk factors, and I think the lowest rates we observe provide an achievable benchmark for the rest of the provinces to aspire to. Examples of approaches that can produce multiple benefits include intensive family support for families at risk, and comprehensive school health and work-site health promotion.

I will say a bit more about injuries because it is an example of a condition that could get an early pay-off on investment in primary prevention and because it has a significant burden that is largely preventable. We have had quite a bit of progress to date in injury control, reflected in declining numbers of injuries, injury deaths and hospitalizations due to injury. Contributors to these include seat belt use, reduced speed limits, bicycle helmets, reduced rates of drinking and driving, and better design of consumer products. However, they are still the leading cause of death in children, and the largest contributors to potential years of life lost before age 65. Suicide and motor vehicle crashes continue to take the lives of our young men, especially among Aboriginal youth, and falls are an important cause of disability and premature death among adults over 65. These require multi-component interventions covering things like medication use, home assessment, strength and balance, and so forth. These variations in patterns of injury across the lifecycle demonstrate the need to develop age specific strategies that also address other dimensions such as settings -- playground versus rural versus workplace settings.

There is a growing research base indicating that health promotion and disease prevention interventions can lead to improved health and quality of life, reduced medical care costs and enhanced workplace productivity. Preventing disease, injury and disability can extend life, reduce the need for health services and produce positive benefits and well-being, quality of life and self-efficacy. We can get significant benefits just from applying what we already know, but we need to invest now and we need to invest upstream to prevent the future burden. We need to look beyond the five year horizon and invest for long term benefits. The major constellation of risk factors overall are diet, physical activity, obesity and smoking, which account for far more than half of the burden of preventable chronic diseases.

To get back to my original title, "What Are the Prospects?", some gaps exist in our evidence base, in our availability of data and surveillance on what works on some causative factors. We certainly do not have what could be called a preventative dose of prevention programming in Canada, and there is unfortunately a history of dealing with things on a one-off basis. Overall prospects are good, however. Canada is recognized internationally as a leader in conceptualizing health and health promotion and in developing innovative programs to address health promotion and disease prevention.

There is a strong and growing research base on the preventable causes of chronic diseases and injuries, and the expanded mandate of the Canadian Institutes for Health Research, compared to the old Medical Research Council, provides a large amount of opportunity to support additional research required to determine what is most effective to create lasting behaviour change.

We have a strong voluntary sector that is rising above its earlier turf wars and building a coalition to make common cause on primary prevention. The health accord, focusing on re-balancing the health system to ensure the sustainability of our health care system, provides a framework for cross-jurisdictional collaboration.

We need to build on these. We need to overcome our complacency, work collaboratively and systematically to plan and implement prevention strategies that make the most of our available resources and knowledge. I am confident that if we do that we can prevent a substantial proportion of the estimated future burden of disease and injury, promote the optimal health of Canadians and contribute to the sustainability of our health care system in the coming years over the long term.

I may not be able to stay with you right to the end of your deliberations today, but if I must leave for the airport, Dr. Clarence Clottey, who is Acting Director of the Diabetes Division, and Nancy Garrard, Director of the Division of Ageing and Seniors, will be able to answer some of your questions.

Dr. Paul Gully, Acting Director General, Centre for Infectious Disease Prevention and Control, Health Canada: First, I would say that many of the points that Dr. Mills has made as regards upstream investment in the importance of prevention apply also to infectious diseases.

[Translation]

I should like to present to you four points regarding infectious diseases. First, the threat of infectious diseases is persisting and increasing. Second, infectious diseases are costly for the health care system and the Canadian economy. Third, prevention and control strategies represent a good investment and, finally, efficient monitoring systems are essential.

[English]

The threat of infectious disease certainly continues. The original optimism as regards the fight against infectious diseases has decreased. We now have new and emerging threats. For example, we have had AIDS since the 1980s, the hantavirus pulmonary syndrome, new emerging threats such as West Nile virus infection, which will undoubtedly arrive in Canada this year, and also the issue of BSE, or mad cow disease, and the human variant. We expect to also identify at least one case of BSE soon, not acquired in Canada but outside.

There are also chronic infectious diseases such as HIV, hepatitis B virus infection, hepatitis C virus infection. Then there are infectious chronic diseases, such as helicobacter infection as a cause of peptic ulcer disease and gastric cancer, and possibly also chlamydial infection as a cause of coronary artery disease. There is a consensus in the U.S., the U.K. and other developed countries as regards the continuing threat of infectious diseases.

I want to give you some more examples. Anti-microbial resistance is an issue that is important to the health care system and an important cost driver in the health care system. There are other substantial costs that I will detail later. I would also like to note that in terms of the estimates of the cost of infectious diseases, and especially the mortality, infectious diseases and the usual classifications do not usually include costs resulting from pneumonia and influenza. This is important in an aging population, as well as issues such as genitourinary infections, gastrointestinal infections and skin infections, which are important in terms of institutionally acquired infections. There are also large amounts of illness, usually morbidity illness, that are never measured by routine data. These include food-borne illness that never result in physician visits or in hospital stays.

Mortality for infectious diseases has increased, as you can see from page 10, which is a graph relating to mortality from HIV. That has been the main driver in terms of increased mortality from infectious diseases. The mortality rate has dropped, but HIV is a chronic infectious disease. However, individuals with this disease are living longer as a result of newer treatments and continue to require a large amount of help from the health care system.

Other drivers of emerging infectious diseases are global travel and migration. On page 11 of my handout is a graph relating to tuberculosis and the increasing percentage of tuberculosis in this country, which is arising in new Canadians. This is a change in trends that we must deal with because prevention and control methods must be tailored to individuals, their cultural and ethnocultural situations.

There is also the increase in travel by Canadians, and globalization of the food supply. You might remember the story of the Guatemalan raspberries and the issue of BSE, for example. There is human activity relating to the possible effects of global warming, deforestation and so on, which could cause diseases such as Lyme disease.

An important aspect is the change in risky sexual behaviour. That is important in diseases such as HIV because the epidemics within HIV are changing. People are doing different things and that requires prevention efforts to be tailored and flexible. Injection drug use is increasingly concentrated in the marginalized socio-economically deprived groups such as street youth and the First Nations populations.

Other threats include blood-borne pathogens such as hepatitis C, which I mentioned, and the burden from that is substantial. I will talk about that later. There are water-borne and food-borne diseases. You will well know about the outbreak of E. coli infection, which is an illustration of what can happen and the pressure that can be produced on the health care system when there are issues in public health infrastructure. I have mentioned anti-microbial resistance.

Resistance to immunization is something I want to mention because there is an increasingly vocal resistance to immunization. We will take for granted the beneficial effects of immunization on measles or polio. The only cases of measles now occurring in this country occur in individuals who are not immunized, usually having conscientious objection to immunization, and as a result of importations into this country. We would not want to rest on our laurels because we have to maintain those immunization rates in order to keep measles away.

Zoonoses, which are diseases in animals, are increasingly recognized as important. E. coli is one of them. E. coli is contamination of the water supply. BSE, the mad cow disease, is a form of a transmissible spongiform encephalopathy that includes a number of other diseases, but it is transmitted from animals. West Nile virus infection is another one, as is racoon rabies, which will undoubtedly arrive close to our doorstep in Ottawa, probably this year.

The economic impact of infectious diseases is often not recognized but is estimated to be more than $6 billion a year. It was estimated in 1998 that Canadians infected with HIV at that time would, through to death, cost the economy in the order of $27 billion. It is estimated now that the annual cost of Hepatitis C is between $1.3 billion and $1.8 billion. Anti-microbial resistance is expensive. It is expensive to keep people in hospital for longer if they have resistant infections, and if they have infections which they acquire in the health care system. Multiple drug-resistant tuberculosis is a small percentage of cases but, as you can see on the graph on page 11, 1.2 per cent of our cases are multiple resistant, and if that increases, those individuals can cost a remarkable amount to the system.

Many infectious diseases can be prevented. Immunization is a good example of that, and there are many new developments in immunization, including anti-cancer vaccines. It is worthwhile noting that probably 15 per cent of cancers worldwide are probably caused by infectious diseases. Screening of the blood supply is a good example of primary prevention. Targeted health promotion is important. I mentioned that in terms of sexually transmitted diseases, but health promotion has to be tailored and flexible. There is no "one size fits all." Therefore surveillance, to be up-to-date with trends in infectious diseases, is very important.

Basic issues such as good hygiene in the home and food establishments and careful activity in the workplace and health care institutions are vitally important and can be very beneficial -- guidelines for infection control, for example, in hospitals, protection of the water supply, and then control of anti-microbial use, good practices by physicians, goods practices by nurses, and good practices by the animal husbandry sector. It certainly is clear that antibiotic use in the animal care sector is an important factor in anti-microbial resistance in humans.

In conclusion, infectious diseases are a significant and increasing threat to the health of Canadians. Modern demographic and environmental conditions favour development of spread of infectious diseases. They are costly to the health care system. Many infectious diseases can be prevented by health promotion, disease prevention and health protection strategies, and these strategies are worth the investment.

The Deputy Chairman: Thank you very much. Dr. MacLean?

Dr. David MacLean, Departmental Head, Community Health and Epidemiology, Dalhousie University: I thank the committee for giving me the opportunity to come here today to speak on the issue of health. I come from an academic background now. I work full-time in that environment. I would just let the committee know that, prior to that, I was a practising physician for a number of years in Nova Scotia, and I spent a certain amount of time after my post-graduate training in epidemiology, and so on, with the provincial government. I have been with the university now for almost 13 years.

At the moment at the moment, my major interest in disease as it relates to our health care system centres on the issue of chronic disease. I have prepared a brief for you, which I will not reiterate today, but I have put forward a number of points. Particularly, you will see that my emphasis today is bringing a case to you for trying to balance our health care system better in a preventative way, and I go into some detail and some evidence. Because everyone wants evidence, I tried to give you the best that I could that will support my position.

I see chronic disease as the major health threat for this country, and our health care system in this century, for a variety of reasons, which I hope I will make clear as I go on. You have heard that it is the major health problem we face today in terms of our mortality, morbidity and our costs. The direct health care costs in Canada now rank about $86 billion, as we have heard from the Centre for Health Information recently. The indirect costs probably are another $80 billion or more. Chronic diseases are responsible for the vast majority of those costs.

Recent trends in these diseases give us some optimism, but they also give us some pessimism. The optimism comes from looking at such things as cardiovascular disease. We have had some declines in mortality from heart disease over the last 25 years. Particularly, we have had some declines in strokes and stroke mortality, which has been very important.

We have had some improvement in some cancers, like cancer of the blood-forming elements and some childhood cancers, but by and large the cancer situation has been disappointing. We are seeing some beginnings of decline in lung cancer in men because of the decline in smoking that has occurred in the past in men. Unfortunately, the situation is the opposite in women. Mortality is rising at an alarming rate from cancer of the lung in women, basically due to smoking.

For most of the major cancers, unfortunately, the rates are either increasing or remaining the same. For example, the mortality from breast cancer in women has stayed essentially flat for the last 40 years. I bring this forward to say that despite the fact that we have had, in relative terms, a massive investment in research and treatment for these diseases, not only in this country but in the context that we benefit from, which is the North American context, the impact of that has yet to be felt. There have been some successes. I am not being totally pessimistic.

These problems are compounded, and will be further compounded, by the aging of our population. I know you are all aware of that. It is important to recognize that even in declining rates such as we have had with cardiovascular disease, because the absolute numbers of the baby boomers will rise, a declining rate will increase the absolute number of cases that will show up in emergency rooms in hospitals, so we are facing an increasing problem with these, a problem that is very costly.

As you have heard, we have a substantial increase in the cost associated with technology, not only in the development of new technologies, which are expensive, but also in things such as drugs, and so forth, which are increasingly costly. That, in itself, will present a fairly major problem for us because the leading edge of the baby boom generation is just now beginning its chronic disease years. We are also seeing that this technology, in itself, is not only getting expensive but we are applying it to a much wider age range than we ever did before. When I went through medical school, people over 65 were considered not to be eligible for intensive care units. I am not justifying that decision, but that is the way it was in those days. I would draw your attention to the recent heart transplant in Alberta in a 79-year-old. There recently was a case in our newspapers in Halifax where a woman in her mid-50s had received her fifth organ transplant. I am not saying these are inappropriate; just that this is what the future will bring for us as we apply this increasingly expensive technology to an older and older population. Maybe just one heart transplant will not be it. It may be three or four in the same person over time. I think these are real threats to us because even in the richest societies, as you can see with the difficulties we have now in affording these cost, we may not be able to afford this.

In some way, health care costs are now bankrupting the other sectors in our society. For example, I also come from an educational institution. The opportunity costs associated with this huge expenditure on health care are significant, particularly to other important sectors in our society and for government policy-making. I am not suggesting that this is inappropriate but I do suggest that, unless we do something about them, these trends pose a major threat to our publicly-funded health care system. These are matters that even a rich country like Canada will need to give way on in the future if these trends continue.

We know, and you have heard, that the social and biological determinants of these diseases are preventable. They can be manipulated; we can change them. This has significant implications for how we should proceed in the future. In my brief I have tried to give you an overview that prevention is something that we can do because we now have enough evidence.

It is important to recognize that these chronic diseases are diseases. They are associated with aging in the sense that they have long incubation periods but they are not the aging process. There are societies where these diseases occur much less often than in our society. There is the potential that most of these chronic diseases we face, namely, cancers, heart disease, diabetes, chronic obstructive lung disease, are entirely preventable, or at least their rates will become low and they will become uncommon conditions in our society in time. They are not necessary. They are not just the inevitable end of aging that you must die with these diseases.

We have enough evidence to take action now, and I have tried to outline this my brief. The real question is not what to do, but how. We know that people who live by healthy lifestyles cost less money to the health care system and society at all age groups, even the most senior. People who live a healthy lifestyle cost less.

That fact itself gives us a clue to one of the solutions to the potential for increased costs, which is to try to reduce the demand for expensive health care services. We can do that through a preventative approach. Government policy and issues such as healthy lifestyle are important to the prevention approach, but it must come out of our communities. We must create healthier communities in Canada because many of the barriers that prevent us from being healthy are in our communities and at the community level. We must look at the whole infrastructure as to how we approach prevention and how we deliver preventative health services in this country if we really want to make a dent in them.

It is easy enough to give people education regarding nutrition and appropriate foods to choose, and remind them that we should only have 30 per cent of our calories in fat, et cetera, but to go into a grocery store and buy the right things requires a Ph.D. in food chemistry. There are many issues we need to address. Similarly, I started out trying to be healthy when I first went to Dalhousie in order to put on a good show for the rest of my department. I rode my bike to work from where I live in Dartmouth. After almost being killed in the first week, I do not do that any more. One cannot exercise on our streets. They are not safe for many people who want to run, particularly women because they are uncomfortable doing that other than in the midday. For people who want to ride a bicycle, you are taking your life in your own feet. I suggest that many of the infrastructures of our society are barriers to achieving good health. We need to make an investment and we must look at how we organize these types of things.

It is important to recognize that the social determinants of health are tied and people who suffer the most from these diseases are people who fall into lower socio-economic categories. It is also important to link our economic and social policies to health if we want to make a dent in these issues. Coming from an area of the country where these diseases are the most prevalent and, unfortunately, we are also the poorest, it clearly is illustrated in my daily life as I go about my work.

Given, then, that we have so much knowledge about how to deal with these things, why have we not done so? I think part of this results from the political economy of these issues, if I may use that term. In other words, there is an industry that supports curative services. There is a huge pharmaceutical industry, a huge technology industry and, quite bluntly, there is a huge industry in my profession that supports these kinds of approaches -- and quite logically so. It is not a conspiracy; it is just a natural fit.

No one supports prevention. No one pays for prevention. The health industry, in a sense, distorts our priorities in health. After all, they are there to treat illness, not to produce health. They distort our priorities in trying to balance our health care system. We need to address that issue if we are to find remedies.

Unfortunately, even things such as our Canada Health Act -- and believe me I support the principles of the Canada Health Act -- basically talks about medically necessary services. The word "prevention" is not in any of the processes. This has many implications but particularly it helps concentrate the mind of the policy makers, who are the provincial health ministers and the federal health ministers. As they get together to decide the issues of health in Canada, they are concentrated on these curative issues and the issue of prevention never gets on the table or receives needed attention.

I must say that no one funds prevention. There are many barriers to this. The outcomes from preventative work are long term. There are no short payoffs. For some parts of the political process, that is not an attractive issue. We have little capacity in governments to deal with the issue of prevention. We have little capacity in our professional bodies and in our professions, whether that be nurses, doctors, what have you, to deal with prevention. By and large, in much of the survey work I have done, it shows that we have a public that does not understand many of these issues or the benefits that can be derived.

Therefore, we must try to give some sort of policy priority to these issues. We must try and scale up the programs and activities that we can do at a community level that will try and address these issues. As Dr. Mills has suggested, this is a preventative dose issue. We have spent most of the money on prevention in this country nibbling around the edges.

In the consideration of infectious diseases, we all know that penicillin is the drug of choice for streptococcal infection, but if you give a person one milligram once, it will do nothing. A person would need 500 milligrams four times a day for 10 days. Prevention needs a similar dose, and it needs it for a length of time. We have the capacity and knowledge to do it. We really need to find the ways to implement all that.

I am happy to answer any questions that senators may have.

Senator Graham: I want to raise my first question with respect to breast cancer, since Dr. MacLean said in his presentation that the rate of breast cancer in women has remained relatively flat for the last 40 years. Yet we are told that cancer has become the second cause of death in Canada compared to fifth in the 1920s and the 1930s. Why is that the situation?

Dr. MacLean: Primarily because there were other causes of disease that were killing people, particularly infectious diseases, in those days. One of the interesting cases around cancer is cancer of the stomach, which in the 1950s was one of the leading causes of cancer death in Canada. It is now still a cause of cancer death, but not nearly to that degree. There has been a precipitous decline in the rate of cancer of the stomach in our country largely due to dietary change. It has been due particularly to changes in the preservation of food, such as in the use of salt, pickling and these sorts of things, which are associated with cancers of the stomach. The change is probably ultimately related to the fact that we had rural electrification and we could afford refrigeration in the country so people did not need to use those methods to preserve their staples. That is an example of a cancer cause that would have been high in those days but now is not. It is changing disease patterns that produce the different rankings.

Senator Graham: I want to mention the question of smoking and its relation to cancer. My mother died at the age of 91, still smoking. She smoked on the day of her death. When I got after her about smoking, she would say, "Now, dear, do you want me to die from smoking or from the stress of not smoking?"

The Surgeon General of the United States has said recently that the rate of lung cancer among women is reaching epidemic proportions in the United States. Would that be true in Canada?

Dr. MacLean: Yes. Mortality from cancer of the lung now exceeds that of breast cancer in Canadian women. That is a massive change. If you would have suggested to an epidemiologist like me 25 years ago that we would see that kind of lung cancer in women, you would have been scoffed at, but it is now unfortunately a reality. It reflects very much the uptake of smoking among women since the Second World War. Cancer is a disease with a long incubation period. Most of the people who will continue the lung cancer epidemic we have now into the next 30 years are already smoking. Cessation is important if we want to prevent that. Eighty per cent of lung cancer is related directly to cigarette smoking, and 50 per cent of people die of their smoking habit. Fortunately, the others have a genetic makeup, or what have you, that prevents that. Your mother was obviously one of those. As I say, 50 per cent of people will die of their smoking habit.

Dr. Mills: I would refer you to the slide showing the mortality counts in women between 1971 and 2010. This is just to reinforce what Dr. MacLean was saying. If you look at just the rate increase, which is the lowest line, that is quite a steep rate of increase for women, and it is directly related to our failure to turn around smoking rates in women the way that we have in men.

I have another slide I wish I had been able to bring to you. It shows the lung cancer death rates in men for 20 years following the smoking rates in the same population, and the parallelism is quite striking. The slope of the curve for lung cancer deaths is identical to the slope of the curve for the prevalence of smoking over time. Smoking among women has not yet turned around, so we have not seen the peak of the lung cancer epidemic in women yet.

Senator Morin: How long does it take?

Dr. Mills: For lung cancer, it is about 20 years. You see quicker responses with decreases in smoking rates in things like acute respiratory disease and acute myocardial infarction, but cancer takes a long time for the rate to decrease.

Senator Graham: Dr. MacLean, you said that no one funds prevention. How would you square that with all of the health promotion programs that are funded across the country?

Dr. MacLean: I suppose I was being a little hasty in that. I would suggest I meant no one really funds chronic disease prevention. There is some funding on lifestyle, and so forth.

In my province, which is your province, the health care bill is approximately $1.8 billion. I think that the health promotion budget of the province is somewhere in the range of $500,000. People often ask me how much we should spend on these things. I do not really know the answer to that, but I do know we do not spend very much. In the province of Nova Scotia, the health care budget has been going up between 7 and 10 per cent a year in the last few years. Let us suppose that next year the Minister of Health kept the budget for health care flat, did not increase it but did not decrease it, and just used that 10 per cent on prevention. That would be $180 million. If you gave us $180 million in Nova Scotia, we could do one heck of a lot in preventing these diseases over the next 15 years.

Senator Kirby: On exactly that point, are there any cost benefit studies that have been done, if not in Canada elsewhere in the world, which attempt to answer your question and show that if you spend a certain amount of money, which is the cost, on health prevention programs, this is what you save the public health care system? It seems to me your earlier comment was correct, namely, everyone is demanding that we spend all the money we have on people who are already sick as opposed to avoiding them getting sick. The data we need are fundamentally cost benefit. Does that exist anywhere?

Dr. MacLean: There is, I would suggest, smatterings of it. I give you the example of Finland in my brief. I recognize that you did not get my brief until today because I was late with it. However, there is an example of Finland and some work there that I think you would find informative. Because of the fact that countries have not run major national preventative programs, it is difficult.

One example I would use is the tobacco control program in California. The tobacco control program there is funded by something that most Canadian politicians do not like -- a dedicated tax on cigarettes. It has been in operation since 1988. It has generated $850 million that has been spent on health promotion and other activities around tobacco control in California. They have had remarkable success. Their lung cancer mortality rates have dropped 14 per cent over this time as compared to 2 per cent in the rest of the United States. Their smoking rate among people under the age of 19 is around 7.5 per cent. Ours is probably more like 28 per cent. They have also had a significant decline in cardiovascular disease and events, and they have published articles on this. They have also looked at some of the costing. For lung cancer alone, although they spent $50 million on the promotion, they suggest that they have saved $3 billion on operative costs and health care costs that have not occurred due to the decline in lung cancer, over and above the U.S. decline as a whole. These data have been published in the New England Journal of Medicine recently, particularly with respect to cardiovascular disease.

The difficulty in providing other than small demonstration cost-effective analysis is that, around the world, no one has taken it on as a national policy and put the resources into it for long enough and then looked at it.

Dr. Mills: I do have a table for you which is a review of cost-benefit studies. I was not able to table it today because we have not had time to have it translated, but we can provide it later. I would, if you permit, cite a few things that you would probably find interesting.

Bicycle helmets have a cost-savings ratio of three to one. For fluoridation for dental health, each $1 spent on water fluoridation results in savings of $80 in dental costs. Folic acid supplementation has a benefit-to-cost ratio of 4.3 to 1, and it is 6.1 to 1 for low- and high-level fortification of grain products to prevent neural tube defects. I cannot find the actual line readily, but there are many immunization studies showing net cost-savings. Controlling drug abuse shows a $15 saving for every dollar spent. There are many unanswered questions, but there is a lot of evidence for stuff that does work.

One of the problems is that the savings are in the health care sector and the people who have to make decisions to invest in prevention are usually not the same people who are paying for treatment. Therefore, you are investing in one place and benefiting somewhere else, and you are investing now and your benefit is two, three, five, ten, twenty or thirty years down the road. It is hard to persuade people who have urgent priorities to invest in important priorities that do not have that same sense of urgency.

Senator Graham: You have made your point with respect to insufficient funds being dedicated to health promotion with respect to Nova Scotia. How does that compare with other provinces in the country?

Dr. MacLean: Unfortunately, they are quite similar. There is no one that I am aware of in this country who is putting in the kind of resources that would be needed. The investment, overall, compared to what we are putting in, is relatively modest.

If you look at disease rates and also risk factor rates, you see a very distinct pattern in Canada. Everything gets worse as you come east. Smoking rates in British Columbia are much lower than in Nova Scotia. Weight levels are much better in the west. Physical activity levels are better. The British Columbia government has not spent large amounts, but they have spent more than we have on a per capita basis.

There is a dose-response relationship here. The more you spend, to a degree, the more you get. It only makes sense. To some degree, the richer provinces have spent more money and have better statistics to show for it.

Senator Morin: I would like to come back to Senator Kirby's question concerning the effectiveness of prevention on cost reduction. There is no doubt that it prevents premature death and premature disability. I do not disagree. I am all in favour of.

However, we were told over and over again that by far the most expensive year of our life is the last year of our life, whenever it happens. It could happen at the age of 17, at 50 or at 85. Whenever, that last year is the most expensive.

As we grow older, become 85 years of age, we reach a point where new diseases affect us that are unfortunately not preventable at the present time -- Alzheimer, all sorts of cancers, although some cancers are preventable, the great such a prostate, breast and so forth, are not preventable -- and osteoarthritic problems, and so forth. Unfortunately, in those areas and in those age groups, prevention is not as effective as it would be in a child or a young adult.

My question, then, is: out of the $80 billion that we are spending on health care, how much real savings are we gaining if we consider that about 80 per cent of what we spend on health care is in the last year of life? There will always be for all of us, unfortunately, a last year of life. We all go to hospital, at one point, and suffer from a disease that will be our final disease, and that will be expensive. We cannot get around that. Unfortunately, I do not think that prevention plays a great role in that. I am not saying that prevention is not important. Of course it is. No one believes that it is not, and I think we are doing a poor job. The position of our government at the present time on smoking is terrible. There is certainly a lot to be done.

However, I do not this we should look at it specifically as though we are considering orders of magnitude as a great cost safer. It is very difficult to say, but I do not think we can do that, in the long run. I would like your opinion on that.

I have another point to make, just for information here. When we are talking about the direct costs of disease, we know the economic burden. When we talk about the indirect costs, we are talking, of course, about lost wages, but what else are we talking about when you are talking about indirect costs?

Dr. Mills: We are talking about lost wages, principally, and disabilities.

Senator Morin: Disability, in what respect?

Dr. MacLean: Pension plans. For example, the payout in the Canada Pension Plan for under age pensioners, 30 per cent is due to heart disease.

Senator Morin: Then here is my question: If someone falls sick at the age of 87 years, what is the indirect cost of disease for that person?

Dr. MacLean: Indirect costs become less certain.

Senator Morin: Is it nil? If it is not nil, what are they? I am just asking out of curiousity.

Dr. Gully: It is a cost to the family. It is the cost to the family of caring for the individual.

Senator Morin: That is indirect. In Germany, for example, where they actually pay the family member to take care of the person, this would now become direct?

Dr. Gully: Yes, it could be. That is correct.

Senator Morin: I will move quickly to Dr. Gully. I was surprised at your page 11 where you state that the aboriginal population has a lower rate of tuberculosis than the general population.

Dr. Gully: This is the percentage of cases.

Senator Morin: It is not per population?

Dr. Gully: No. It is not the rate.

Senator Morin: We know that the most cost-effective preventative measure for chronic disease is smoking cessation. For the existing diseases at the present time, what, in your opinion, would be the most cost-effective preventative measure? My question is for Dr. Gully, with respect to infectious disease?

Dr. Gully: For infectious disease? Immunization.

Senator Morin: But the diseases for which you are immunizing are almost non-existant. What would it be for an existing disease?

Dr. Gully: The cost benefit is in preventing the disease. If we did not invest in immunization, then the diseases would undoubtedly come back.

If we were to exclude immunization, I believe that it would be the reduction in transmission of sexually transmitted diseases such as HIV and blood-borne pathogens such as HIV and Hepatitis C.

Senator Morin: There are cost-effective measures to do that?

Dr. Gully: There are cost-effective measures for doing it. However, the targeting of those measures is extremely important, and therefore the strategies and the tactics have to change constantly because the individuals that one directs those measures to are constantly changing. That is a challenge.

Dr. MacLean: Would you like an answer to some of those questions? I should like to speak to some of them, without taking too much time.

The Deputy Chairman: Perhaps after some of the other questions.

Dr. MacLean: I would like to speak to some of those questions, particularly on the issue that everyone gets old, and we all incur these costs. I would like to address that.

The Deputy Chairman: Perhaps you could make a note, Dr. MacLean, and weave that into your answer to one of our other questions.

Senator Fairbairn: This is tremendously interesting because we are all, in one way or another, living with it, either ourselves or members of our families. Because of incidents within my family life, I know that prevention is doable and very important. I am wondering whether some of this gets into the area of communication. Even with smoking, on which I agree with Dr. Morin we are not doing a good job. Sometimes it is easier to get people to agree to stop something because it is bad for their health, rather than to begin something that is a new pattern and will have good results.

For example, how long have we had a nutrition guide? We have had for some time the Canada health rules on what are the good things eat. Many people simply do not pay any attention to that until, perhaps, they develop diabetes, or something like that. Particularly in reference to diabetes, when the chips are down and you put aside the drugs, the answer you get from good doctors is that you must have the combination of diet and exercise.

I have had evidence in my own family of the astounding result that that combination produces. The opportunity for saving dollars in the area of that and other diseases seems to come down to a solution that, perhaps, is not very scientific. How do you persuade, most effectively, either as a doctor or as a politician? How do you persuade people to do the kinds of things that will have an extraordinary result?

I read about the comments on breast, prostate and bowel cancers. Breast and prostate cancers have certainly been receiving tremendous publicity, activity and effort. Dr. MacLean, you said that there has been little or no improvement in overall outcomes. Is that because we did not know as much before? Why, with the science and the technology that we have now, is it that you are able to say that there has been little or no change in the outcomes?

Dr. MacLean: I will answer that last question first, if you do not mind. We have done many of the right things. I am not saying that we have not. Investment in research and treatment should continue. However, we have not done the other obvious things. For example, the breast cancer mortality rates and the rates of breast cancer in Japanese women are one-sixth the rate of breast cancer in Canadian women. We know it is not genetics, because Japanese women who move to Canada succumb to the same rate of cancer as Canadian women.

Senator Fairbairn: Is it diet?

Dr. MacLean: We do not know why. However, we know for a fact that it is one-sixth the rate, but still we do not know the answer. We unravelled the whole issue of cardiovascular disease by doing the Seven Countries Study, which identified the whole process of arteriosclerosis and the risk factors of blood lipids and cholesterol, et cetera. We have not done those studies in the area of breast cancer, yet we have poured billions and billions of dollars into research on it.

I am not suggesting that you need that much money to do this kind of study. However, we have not done the basic epidemiology. We have a massive campaign on breast cancer screening, and I am not necessarily suggesting that it is not effective. However, we do know that, for example, in the United States they do breast cancer screening for women under the age of 50, and not because there is any science to support that. The evidence for breast cancer screening in women is that it is probably a benefit, if you look at the epidemiology and its root, but it is no silver bullet, and never will be. However, one of the things that it does is that it creates what we call a "lead time bias" so that it appears that the five year life expectancy is improved, but, in fact, it has only improved because you diagnosed it earlier, in many cases, with a lead time bias.

Therefore, I suggest that we have not looked at the issues that I think we should have. In other words, we are out of balance in how we approach these issues. Care is important. I would not suggest that we begin neglecting the people who are ill and need treatment. I am saying, though, that we are headed for bankruptcy, unless we can slow that down. We have to balance the system better. We have not really done that to the degree that we could.

There are many other issues that we could look at. No one has even looked at the issue of attempting to document the impact on stomach cancer. A major cause of cancer deaths in our country is now virtually gone. We could do the same thing with breast cancer.

Dr. Mills: There is another element with respect to breast cancer mortality, and that has to do with the dose effect that we were talking about in terms of primary prevention. In order to receive the benefits from breast cancer screening, as has been demonstrated in randomized trials, we need to be able to screen 70 per cent of the target population every two years. That means 35 per cent of all women in the target age group every year. Our programs are still fairly new, in relative terms. None of the provincial programs yet has the capacity to succeed in recruiting 70 per cent of the target population over two years. We are still in the build-up phase of reaching the point where we could begin to identify benefits in mortality reductions. Nevertheless, we are seeing suggestions of the beginnings of a mortality reduction, but it is too early to attribute that to the screening programs.

Dr. Gully: If I can make a point about the first question, I think there is a social science behind health promotion. Dr. MacLean's argument about money is that good health promotion costs money and that we have to learn from marketing techniques. The Canada Food Guide is good, but if we were a business, we would not be producing the same guide year after year. We would be marketing and presenting it differently, and it would be targeted differently. We would have new emphases, and so on and so forth.

Therefore, the evidence that health promotion works is correct. It does work in the studies, but when we actually put it into practice, we should not continue to do it in the same way as we have always done it. That comes down to resources and flexibility and inventiveness, and how to put forward those campaigns.

Senator Fairbairn: It seems to me that, with the potential that one would have from succeeding at this, that a little more brain power and a larger pocket would be of great benefit to our population, of every age group across the country.

Dr. MacLean: Absolutely. I agree that the Canada Food Guide is great; it is an important one, but we have not marketed it at all. We have not spent what Kellogg's spends in a week, on that guide over the past 10 years. These things will not diffuse by osmosis to people. If you want to change habits, particularly in people after they develop them, there is an effort required. Most of the habits that we develop, we develop as children. I could not drink skim milk as an adult because I hated the taste of it. My children today would never touch whole milk, because they hate the taste of it.

We are given different things as children. We have to start a lot of the habits in childhood, so that we do not have to change people's behaviour. It becomes a pattern of healthy living.

Senator Keon: You have made the point that the science base is clear. We know where there is science and where there is no science. We know what we can prevent and what we cannot prevent from the science base. Our big problem has been that we cannot get the act together. We listen to a great presentation about population health. However, as we have heard, the population health people are in their silo, and the health care people are in a provincial silo. Therefore, we are not taking these big disease entities and hitting them with everything that we have. As you know, since we have known each other for a very long time, I have made a career out of trying to do that.

Let me hear you speculate about how this Senate committee could influence the authorities at the federal and provincial levels to use the science that we have, to stop wasting money on the science that we do not have, and to fund our health care system on a program basis -- the big entities, and to make all our decisions on scientific outcomes. How can we do that?

Dr. MacLean: I wish I knew. We definitely need infrastructure to deliver the programs. We have infrastructure when it comes to care. Even in Nova Scotia, if you fall down and break your leg in a rural area, they will pick you up in the fanciest ambulance you ever saw and whip you off to the hospital where there are all kinds of people and facilities that will fix you up and spit you out. That huge infrastructure is there, and is maintained. However, if you go into the same community and say, "I want my dose of prevention," you will be talking to yourself. There is no one there and no infrastructure in place to deal with this. We have to look at an infrastructure issue and policy issue.

One of the unfortunate things about health reform across the country is that, in my view, it is devastating the public health system of the country, which is a mere shadow of what it was 20 years ago. Again, it is being marginalized by this concentration on how to get the money to treat people. The only thing left is the bare bones of communicable disease control, and even that is wearing thin, as I think Walkerton showed us.

One thing I would suggest is that the federal government use its time-honoured way of influencing provinces, which is the 50-cent dollars. The federal government could start by making a policy priority of trying to increase the infrastructure for prevention, because they have to work with the provinces on these issues. Starting to advance funding in this way would help build and sustain infrastructure over time. They could start by funding.

We have never had a cost-shared process for public health. We have dealt with the aspects of hospitalization and physicians and so on, but some people say we have an unbalanced system because we only have two legs on the stool. We have to put the third leg on, which is trying to cost-share on some of these basic infrastructures that would leads towards prevention.

The public health system as it is now cannot take this role on, but it could re-tool itself -- I really mean "re-tooling" itself -- if it were given the appropriate resources and mandate to do this. Public health in Canada today has a mandate and responsibility for communicable disease control, and it does not accept a mandate for non-communicable disease control. That is one way to start.

We have to fund some of the research. There is a certain amount of research on these issues. I am very excited by the Canadian Institutes of Health Research and their big increase in budgets, but I am also very sceptical on how much of that will go to health promotion and disease prevention, and so on. I work in a medical school where there are all kinds of basic scientists, and they have not stopped grinning and rubbing their hands yet.

Dr. Gully: I am a public health physician, as are Dr. MacLean and Dr. Mills. My colleagues in England are involved in the health care system and analyzing the cost-effectiveness of the system. They are able to bring epidemiological science and other sciences to that analysis, and the infrastructure is being used in the United Kingdom to do that.

That does not happen in Canada. There has been no tradition of that. In fact, the public health infrastructure is not strong enough to offer that to the health care system. Think of that as a possibility. It is difficult for public health physicians to come in and talk to clinicians, but that is what we might have to do. It may bring the scientific basis or analysis that might be useful.

Senator Keon: I should like to ask Dr. Gully an important question, and I hope I am not being unfair because you may not have dealt with this lately. In the years that I served on various advisory committees, one of the big issues we kept addressing was the global safety net. Every time we got a big environmental scare or a big infectious disease scare, the issue surfaced again, but it seems to me we never got our act together to put the pieces in place, whether through World Health or anyone else. When something happens, we flip down to Atlanta or to Dalhousie to see if they have the answer; we flip out to Winnipeg; we try to cobble the solution together, piecemeal. The global safety net has not come together.

Can you bring us up to date in terms of infectious diseases and environmental threats in public health?

Dr. Gully: That is an issue, undoubtedly, and there is always a difficulty in balancing resources put into immediate issues with issues such as chronic diseases. I think that we are perhaps a little further on than we were before, especially relating to the Health Canada laboratory in Winnipeg, which is undoubtedly becoming more active and able to deal with external threats such as Ebola, which we could not do before.

In addition to that, through the Canadian Institute of Health Research government scientists will now be able to have access, or request, or bid for those funds and do research which, in fact, has public health significance nationally, as is certainly demonstrated by some of the money going into the Winnipeg laboratory and elsewhere as well. The infrastructure is improving; however, it is always difficult to make a bid for contingency funds for new threats.

The surveillance for West Nile virus this year will cost $2.5 million, which has to be new money from somewhere. It is either that, or we take it from somewhere else. It is a very minute issue in terms of mortality and perhaps morbidity. On the other hand, the Canadian public wants to know what is going on, which will be costly. We are perhaps slightly better organized than we have been in the past, and the Winnipeg laboratory helps, but certainly we have a long way to go.

In terms of information infrastructure, money being put into that area by the federal government will be a distinct advantage, and therefore the networking and the ability to share information and gather information from provinces and territories and collect information over the Internet is certainly advancing, and is much better than previously.

Senator Keon: There is still no form of structure, is there? There are still no global links.

Dr. Gully: Do you mean global links relating to other countries?

Senator Keon: Yes.

Dr. Gully: One of the problems with that is we often look to WHO, and it does have a better infrastructure for communicable disease control than it did previously, but WHO is not well funded. Therefore, inevitably the well-funded disease control agencies, such as CDC, are often able to be there offering resources before the rest of us are, although I might say that, internationally, they often wish they had Canadian involvement. However, not having a very strong infrastructure in WHO is not helpful in developing that global infrastructure.

Senator Robertson: Senator Morin asked a question about that last year of life being so very expensive. I did have an opportunity, Dr. MacLean, to peek into your document, and I was pleased to see your reference to Finland. Would that same percentage hold up in Finland?

Dr. MacLean: It very well might, in the sense that the Finns started with much bigger problems in the early 1970s when they tried to tackle these things than we had. I would reiterate that these are disease processes. That does not mean if we do away with them, we will never die. That is not the case, obviously. There are aging processes which will do us in, as appropriately they should. For example, heart attacks and strokes, and so forth, result from arteriosclerosis or hardening of the arteries, which is a disease process. The cardiovascular system does age, but it is not that process. The outcome of the disease process is heart attacks and strokes; the outcome of the aging process is heart failure. What happens with heart failure is you live to be 90, and you go to bed and you die in your sleep. Heart attack or stroke is when you get ill earlier and you must go through 10 years of care. This is an idealized sort of process.

I suggest that if you look at the studies that have been done, and I quote a number of them, people who have less risks and live a healthier lifestyle, are physically active and eat a better diet and do not smoke, cost a lot less money at every age group, even in the last year of life.

There is one study I quote where a large HMO -- health maintenance organization -- from the United States categorized their patients into groups who were not overweight, did not smoke and exercised at least three times a week, which is not much, and people who smoked, were overweight and did not exercise, and they followed them for eight years. The people with the better lifestyle cost the HMO 50 per cent less in health care. We spend $86 billion. Just by that extrapolation alone, which I realize you cannot do, we would save $40 billion. That is a great deal of money and those are feasible goals.

Senator Morin: Were you talking about the last year of life?

Dr. MacLean: It is not the last year, but what I am trying to say is that you can make the last year of your life much less expensive than it is now.

Senator Robertson: There is much going on in sustainable longevity, internationally. I have been fascinated by some of the statistical evidence and wondering how accurate it is and how it could relate to what we are not doing. We do not even have our kids exercising in the school system any more. It is disgraceful that they do not learn earlier.

I wish we had more time because this is refreshing and interesting. I personally believe that we must concentrate on this area to get the population healthy.

I feel that that last year of life is very important. In Canada, I do not know if we have done any separation of the health benefit systems in the agricultural areas compared to the urban areas. Do we have statistical evidence on the differences? Many older people remain in the agricultural communities. It is usually the young people who move to the urban areas.

Dr. MacLean: There is data on different disease rates, but again, surprisingly, we are a fairly homogeneous country and there are urban-rural shifts in some illnesses, but it is not as great as you would think.

Senator Robertson: Over the years we have read much about children in the home, and that is where most of their accidents and their problems occur. Is that still true? Have we not done a good job of educating parents on how to keep their homes healthy?

Ms Nancy Garrard, Director, Division of Aging and Seniors, Health Canada: There has been a downward trend in children's injuries that has resulted from safety messages out in the home as well as child restraint seats and safer driving. There has been a major reduction in motor vehicle collisions. There is still a sizeable problem that we think is preventable, and the best evidence suggests that there is a large amount of product safety and playground safety that could reduce it, as well as general education about keeping a safe environment and safe parenting. Watching your children will reduce accidents, as well as reduction of motor vehicle collisions related to inexperience and drinking and driving.

Senator Robertson: What about the chemicals we use in our home that are contained in cleaning supplies? Is there anything being done about that?

Dr. Gully: I cannot give you the information but we could get the information for you. We have a surveillance system for childhood injury and we could look at the data relating to consumer products in relation to that.

Senator Robertson: In our medical schools, what percentage of instruction concentrates on prevention?

Dr. MacLean: Sadly, not as much as it should. I can only comment on my own medical school. We have made inroads. My own department, which largely carries the can for this kind of curriculum, has increased its hours of instruction over the last seven to eight years. However, it is a difficult issue because the curriculum time is jealously guarded, and it is hard to get this into the curriculum. Students are interested early on in their medical school careers. They are not that interested once they are exposed to the blood and guts. However, they are certainly interested in the early years, and that is when we try and interest them and plant some seeds.

I would suggest the major deficiency is in the area of nutrition. Most physicians, unfortunately, have information that is probably not enough to even give reasonable guidance to people.

Senator Robertson: Nutrition and aging.

Dr. MacLean: Yes.

Senator Cook: Thank you for a most informative presentation. There is one subject that I have not heard anything about and that I believe impacts on the discussion today, and that is poverty, particularly poverty in children. It is all well for us to talk about the Canada Food Guide. That costs a large amount of money. If children are living in poverty, so are the parents, be they from single-parent or two-parent families.

Have you looked at that aspect as a barrier to wellness and healthy communities? I believe there is a great deal of evidence based on material out there such as with respect to the school programs, with breakfasts and whatever, because hunger impacts on the ability to learn, and we certainly will pay the price for that.

Also, the incidence of smoking at the lower level of income has an impact. I think this is where it will be in the next generation. Just this week in my home province of Newfoundland, I am sad to say, the Department of Education cut their programs in physical education, music and art. If there were any three subjects that would build a healthy community, those are they.

I welcome your comments.

Dr. MacLean: You are absolutely correct. The association and the, as we say epidemiologically, stratification of risk and disease outcome associated with socio-economic status is a strong one. That is evident in my own province of Nova Scotia. Some of the studies that I have been involved with have clearly illustrated this.

Similarly, one of the things that associates with poverty is literacy levels. This has a clear impact on the ability of people to uptake health promotion and disease prevention messages. That has clearly been demonstrated in the literature as well. We know that in many of our disease prevention and health promotion programs, like many other things, the people who derive the most benefit from those messages are people in the higher socio-economic categories. Clearly we must target others, and this is one area I would illustrate for research. I have been in this business for 20 years and, to be honest, we really do not know how to target people in the lower socio-economic strata on how to reach them with our messages. There is no population anywhere that is poor that is healthy.

Senator Morin: Is it poverty, or lack of education?

Dr. MacLean: From an epidemiological point of view, the gradients are stronger with educational level than income, but I believe there is a great interaction between those two.

Senator Morin: You would say it was more education than poverty?

Dr. MacLean: It is a difficult call to make. I would suggest that there are relative degrees of poverty. There comes an area of poverty where even if you are educated, you will be unhealthy.

Dr. Clarence Clottey, Acting Director, Diabetes Division, Centre for Chronic Disease Prevention and Control, Health Canada: The point about poverty is certainly an important one, and it touches on a general principle in our ability to essentially provide health promotion and prevention interventions in a sustainable way. Over the past decades we from the public health community have pretty much been involved in interventions that have tended to be a little paternalistic. We have been trying to provide the science of appropriate health education in a "thou shalt do this and thou shalt not do that" kind of atmosphere. We realize that one important factor in ensuring that that behaviour is adopted is by creating an environment that allows the person to make the right choices. It is only by enabling them to do that that you will get the right kind of result.

Poverty is a very important stumbling block or barrier to people having the right kind of environment that allows them to make healthy choices. That factor negates some of our efforts in trying to foster healthy habits. Poverty becomes a fundamental issue to grapple with as we try to look at health promotion and prevention efforts.

Senator Kirby: If the federal government were to make available new funds of $100 million or something of that order of magnitude of money, and we were to recommend to the government where the money should be spent vis-à-vis prevention, recognizing that we cannot do everying, where would you tell us to spend it?

Senator Morin: Might I just ask one question before you answer Senator Kirby's question. What do you mean by supporting infrastructure? Earlier on you said that you thought federal government should support infrastructure. What did you mean by that?

Dr. MacLean: I would suggest that we could spend the money in ways other than social marketing campaigns.

Senator Kirby: The 60-year old Swede would not reappear?

Dr. MacLean: Not necessarily, no. I would suggest that prevention measures and the ability to live healthy lives have a greater impact on, of all governments, the municipal level of government. They are afraid of health issues because they do not wish to have those costs downloaded on to their budgets. However, basically, they provide most of the infrastructure that can facilitate health or be the barriers to it, and unfortunately in our country it is largely barriers. Therefore, there is a certain amount of that which is infrastructure.

I do research at a community level and we have an active research program in Nova Scotia. We work with community groups and coalitions and we establish coalitions that come together and bring the existing infrastructure and capacity of the community together, for instance organizations such as the Heart and Stroke Foundation and the Cancer Society are brought together and by virtue of the research funds I am able to give them support in all sorts of areas from secretarial support to research support, and so on, and in that context, we do many things; we develop programs, we lobby municipal governments for smoking by-laws, we build exercise trails, we work with schools, and we do all kinds of things. We have established an infrastructure and built a great web site, called the Health Promotion Web Site. It has all kinds of information that anyone in that community who wants access to information, can get it. Therefore, infrastructure is providing information in an easy way for people to access it.

Some of the support is through providing the appropriate skills to personnel. People who work at community development and bringing people together are not necessarily the doctors. There is a need for other health professionals who are trained in the skills of this area.

Therefore, I would say that where to spend the money is in infrastructure. I would suggest that if we took $100 million a year in Canada, which would be roughly $3 per person, we could probably cut heart disease rates in half in 10 years. We could probably reduce them by 50 per cent in 10 years. I base that on an extrapolation of some of the work that we have done in Nova Scotia. If we jumped it up to $5 per person, we might even make heart disease an uncommon occurrence in 15 years. Some people might think that I am crazy to say that, but we could actually do that. Eschemic heart disease or heart attack in a country like Japan and in many other Asian countries is something that is really uncommon.

Dr. Gully: I agree, but I am not familiar with the figures. If we build sustainable infrastructure so that the research is done and the evidence is in place, then we have public health nurses, public health physicians and educators. They can then use the research findings to apply to chronic diseases, lifestyles, sexually transmitted diseases, and so on and so forth. However, it needs to be maintained because we have to have the capacity to do surveillance in the population and know where the diseases are, where they are changing, and then be able to intervene. We cannot do that if we do not have that infrastructure.

Senator Morin: Infrastructure is people?

Dr. Gully: Infrastructure, to a great extent, is people.

Senator Kirby: Let me ask you one last question: I am intrigued by the skim milk example, by the way, which makes sense to me, knowing children. If you really want to have long-term success, does it make sense to give up on old people like me, and we intend to put all the prevention efforts into kids? In other words, since we will wash off the end sooner rather than later, and given your children's example, if the trick is to change behaviour early on, because then it stays for your lifetime, why would you not put all of the money only on the kids?

Senator Graham: I am sure Senator Kirby is speaking only for himself.

Dr. Gully: Who influences children? Parents, grandparents, uncles and aunts influence children.

Dr. MacLean: I would suggest as well, from a statistical point of view, that the rapid payoff comes from people who are in the highest disease rate. An investment in people who are 50 will really pay off in terms of reducing the rates of disease, and keeping people healthier.

Dr. Clottey: I would suggest that, certainly, there is much to be benefited from across all age groups, without question. I will use diabetes as an example. Oftentimes, we know that the prevalence and incidence of diabetes shoots up significantly after the age of 40. Yet, even though people may actually have prevalent diabetes, the chances of developing complications rise with age. However, these complications can be prevented by the same things that will prevent diabetes in the first place in younger people. Therefore, you can have a multiplicity of benefits by looking at these types of treatments across all age groups.

Ms Garrard: To add one more comment to the point about the success of infrastructure, I would say that it is important to take ownership and responsibility in terms of reporting on it. If we reported on a regular basis on how poorly our health is being sustained, and not just on how we die, but on how we live, and be held accountable, then all of that would fuel all the energies of individuals and communities toward it. That would include the children and the public education system and the community services. Therefore, it is building on the infrastructure that is important, and it is never too old to change, just as it is never too early.

Senator Graham: We are told that infectious diseases such as tuberculosis and pneumonia are becoming increasingly resistant to anti-microbial drugs. Why would that be so?

Dr. Gully: There are three reasons: first, there is the issue of medical practice in terms of physicians not use anti-microbials appropriately, although I think that is changing. There is evidence in this country that that is improving. Second, there is the issue of using anti-microbials inappropriately in the agriculture sector, and there I think we have a long way to go, because there is ample evidence that resistance of organisms found in animals can certainly transfer and infect humans. The other issue relates to diseases such as drug-resistant tuberculosis. Such diseases require anti-microbials over a long period of time. It also requires a lot of public health infrastructure to ensure that individuals take those drugs day after day, for at least six to nine months.

We are not too badly off in this country in terms of infrastructure, although that is less true amongst First Nations. The real threat comes from abroad, from Eastern Europe or Russia, where the instance of multiple drug resistant tuberculosis is a huge problem, and therefore the importation of those infections and diseases that are multiple resistant is a problem. It is a medical care system problem, it is an agricultural care system problem, and it is a global problem.

If money is put into it, though, as was shown in New York City where they had a large problem with multiple drug-resistant tuberculosis, then the problem was certainly obviated.Again, however, it is money into a public health infrastructure.

Senator Graham: Does Health Canada have, or plan to have, a travel advisory with respect to the United Kingdom?

Dr. Gully: In terms of eating beef?

Senator Graham: An advisory on travel to and from the United Kingdom.

Dr. Gully: There is information on the Health Canada Web site in relationship to eating beef in the United Kingdom. There is evidence provided to people on that.

In terms of any other disease, I do not believe that there is a travel advisory as regards the United Kingdom. However, we do have travel advisories which change daily for other countries across the world.

Senator Graham: My question was prompted by the mad cow disease incidence and foot and mouth disease?

Dr. Gully: There is certainly a travel advisory relating to the consumption of beef in the United Kingdom.

The Deputy Chairman: Colleagues, it is left to me to thank our witnesses. As Senator Robertson said, we could have gone on for another couple of hours. This session has been most interesting.

We will have an in camera session when we have our meeting tomorrow.

The committee adjourned.