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

Issue 9 - Evidence

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:03 a.m. to examine the state of the health care system in Canada.

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: Senators, I suggest we begin. We have three witnesses this morning. We will hear them sequentially, rather than as a panel, because they will be speaking on three different subjects.

Our first witness is Dr. Alan Bernstein, President of the Canadian Institutes of Health Research, also known as CIHR. We should congratulate Dr. Bernstein, as it was a year ago today that his bill was passed. As you will recall, this committee dealt with the bill that created the CIHR; we had extensive discussions with many individuals, including Dr. Bernstein, as I recall.

We are delighted to have you with us.

Dr. Bernstein has distributed a handout, which includes on the last four pages overheads, to which I presume he will referring.

Dr. Alan Bernstein, President, Canadian Institutes of Health Research: Thank you very much for this opportunity,Mr. Chairman and honourable senators. I do appreciate this opportunity to appear before the Standing Senate Committee on Social Affairs, Science and Technology for your study on Canada's health care system.

I notice that Phase 2 of the study is entitled "Future Trends, Their Causes and Impact on Health Care Costs," and it is to that aspect that I would like to speak to you this morning.

As Senator Kirby said, today is the anniversary of Parliament's passing of the bill that created the CIHR. This committee was one of midwives of the bill that created CIHR.

The Chairman: As such, we are not covered by medicare.

Dr. Bernstein: I would note that your colleague Senator Morin is undoubtedly one of the parents of CIHR. He was, first, a distinguished member of the Medical Research Council, the predecessor organization of CIHR; he served on both the interim governing council of CIHR and then the governing council of CIHR before you stole him away to the Senate. It is our loss and the country's gain. Of course, Senator Morin is himself a distinguished clinician and researcher.

It would not be an understatement to state that the current revolution in health research will be one of the drivers, if not the single largest driver, of change in the health care system in the next 10 to 20 years. This scientific revolution is being fueled by our rapidly emerging understanding of the molecular basis of life, of human biology and human disease, and the recent and ongoing advances in genetics and genomics, together with an appreciation that our health and susceptibility to disease is really the summation of a complex interplay between environmental factors, genetics and social factors. That appreciate will transform our health care system in the next 10 to 20 years.

I have divided those changes into four areas. At the moment, our health care system is largely reactive. We largely interact with the health care system when we are ill. That is going to change as a result of the genomics revolution. For example, the genes that are involved in about 10 per cent of breast and colon cancers have been identified. Schizophrenia and diabetes will be next. We have the potential now, if one has a family history of those diseases, to do a DNA test and to say, "You will get breast cancer with a 94 per cent probability in 60 years, based on genetic inherence."

There is not much we can do about breast cancer other than a preventive mastectomy. Yet, studies have shown that many women want to know, if they have a family history of breast cancer, whether they have these mutations. Again, with colon cancer the gene has been identified. We have gone from an ignorance of that disease to now being able almost routinely, if one has a family history, to sequence the FAP gene, which is involved in colon cancer, and if one has the mutation, to removing the polyps, the pre-malignant growths that emerge and prevent that disease, which is inevitably otherwise fatal.

This is a different kind of health care. It will develop as more and more disease genes are identified over the next few years.

It is also raising profoundly new ethical, legal and social issues for all of us to deal with. Those new molecular insights, of course, will also mean that we are moving from a descriptive phase of medicine and health care to a mechanism-based description, where we understand the basic underlying biology of disease. That will change how we diagnose disease. It will also change and is changing how drugs are discovered. These new therapies, whether they are drug, gene or stem cell therapy, will be expensive but effective. They will also, for both those reasons, have profound impacts on Canada's health care system.

Information technology, another major driver of change, is also, as I said in my submission to you, effectively going to democratize the health care information highway. Anybody now has access to the information. The clientele is going to be knowledgeable and will want access to the latest drug or other therapies. Of course, it will have an impact on delivering health care to Canada's remote rural and northern regions as well.

The final driver of change will be demographics. There is a bulge of people my age moving through the system. It will have quite a profound impact on the health care system over the next 20 to 30 years.

It is within the context of a revolution in research that CIHR was born exactly one year ago. Canadians place a great value on health and the health care system. The creation of CIHR, with its very broad and integrative mandate, explicitly recognizes that a cost-effective and innovative health care system cannot exist without a vibrant internationally competitive and strategic health research enterprise.

I am sure honourable senators are familiar with the Fyke report out of Saskatchewan. That report emphasizes that research is a pillar of the transformation to a high-quality health care system that is both accessible and efficient.

CIHR has developed a bold and broad new vision with an innovative structure that includes the creation of 13 virtual institutes that span the entire spectrum of health concerns of Canadians. CIHR is the primary agency through which the Government of Canada funds health research.

I would also add that, although I do not think it is within your immediate mandate, CIHR is also key to building a knowledge-based economy. In addition to contributing to a health agenda and a more cost-effective health care system, CIHR-funded research and programs are contributing directly to Canada's health-related biotechnology sector, a sector that is key to Canada's growth in the 21st century.

In addition to the 13 institutes that were announced in July and the scientific directors from across Canada that were announced in December, we are bringing together researchers from all pillars of health research, biomedical and clinical researchers, health systems researchers and population health researchers, as outlined in the legislation.

The advisory boards that were announced in January bring together from across the country 218 volunteer Canadians who will advise those 13 scientific directors about the strategic initiatives that should be developed by CIRH's 13 institutes. This is a brand new structure. We have never had this in Canada before. Early signs are that it is working.

A key part of our mandate is to promote and disseminate knowledge and the application of health research, to improve the health of Canadians. CIHR is developing as we speak a multifaceted knowledge translation initiative.

All levels of government need objective and scientific evidence in order to make informed policy decisions, given the avalanche of new treatments in the pipeline. Canada's health research community already serves as a receptor for the world's scientific advances. Canada is a small country, scientifically. Thus, we are not only contributing to our own science, but also helping our policy makers evaluate new advances, made worldwide, to guide decision making.

We need to understand this complex interplay between our genetics and the psychosocial environmental factors that affect our health and disease. We also need to worry about the ethical implications of this new technology. For example, the government is proposing to put into place a legislative framework around the use of assisted human reproduction and the uses of the human embryo.

CIHR has anticipated a great interest in stem cell research for disease therapy, and actually released, a few weeks ago, a guideline for researchers in Canada for all CIHR-funded research involving the use of human stem cell and human embryos. This document has been received positively by the international scientific community. Two weeks ago, Nature, the world's most prestigious scientific journal, carried a story on our guidelines. The story was entitled, "Canadian Panel Aims for Middle Ground" - the usual place that we in Canada like to be in.

The Institute of Health Services and Policy Research will support research to address the need for health systems, technologies and tools to promote health, prevent disease and deliver health care effectively for all sectors of the Canadian population, as well as to evaluate the economic impact of the health care system. I will not list the details of the mandate; it is included in my written submission.

I give several examples where I think research funded by CIHR has had an impact within the health care system, in terms of saving the system money. There is an example on pneumonia that I will not expand upon. There are also examples on heart attacks and diabetes. As well, there was a study reported last week in the prestigious New England Journal of Medicine on ear infections - which is the most common reason that children are taken to the doctor - that commented on the current practice and how these operations are unnecessarily spending money without really helping the children. If the guidelines of that study wereadopted, it would save Canada's health care system approximately $300 million a year. That is not a bad return on such an investment.

We are all too familiar now with the E.coli infections in Walkerton, Ontario that led to several deaths, and other incidents have been reported involving hamburger meat. Dr. Brett Finlay, a UBC researcher, is a CIHR distinguished investigator. Dr. Finlay's work is noteworthy on two levels - and this is illustrative of what CIHR is about. He has elucidated in a beautiful series of experiments exactly how E.coli causes kidney failure and death and how it adheres to the intestinal linings in our body to cause diarrhea and the like. As well, he has gone beyond that science and, in collaboration with the Alberta Research Council, the Saskatchewan Veterinary Disease Organization, and Bioniche Incorporated, a biotech company in Ontario, has developed a vaccine against that particular strain of E.coli, and this vaccine is now being used to immunize cows. Cows are latent carriers of that bacteria and undoubtedly the runoff from that herd caused the problems in Walkerton. They are now doing experiments with 300,000 cattle in Canada to see whether they can effectively immunize them against E.coli and as such prevent contamination of our water supply with that bacterium. That is a great example of wonderful science and a partnership between four provinces and the public and private sectors. Dr. Finlay is also a wonderful communicator. He gives the annual Christmas lecture at the Howard Hughes Medical Institute, in Washington, D.C. This is something that all Canadians should take great pride in.

Another example is Dr. Jacques Simard, at Laval University. He is working on genes involved in prostate cancer, following on work that he had done earlier on genes involved in breast cancer. We have just funded Dr. Simard with a large grant, including a multidisciplinary team, to work on the genes involved in various cancers, working with community groups in the population and researchers from all four pillars to understand how these genes work, how they can be used in diagnostic methodologies and, it is hoped, to prevent and treat diseases.

I have other examples of CIHR funded work that, because of time, I will not go through, except for one example, which is the problem of diabetes in Canada's Aboriginal population. It is an epidemic, to put it mildly. Over 50 per cent of Canada's Aboriginal peoples have diabetes.

The Chairman: I saw that number and thought it might have been a typo.

Dr. Bernstein: No, that is the right number. You might wish to invite Dr. Bernie Zinman from Mount Sinai Hospital, who is working closely with Aboriginal peoples on this very serious problem.

Undoubtedly, the epidemic of diabetes in that population and the complications and deaths that arise from that disease are a combination of genetics, family history and lifestyle. Dr. Ann Macaulay heads the Kahnawake Centre for Research and Training and Diabetes Prevention. She heads a community alliance for health research, a new program that we started this year that involves researchers from McGill University and community researchers in the Aboriginal community to develop and evaluate a model for diabetes prevention in the Aboriginal population.

I have met with Aboriginal leaders from Sandy Lake, in northwestern Ontario, about this. It is really a terrible disease. It is a chronic disease. It probably is at least 50 per cent preventable, and we need to be doing research and working with community groups.

To conclude, in the short 10 months since the act was passed that created CIHR, we have moved quickly to realize the bold and broad vision that was set out by Parliament in this committee last April. A slate of institutes has been named, including 13 directors and advisory boards. They are actively developing their strategic plans. I would love to list all of the ones that are on their menu. We have funded two novel programs. I mentioned the Community Alliances for Health Research. We have also funded another program called Interdisciplinary Health Research Teams. Together, those 29 projects are an $80-million investment over the next five years.

They involve over 550 researchers across Canada. The number and breadth of CIHR-funded investigators has been broadened to reflect our new mandate. The average size of grants has been increased in 10 months by 20 per cent, an urgent step to make Canada internationally competitive and to keep our best and brightest researchers in this country. Most important, the Canadian health research community has a new energy and optimism, which is essential as we move forward in this new century.

Ten to 20 years from now, our health care system will undoubtedly be vastly different than it is today. These profound tectonic shifts will be largely driven by science. The health care sector is truly Canada's largest knowledge-based industry, and to contribute to this global health revolution for the health and wealth of all Canadians our country needs a robust, innovative and evidence-based health care system. We require a culture that can respond to change, that can innovate and originate change, a culture that recognizes and awards excellence and evidence-based decision making.

I know of only one way to achieve that goal. Although I look at it through a distorted lens, I think that the only way to have a culture of innovation is through a culture of research, and that needs to permeate everything we do in health.

We are today in the midst of an unprecedented revolution in health research. In a very real sense, the future of our health care system depends on how successfully we both contribute to and benefit from that revolution.

The Chairman: Thank you for that update. We are grateful to hear what has happened in the year since we dealt with the bill.

You have addressed with the role of the federal government in what I would call basic research; I want to move to the patient end. There is tremendous pressure from patients to have the latest drug, the latest device, the latest whatever. What are the stages between the completion of one of your research projects and the outcome of that research, be it a drug, a test or a procedure, being available to Canadians?

My second question is related to that. What is the process by which one decides whether it is worth doing, in a value sense? Because we cannot afford all the bells and whistles, how are the trade-offs made? They are obviously made, because some things are offered and others are not; there is at least an implicit trade-off mechanism. What is the process by which we determine that a wonderful new toy is too expensive and would help too few people to proceed with it?

Dr. Bernstein: First, just to correct a misapprehension, CIHR does not fund only basic research, by which I mean laboratory research on fundamental mechanisms.

The Chairman: I meant basic, as in a process that takes your output and moves into the marketplace.

Dr. Bernstein: I skipped over some examples. We also fund clinical research, including clinical trials. One example I skipped over was the work by Dr. Yusuf on the drug Ramipril. We are funding a very large study with Dr. Yusuf in collaboration with two pharmaceutical companies. We have learned that Ramipril might prevent diabetes, so we are now funding a $2.5-million clinical trial on patients to see whether, in a larger group of patients, Ramipril really will prevent diabetes.

We are also funding this year, for the first time, a tri-national study involving the U.S. and the U.K. on new therapeutic modalities for HIV/AIDS. In addition, the health services pillar of CIHR will be evaluating the health economics of any new innovation within the health care system.

On your second question, one can make great advances scientifically, but someone must evaluate their cost effectiveness in the real world.That is the function of the Institute of Health Services and Policy Research headed by Morris Barer. They are asking questions exactly along those lines. We are hoping then to have a venue to transmit that information as part of our knowledge-transfer mandate to policy makers across the country. I have already met with deputy ministers of health across Canada to set up ongoing dialogues with them about scientific and research innovations and to convey to them the latest results and the advisability of incorporating them into Canada's health care system.

These are big issues and we need good and objective data to evaluate them. I totally agree with you.

The Chairman: What does Morris Barer's organization do?

Dr. Bernstein: Of the 13 institutes within CIHR, one is Health Services and Policy Research. You will see that on page 4 of the overheads we have provided. The mandate of that institute is to evaluate the cost effectiveness of innovation within the health care system.

For example, if Dr. Yusuf finds that Ramipril really is effective in preventing diabetes, one of the functions of that institute will be to look at the cost of that drug, look at the number of people with diabetes, look at the side effects, and evaluate whether it makes sense to recommend Ramipril to people at risk of getting diabetes.

The Chairman: Is there a document that summarizes what that institute is working on now?

Dr. Bernstein: Currently, all the institutes are developing their specific strategic initiatives. The broad mandate for that institute in particular is listed at the beginning of my presentation to you. I am sure that Dr. Barer would be very happy to appear before this committee.

The Chairman: This is very important. There is no sense in hearing from him before he completes his strategic plan, but can we assume that it will be done before we rise in the middle of June?

Dr. Bernstein: Absolutely.

Senator LeBreton: There is much information here. It is obvious that the delivery of health care will change dramatically. You talk about it going from reactive to proactive. I will use Alzheimer's disease as an example. As researchers are able to identify genetically or by other means conditions that signal that a person may be a candidate for Alzheimer's, those people will begin to be treated. Are other bodies looking into the positive economic outcomes of that? For instance, with the growing aging population, there are increased numbers of people in chronic care facilities. That number may decrease in 10 to 15 years as a result of new research and treatment. Has there been a study on the savings that will result from that?

Dr. Bernstein: That is a very good point. I think it is our responsibility, senator. There are health economists in the country whose research we will be funding. They will look at the economic burden of disease and, therefore, the resultant savings of either eliminating or ameliorating the disease or shortening hospital stays, et cetera.

I have given examples concerning pneumonia and ear infections. I give dollar values in that regard. Some of that information is available, and some of it is very hard to get. You are right, senator, we need to document that very well.

Senator LeBreton: As your research continues, you will have to look at the anticipated crossover point. That is to say, when you look at the next 10 to 15 years and consider the gradual shifts in the system, you will have to consider where it crosses over from a reactive to a proactive health delivery system.

Dr. Bernstein: I think we are seeing the tip of the iceberg now. Colon cancer is one example. In my previous life, I was director of research at Mount Sinai Hospital in Toronto, which houses the familial colon cancer clinic for southern Ontario. If an individual has a family history of colon cancer and comes through the door of that hospital, some DNA is taken and the gene is sequenced. This is done even before any symptoms appear. The individual is then followed on an annual basis and the polyps are removed. We are starting to see that happening increasingly. It will permeate the health care system within 20 years.

Senator LeBreton: It will cross over in degrees, then.

Dr. Bernstein: It will happen incrementally, as these risk factors are identified.

Senator LeBreton: But as people come to expect a better delivery of health care, the impact could be huge.

Dr. Bernstein: Expectations will also rise with these advances.

Senator LeBreton: Once the research is done - and Senator Kirby talked about getting it out to the patient - will there be more pressure placed on practitioners? The practitioners are busy, and the health care system has many patients. What about the individual who has genetic proof of familial breast cancer? How will information be disseminated to the population at large?

Dr. Bernstein: I talk a little bit about the Web as being one way of democratizing knowledge in the health care system. Consumers are becoming very knowledgeable. Quite often, individuals with disease X, Y or Z will search the Web to learn more about that disease. They often end up knowing more about the disease than any physician will ever know about it. It is hard for physicians to keep up with all these advances. One of our knowledge-transfer functions is to ensure that information about research advances not only is transferred to policy makers but also to health professionals, such as physicians, nurses and other caregivers. In this way, we will be delivering the very latest advice and science within the health care system. It is a challenge.

Senator Robertson: Thank you, Dr. Bernstein, for attending here this morning.

My questions relate to something that Senator Kirby identified, as well as to something Senator LeBreton touched upon.

We hear a lot of moaning and groaning about the cost effectiveness of research for new programs. I have always felt that, if research looks after the side effects and ensures that one can live with them, the next step on the part of researchers is to ensure that the end result of the research, whatever it is, can be made cost effective. It seems to me that the two go hand in hand. One should not throw up his hands and say, "We cannot afford that," because, as you identified correctly, the system will change radically. However, there is some responsibility in the research end of things to determine cost effectiveness, to the point at which the public can feel comfortable. There have been many new health care innovations, drugs, et cetera; however, if we measure their cost against the heavy cost of traditional-style care, of keeping patients in hospital beds for protracted amounts of time, goodness knows what we could come up with. There is a trade-off there.

Dr. Bernstein: I agree with you. I gave examples involving pneumonia and ear infections, where CIHR-funded work has looked at current clinical practices in hospitals and questioned it. In the case of both conditions, our research has asked: Is current practice the best way to treat this disease? The answer in both cases was no, that more cost-effective methods are available, thus saving Canada's health care system hundreds of millions of dollars.

Senator Robertson: It is important for the public to understand these things. The value of the research, I believe, follows that path and makes people comfortable.

Senator LeBreton touched on the plight of physicians and health providers. There is currently a shortage of physicians, and this shortage will continue because of the time required to train physicians. I look at my little province and wonder how we will keep up to date with the research. How will the medical schools respond? How will we retrain? Its seems to me that retraining all the people involved in the delivery of health care will be required.

I am not sure if applied practical research has to go into that. Will current medical practitioners be overwhelmed by this? Will they be able to absorb it? How will we educate not only those in the medical and nursing schools but the army of other people currently working in the field?

Dr. Bernstein: You are all identifying a challenge, and it is a real one. The professional bodies, such as the Royal College of Physicians and the Canadian Nursing Association, are well aware of this avalanche of new information. There needs to be ongoing continuing medical and health education for health professionals. That is one reason I made the comment in my closing remarks that in order to have an innovative and leading-edge health care system we need leading-edge health research enterprises. It is these people who are at the front lines who can do that ongoing medical education and dissemination of new knowledge.

If CIHR were to disappear tomorrow, if Canada were to decide that we do not need to do health research because we are a small country and we can import it from the United States or Europe, we would immediately lose all our researchers, including those people in the health care system. They are the people who are the nodes, the centres of immediate new knowledge. They can talk to their colleagues and say, "There is a better way of doing this, that or the other thing." We would lose that immediately. That would be one huge negative impact of not having a vibrant health research enterprise in Canada.

Senator Robertson: I applaud the research. I agree that we need as much as possible. The more money we can direct at research, the better off we will be. However, let us go back a few years. Do you know the name of the first ulcer pill? I cannot think of its name right now. Do you remember how upset the surgeons first were when ulcer patients began to be treated by drug therapy rather than by surgical methods? The surgeons practically ran those allies of drug therapy out of the hospitals. Our most difficult challenge may be to change the perception and the practices of some people in the health care system.

Dr. Bernstein: I agree with you. My closing comment is that there is a culture of research. Research always questions. If there is a culture of research that permeates the health care system, it makes it easier to innovate within the health care system.

Senator Cohen: Senator Robertson and Dr. Bernstein referred to our little province of New Brunswick. In looking at your scientific directors in the institute, I notice that the Atlantic region is not represented there at all. There are illness that are unique to our area. I know that the Alzheimer's Society is studying a family in the St. John River Valley that has had generational cases of Alzheimer's; asthma is another area.

How are you getting your information on the Atlantic provinces? Is there an advisory board with respect to the Atlantic region? Do we not have people who would be capable of serving in this area?

Dr. Bernstein: I absolutely agree with you. It is important, based on the arguments that I have been giving to you, that CIHR be represented right across this country, and it is. You are right, there are no scientific directors from the Maritimes, but the advisory boards have strong representation from all regions, including the Maritimes.

Mavis Hurley, from New Brunswick, is on governing council; Alastair Cribb, from Prince Edward Island, is on governing council; Nuala Kenny, from Nova Scotia, is on governing council. It is important to note that we are funding a significant amount of research in the Maritimes. We have just made a $3 million investment into Maritime safety - health research, broadly defined.

I have appointed Dr. Renée Lyons, from Dalhousie, as my special adviser on the delivery and continuity of rural and remote health issues, which is obviously a unique problem for Canada.

As well, I have encouraged the research community in the Maritimes to get together and determine how they can best take advantage of the federal funding through CIHR. I was in P.E.I. in January and attended a meeting of the nascent health research institute. I have actually given a bit of money for researchers from the four Maritime provinces to meet and form an eastern Canadian health research institute that will facilitate them being nationally competitive and take advantage of funding from CIHR.

Senator Cohen: I am glad to hear that. My case rests at the moment.

What is the future of the Maritime Centre of Excellence for Women's Health in the Atlantic region at this point?

Dr. Bernstein: You would have to ask Health Canada. That is outside my area of immediate purview. Senator Morin might know, but I am not sure.

Senator Morin: Dr. Bernstein, as you stated earlier, CIHR is the only organization that is devoted to the full spectrum of health research in the country.

On the basis of what is being done in other countries, and from your own experience, what should be the budget of CIHR in relation to the total health care cost in the country of $80 billion? What percentage should we aim for, in view of the increasing importance of research, as you stated earlier?

Dr. Bernstein: Let me try to answer in two ways. I said in my presentation that health care is Canada's largest knowledge-based industry. If I were a CEO of Health Canada Inc. and said that we are going to double our spending to 1 per cent of our total budget on research, you would fire me if you were on the board. You would say that 1 per cent is ridiculously low for a knowledge-based industry. Despite Nortel's problems, Nortel and all the high-tech companies down the road here in Ottawa spend between 20 per cent and 40 per cent of their revenues on research. How else can they be at the leading edge?

At the moment we spend through CIHR, as a country, about 0.5 per cent on health research. In round numbers - and I am rounding up - we will receive about $500 million this year for CIHR, which is a significant increase from what it was. Our health care budget in total for the country is approximately $100 billion, so $500 million is approximately 0.5 per cent.

My own judgment - in terms of the broad mandate that you gave us a year ago, in terms of international benchmarks in other countries and the capacity in this country to do the research, is that we should grow over the next three to five years to that 1 per cent level, which would be a doubling of where we are now. Others would argue that is too modest, that we should be above that. My number would be $1 billion, which would be approximately 1 per cent of today's dollars spent on the whole health care system.

Senator Fairbairn: What a tremendously upbeat presentation; it has been a delight to hear. I have listened to your emphasis on the fact that health care is the largest knowledge-based industry, and you have focussed quite properly on efforts to democratize this knowledge, use the new technology to get it out, have the Institute of Health Services and Policy Research reaching out to disseminate as best they can into communities and services that actually deal with people.

My question goes to the issue of the ability to understand the knowledge that you are hoping to pass down through practi tioners, and that leads me to the question of the millions of people in Canada who are at risk because of their low literacy skills, their inability to comprehend at a certain level of information. We will hear from Scott Murray from Statistics Canada on this issue as it pertains to older Canadians.

Generally, most people experience some difficulty trying to understand instructions from medical practitioners, reading and understanding prescriptions, formulas for kids, all those kinds of things. Is the institute involved in any manner with literacy issues, with reaching out and assisting those who most need help in the area? Are you factoring this into any of your considerations?

Dr. Bernstein: That is a good point. We are not funding literacy issues directly. It is interesting that one of my first trips as president was last June to UBC in Vancouver. I happened to meet there a professor of English who was interested in health. I asked her what her specific interest was. It was exactly around these areas, about language as metaphor in the health care system, about the issues of telling an individual that he or she has cancer, about the fact that first-generation Canadians and their families will receive the information in one way, whereas fifth-generation Canadians will receive it in another.

I became very interested in exactly this issue. We are funding her to do some work with clinicians on how they interact with families and patients who are affected by the news that they have cancer or some other serious disease.

With regard to how we reach "ordinary Canadians," Canadians are very quickly getting up to speed on using the Web. They are very interested in it as a portal to the world's knowledge. As one way of reaching out to the country, we are developing a research portal concept. There will be one Web site for all Canadians, be they researchers, caregivers or professionals in the health care system. The site will be called "Research Net." It will contain information for everyone, from students in grade 6 doing a science project on health, to health professionals learning the very latest in the field, to researchers who want to know how to apply to us for money, to policy makers across the country who are interested in the latest evidence-based decision-making issues with which they must deal.

There will be subportals within that one portal. My information technology people are working hard, in partnership with the other federal granting councils, the health charities, the provinces and the government online initiative, to realize this over the next 12 months.

We are leading this discussion and I am very excited about this as an innovative way of reaching out to Canadians.

Senator Fairbairn: Last year, the Public Health Association of Canada, for the first time ever, chose to have its annual cross-country conference on the issue of literacy and health. I leave that with you because this affects about 8 million people in our country. Over 40 per cent of our adults have these problems. It is a side issue to what you are doing. I am just waving the flag and hoping that at some time a special focus could be put on this.

Senator Graham: Thank you and welcome. In your presentation, you talk about the future. You say thatthe $110 increase in funding for fiscal 2001 and 2002 represents significant support for health research in Canada, bringing the federal government's total investment in CIHR to $477 million, or approximately .5 per cent of Canada's total health care budget.

You go on to say that international benchmarks suggest that a minimum of 1 per cent of a country's health care budget is essential to maintain a vibrant, innovative and leading edge health research enterprise.

I recall meeting with the president of what was then the medical research council prior to the health budget, as it became known. After the presentation of the budget, I asked him his impression of it and he said it was stunning. In spite of his term "stunning," are we still only halfway there?

Dr. Bernstein: The trend line is in the right direction. With that $110 million increase this year, our budget has almost doubled over that of the old Medical Research Council, and that is in a short three years. That is a huge recognition by the Government of Canada of two things: the importance of health research and the shortfall in the budget of the old NRC.

The trend line is in the right direction, although we still have significant room to grow over the next five years.

Senator Graham: Can you give us an example of countries that are at 1 per cent?

Dr. Bernstein: I can give you dollar amounts but not percentages. This year, the National Institutes of Health in the U.S. received a 14 or 18 per cent increase in their budget, to approximately $18 billion U.S. Therefore, they are currently four-fold to six-fold per capita above where we are. The U.S. spends more per capita on health care than does Canada, so one can safely assume that that is about 1.5 to 2 per cent of their health care budget.

With regard to U.K., it is about 2 per cent of their health care budget. They have legislation that requires that, within the National Health Service, 1 per cent is spent on research. However, they actually spend more than that on research.

Senator Graham: I want to talk for a moment about cooperating with the private sector. You illustrated an example where you are investing $2.5 million with one pharmaceutical company for some particular research. How widespread is that cooperation between CIHR and the pharmaceutical companies?

Dr. Bernstein: I would say that roughly 3 per cent of our programs are in partnership with pharmaceutical companies. In clinical trials, for example, it would be illogical not to partner because the pharmaceutical companies have so much to add, not only financially but with access to the latest drugs, et cetera. We also partner with them in training young people, particularly young clinicians in research. They provide some of the salary support in partnership with us to train young people.

Senator Graham: Do you partner with institutes in the United States in your research?

Dr. Bernstein: Health and health research is not a Canadian problem; it is an international issue. There is great international interest in the CIHR structure, model and vision. We have been visited by the Netherlands. I have been invited to Australia to talk about CIHR. Our scientific directors have been to the National Institutes of Health to talk about partnering in the North American free trade area on cardiovascular and cancer research, and that area will broaden over time. I visited the U.K. two months ago to talk about a joint initiative with the Medical Research Council there around various projects, although we have not yet finalized what they will be.

Yes, there will increasingly be international partnerships in health research between Canada and other countries.

Senator Graham: In response to what I think is a justifiable concern expressed by Senator Cohen with respect torepresentation from the Atlantic area of our country, you said that you were encouraging the scientific community in Atlantic Canada to get together. Does that suggest that they are not currently cooperating as best they should to take advantage of money that might be available for scientific research?

Dr. Bernstein: No, I do not mean to suggest that at all. An issue in Canada as a whole is our geography. Science research is all about critical mass and having lots of other researchers around you. The public image of researchers going into a lab and coming out every 10 years to talk to someone is entirely wrong. Research is all about meeting other researchers, talking about what is new and being stimulated by your colleagues. In many regions in this country, including Atlantic Canada, it is hard to get a critical mass because of the population structure and base. Therefore, I have given a little bit of money to help people get together.

In response to Senator Cohen's question, I did not mention that we have a regional partnership program for which only the Maritime provinces and Saskatchewan are eligible. We have put up $1 million or $2 million, and we expect the provinces to match that, to specifically stimulate health research in those five provinces. There has been great uptake of that money by both the Maritime provinces and Saskatchewan. That is separate from our national competition. Only those five provinces are eligible for that money.

Senator Graham: When I was in cabinet, I met with many people in the Atlantic provinces and here in Ottawa who said that there was room for greater cooperation in the scientific community among our institutes of higher learning in Atlantic Canada.

Dr. Bernstein: There is always room for more cooperation. I do not think at all that Atlantic Canada should be singled out in a critical sense for that. I would say that the mood in this country has changed a lot in the last few years towards more cooperation, and the recognition that we need, not just Dalhousie talking to Memorial, et cetera, but to have biomedical people talking to clinical people and health services people. The creation of CIHR has served to be a major catalyst for all of that.

The Chairman: Thank you, Dr. Bernstein. We are pleased to get your update. We should do this on an annual basis so we know where you are going.

Dr. Bernstein: It would be my pleasure.

The Chairman: In order not to lose sight of a point we talked about earlier, once the Institute of Health Services and Policy Research has its strategic plan - and I would also argue once the Institute of Population and Public Health has its strategic plan - we would like to hear about that.

Our next witness is Kimberly Elmslie, the Acting Executive Director of the Health Research Secretariat in Health Canada.

Before Ms Elmslie begins her presentation, I wish to say, in response to Senator Graham's question about where Canada stands, that in a document circulated by our staff there is an interesting table on page 8, which compares health care spending by country. It is interesting, in that generally Canada is sixth on various per capita data kinds of numbers. I am not surprised that we are behind the U.S. I am rather surprised that we are behind France and Australian. That is counter-intuitive to me, and wrong. The data is right. I do not like the result.

Ms Elmslie, thank you for attending here. I know you arrived during the previous discussion, so you know what Dr. Bernstein had to say to us. I would ask you to review the highlights of your brief, and then honourable senators will ask you some questions.

Ms Kimberly Elmslie, Acting Executive Director, Health Research Secretariat, Health Canada: Honourable senators, I am delighted to be here. This is an important opportunity for me, and I am also happy to be following on Dr. Bernstein's presentation. There will be some similarities in the things we have to say. I will talk about some things that I have learned from my experience in the research field and from working in a federal health department with provincial and territorial colleagues, issues related to health care and the health care research system and observations that may again reinforce some of the comments that I heard senators make around the table earlier.

Let me start by giving you a bit of the landscape. We have, in the federal government, a multifaceted role in health research and in health care research, and more and more are getting involved in facilitating efforts to influence priorities, to bring more precision to discussions about what our health care research priorities should be. We are highly involved in undertaking research ourselves in areas that are directly related to federal responsibilities in the areas I will point out, particularly of health protection and risk management.

I am sure Dr. Bernstein has talked to you at great length about the funding of extramural health research and related science in engineering research, and the new and improved ways that we are striving to move health research forward in this country. I will not go into the details around that.

I wish to talk about other organizations that in this country will be essential to moving the results of research into the eyes and ears of the Canadian public, to policy makers and to those in the health system who need to have information on a regular basis.

We all know how inundated we are with information. Thus, there are specific challenges to us regarding organizations like the Canadian Health Services Research Foundation - a federally funded organization dedicated to engaging in research that looks at the health system specifically. Our challenge is to bring the results of that research into the policy processes and into the dialogues that Canadians are having at various levels about research.

One of the take-away messages that I want to bring to your table today relates to investing in the transfer of research into decision-making processes, learning how to do that more effectively and really thinking about that in the context of the whole research process.

Organizations like CHSRF, the Canadian Health Services Research Foundation, are certainly common entities around the world these days. You only need to do a quick search of the Web to see that governments around the world are dedicating resources to the transfer process. It is no longer seen as the second cousin to the research process. We are seeing governments saying that they are really not using research to its full potential. We have invested for a long time in the front end, and we are doing more in the front end, especially with the Canadian Institutes of Health Research now in the Canadian landscape. However, we must think about how to use that research most effectively to the benefit of Canadians.

Another organization that I would like to highlight is the Canadian Institute for Health Information, which is another important national entity that brings data into the decision-making process. The federal government has enhanced funding to that organization in the 1999 budget to really focus its efforts on reporting on the health of Canadians and the health of our health care system. We must ask ourselves about how we ensure that we are mobilizing research and directing it in a way that brings its benefits to Canadians and about how we know that our health care system is doing what it should do to improve health outcomes.

We have all been thinking a great deal about these questions over the past years, not only in the past two years when CIHR was in formation but for a long time. We know that the health care system is only one piece of a much larger puzzle, and we know that health is about much more than that. Studies have been coming to the fore that compellingly demonstrate the influence of the social and economic factors in our environment on the health status of our population.

No one research discipline can answer the fundamental question of why some people in our population are healthy and others are not. This speaks to and illustrates the absolute importance of the CIHR model of integration that brings together researchers from a multiplicity of disciplines and says, okay, here we have the problem. How do we understand better what are the main factors and the interactions between factors that result in positive and beneficial health outcomes in some groups of our population and absolutely appallingly negative health outcomes in other segments of our population? I am making reference here to our Aboriginal peoples and the circumstances in those populations that we need to understand in concert with Aboriginal communities, and not as researchers looking into Aboriginal communities.

Research is an important tool, but the tool is only as good as the use we make of it. Without investing in the transfer piece that one of the senators on this side of the table made reference to earlier, we are really missing the opportunity to be able to see positive outcomes in the health of the population.

What is at play? The list on the bottom of page 2 is not rocket science. We all know these things. They include the changing demographics of our population and patterns of disease. We know that infectious diseases are re-emerging. We can expect new infectious diseases to emerge in this century. Those who thought years ago that we had beaten the infectious disease challenge, of course, are realizing that they were sorely mistaken and that this is something that the population globally will be dealing with for centuries to come.

We are seeing rapid advances in science and technology. They are very exciting. However, we cannot forget the social and ethical issues that they raise for us as a society and as a population. Research that moves us forward, for instance, in genetics and genomics, needs to be accompanied by a vigorous research agenda in the ethical and social aspects and implications of that research. The purpose of the agenda is not in any way to prevent bringing the benefits of that research to the population. Its purpose is to understand the impacts on what we value as a society and what we need to do to put the pieces together in a way that Canadians can understand and make informed choices concerning the options that become available to them.

Public expectations are on the rise. When I started working in the field of health about 20 years ago, my first job was in the area of HIV/AIDS. Any of you who have been in that area will have witnessed the explosion of information that patients were using to direct their own health care at that time. Many other areas were not experiencing that. I truly believe that it was HIV/AIDS that brought us forward in understanding that patients, consumers, work with their providers to decide on the best choices for them in terms of their health care. The public expects that. As we get a more knowledgeable public and as the information revolution continues and we obtain more knowledge on which to base our decisions, there will be an increasing demand for more information from the public and greater involvement in decision making.

Are we equipped as a society? Is our health system able to deal with that increasing demand? Probably not right now.

Rising costs and concerns about effectiveness in efficiency are not new phenomena, by any means, but clearly they have risen to the fore as we look at new pharmaceuticals coming on to the market.

I deal now with the drive to commercialize, which, again, is not in and of itself a negative thing at all. However, it needs to be within a framework that allows us to ask these questions: How does our system cope with this? What does it pay for? How do we decide?

Overarching issues around health care quality, the access to care, health outcomes and system affordability continue to be at the centre of the dialogue on health care. As a country, we need to think about the architecture, management and financing of the system. Again, these are words that are not new to anybody around this table. I put them out again because in the face of the new CIHR and its Institute of Health Services and Policy Research - and, in fact, all of its institutes - we need to be thinking about tying the outcomes of research to the system that delivers the products of research to our population. Therefore, I see health care research as a very integrative and unifying piece of Canada's health research agenda.

There is also an important role for our voluntary health sector. I have highlighted this in my brief because I have been involved recently in some consultations around research. The role of the voluntary health sector keeps on coming forward as we think about new models for this century, new ways of integrating care and the fact that Canada has a very caring and volunteering society.

How do we best value that, in the context of the health care delivery system, recognizing that caregiving happens in a lot of different places in your society? The relative roles of informal and formal systems of care present us with new opportunities and challenges. We need to bring that into our thinking about research and how we mount a research response.

I have some thoughts for you on the way forward. I do not think anyone would disagree that the CIHR model is the right one. The word "integrate" keeps coming to my mind as I look at the way we are dealing with the new CIHR. That is to say, integrate the ideas, the talent and the resources. We are trying to create an environment that harnesses Canadian research talent and draws together the stovepipes, the separate entities, and gets people talking about the right solutions. In some ways, it is as simple as that and as complex as that.

I would like to raise two challenges - and, again, they do not involve rocket science. Do we know what we know and therefore what we need? We tend to get caught up in the potential of new science and discovery. We need to ground ourselves and ask ourselves what it is that we know and what it is that we do not know. We have to know when to ask ourselves, "Do we need to take some action here?" Those are some of the questions that come to my mind as a I look at a research and science agenda.

How do we use what we know in order to change what we do? It seems like a simple question, but we are not doing a good job in Canada of getting research into practice. We know that the clinical practice guidelines that are available do not change physician behaviour. Information does not change health policy development. It does not influence it enough. Traditional publishing of health research in journals is not enough. This is an area of focus that we really need to put some of our creative talents behind. I have no doubt that we can do that.

Synthesis of research findings is important in assessing the state of the art. It is rare that one research project, or even a few, is enough to bring us the evidence we need. It is the power of many good research studies and good research champions that brings together information from science and makes it real to people and to organizations so that they use it.

Evidence consolidation is a business that many are in right now. We have to determine how to broaden that scope and how to bring it into our mindset. Dr. Bernstein talked about the idea of the culture change. That is part of it. We also have to ask this question: What important tools do we need to put into place?

I would say that we are on the right track. For the first time, CIHR is starting to specifically align research with policy needs. We have to see how it works. We know that that is the intention, but we have not had time yet to see it actually work. We are all committed to evidence-based information. We need to direct some attention - and we are starting to do this - to health-care-system-level evidence and to the impact of making a change in one part of the system. We must ratchet up our lens to say, "We have a big system" - some would say many systems - "operating out there. When we make a change in one area, how do we look at the impact of that on other parts of the system, to maximize the benefits?"

Analysis of the effectiveness and appropriateness of new approaches to care will be important to our system as we get it ready for the future. Many predict that the acute care system will change dramatically because of the availability of new drugs and new approaches to care delivered in the home, telehealth and telehome care. These are all words that are on everyone's radar screens, but what do they mean to us and how do we know that the health outcomes and the quality that we are delivering to Canadian is where we want to be?

More health care outcomes research is critical. We do not know yet what works. That will be a very important guiding feature for the future.

Finally, I will make the observation that the building is only as solid as the foundation. We are on a very important track with CIHR to mobilize health research, to train and build the capacity for health research in Canada. We still have a fairly small health-services research community. We need to attract researchers into that area. By doing that, we will achieve the important outcome of keeping that talent in Canada, where we are desperately needing it, if we are to turn a huge system around or even modify it in important ways to meet the health challenges of this century.

The Chairman: Before turning to my colleagues, I wish to ask you a specific question. On page 4, where you say "we are on the right track," you then list the bullet points you just talked about. Is that kind of work - the effectiveness, the research, the outcomes research, and so on - being done elsewhere than under the mandate of the Canadian Institutes of Health Research?

In other words, are there other organizations doing that; if so, is there a synopsis of what is going on in the country in that area?

Ms Elmslie: The answer to your first question is, yes, health outcomes research is going on in other areas by organizations other than CIHR. As to the synopsis question, I believe there may be pieces of that, but not a consolidated piece of which I am aware. I would be more than happy, though, to look at that and provide the committee with what is available.

The Chairman: That would be helpful.

Senator Morin: We might hear from the national centres of excellence on evidence-based medicine then. This is exactly what people have been trying to grapple with.

The Chairman: We would appreciate anything you can give us on that, and picking up on Senator Morin's point will be helpful.

Senator Robertson: You raised something that I thought was rather important. You spoke about the health of our health care system. Has there been any research on the socio-economic conditions, for example, of our medical students?

Ms Elmslie: That is a good point. I am not aware of any specific research on that particular point, senator.

Senator Robertson: Where could we find that information? I hear different things in different quarters about the socio-economic difficulties or not of medical students; it is difficult sorting the rumours from the truth. I should like to obtain information on that subject.

Ms Elmslie: I will undertake to get that.

Senator Robertson: What socio-economic class are doctors recruited from? If we were to look at the first year classes of the country's medical schools, would we find that a majority of the students were from well-to-do families or would we find that they were broadly representative of all income brackets in the population at large?

There is the belief out there that talented students, who otherwise would apply to our medical schools, decide to pursue other studies because of the huge financial implication of a medical education. I have been told that because of the cost implications of a medical education we are losing some of our brightest.

I know that medical schools have bursaries and that sort of thing; nevertheless, it is a shame if we are losing some of our extremely bright young people. I am very interested to know whether there is research out there to confirm or deny that.

Ms Elmslie: There is a researcher whom I know at McMaster University that has done quite a bit of research into the medical student array, if you will, in Canada. That would be my first checkpoint.

Senator Robertson: It is important for Canadians to know that we are attracting our best and brightest.

Senator Graham: As well as keeping them.

Senator Robertson: Yes, but we have to get them in first.

Are there enough medical schools in Canada, compared to other OECD countries? Perhaps Senator Morin will address that topic further.

I would be most appreciative of any information you could get for me on these questions.

Ms Elmslie: Thank you. I will definitely follow up on that.

Senator Robertson: The Department of Health is so big nowadays that it is difficult even to find one's way through the directory; it is almost impossible to determine where to go to get information.

Could we get a simple directory of all the divisions in Health Canada, so we know what we are talking about?

Senator Morin: It depends what day of the week you are talking about. They change every day.

Senator Robertson: I agree with you, senator.

What division of Health Canada is responsible for the research and approval for drugs? That is not your division, is it?

Ms Elmslie: No, it is not.

Senator Robertson: At some point it would be interesting to have a discussion, Mr. Chairman, about the possibility of coordination with other countries of the approval process. We might get a better system in place. There is much general discontent with the approval process.

Ms Elmslie: The branch in the department responsible for that is the Health Products and Food Branch.

The Chairman: Senator Robertson, you are not alone. In the year and-a-half that we have been in this job, we have received an incredible number of organizational charts for Health Canada; if you add to that the number of personnel changes, the figure is incredible.

Senator Graham: What you are saying is that it gets confusing, Mr. Chairman.

The Chairman: It works on the assumption that there is someone who truly understands.

Senator Graham: Having heard the witness say, "Do we know what we know?" I am reminded of the old expression, "We are all here because we are not all there." One hopes that we will be able to justify our existence as time goes on.

I am particularly interested in the questions that Senator Robertson asked. I hope we are able to get answers to those questions. If not, then why? There has to be a mechanism to find those answers.

I am interested in the general picture. Is the secretariat, which is relatively new, the link between Health Canada and CIHR?

Ms Elmslie: We are one of the links. Our intent, when we formed the secretariat at the time that CIHR was launched, was to ensure that the department understood and was taking full advantage of the opportunities to work together with CIHR.

In the past, in the days of the medical research council, the organizations were separate entities. There was some collaboration, but both organizations felt there was room for more. The secretariat provides, if you will, a navigation function to link into CIHR at the corporate level and to the institutes to determine where we can work together, where it makes sense for us to join forces and combine our resources.

Senator Graham: Was the function of your secretariat fulfilled under another name prior to the reorganization?

Ms Elmslie: No, it was not. It is new.

Senator Fairbairn: My question is becoming a perennial one at the committee, and I take it from your question about how to use what we know in order to change what we do. My question is about the degree to which Health Canada can be a leader in getting information to Canadians who have difficulty with basic reading skills. It goes to your concern about issues of taking health care into the home, thereby shifting responsibility to the person who has to manage his or her own situation.

Ms Elmslie: It is an incredibly important issue, and one that we do not spend enough time thinking about.

One way I have seen information being brought into the home and being used in a situation where literacy levels and understanding may not be at the highest level is in the whole area of working with our immigrant populations.

I think we can learn a lot from the Metropolis experience. For those who do not know about Metropolis, it is a research program concentrating on immigrants living in urban centres in the country. It is funded by a number of federal government departments. People working in that area are spending time on this question of transfer of information, boiling it down and making it understandable to people from various cultures and in various linguistic ways.

Although I do not have answers to the question, I think there is a recognition out there that we have to get better at it. We have to use what communities are already doing through community associations and other grassroots organizations and not just rely on what we think is best for everyone else. We have to really engage and start to work with those community organizations that on a daily basis are out there with real people in real circumstances who need real help.

Senator Fairbairn: A great number of them are not from the immigrant population; they are home grown.

Ms Elmslie: You are absolutely right. I am thinking of models that we may be able to draw on, and that model came to my mind, but I take your point that they are Canadian people who are home grown as well.

Senator Fairbairn: Keep at it.

Ms Elmslie: Yes. And if anybody figures it out, call me?

Senator Morin: Under the influences of the health care system, most governments are faced with two factors. In addition to changes in age and so forth, public expectations have increased, and we are faced with demands for costly procedures or drugs that are only marginally effective. Every provincial government has been lobbied about drugs - for example, drugs for multiple sclerosis. These powerful lobbies pressure governments to give them drugs or procedures or technologies that are marginally effective but extremely expensive.

I am sure you have thought about this issue. This problem is one we have been trying to grapple with. How would you deal with this situation?

Ms Elmslie: That is the $6 million question, so to speak. You are absolutely right, Senator Morin. There are a variety of pressures on government from many different sources to bring to Canadians various products, drugs, and pharmaceuticals in a very timely way.

To be overly simplistic, it comes back to knowing what works and what are the marginal costs that are associated with the delivery of various products, drugs and interventions to the population.

To me, it is a matter of looking at better studies of intervention effectiveness, cost-effectiveness and benefits, and being rigorous in those evaluations so that they become one piece of the evidence base. They are not always clearly the only piece that we can use in making those kinds of decisions. However, if we do not even have that evidence, then we are only working on the basis of pressure and opinions. I think we all want to be working on the basis of sound science wherever we can. I do not mean to imply that we have to wait for definitive answers before we take action, because I do not think that is appropriate. We need to put ourselves to the task of building the evidence base so that we can use it as part of the decision-making process.

Senator Morin: Following Senator Robertson's point here, what is the Applied Research and Analysis Directorate? That is a new one for me.

Ms Elmslie: I will probably be naming another new one for many of you. The department, about two years ago, created a new branch called the Information Analysis and Connectivity Branch. In that branch, the Applied Research and Analysis Directorate is a new directorate.

Senator Morin: Do they actually conduct research?

Ms Elmslie: They conduct some in-house research on existing databases. They also work with organizations like the Canadian Institute for Health Information and Statistics Canada. As well, they fund some policy research extramurally.

Senator Cohen: My question is about the Centres of Excellence for Women's Health.

Ms Elmslie: I knew you would ask me about that.

Senator Cohen: The six years is finished for funding, and I am interested and concerned as to what the future will be for these centres.

Ms Elmslie: Yes, and I will undertake to provide with you that information. I do not know the definitive decision on that at this time, but the Women's Health Bureau in the department will be my first call when I get back. I will ensure that you get that information.

Senator Cohen: Thank you.

Senator Robertson: Is your department or division involved in planning or developing preventive processes and education material for sustainable longevity?

Ms Elmslie: Yes.

Senator Robertson: If you are, and if you have any data on that, could we have it.

Ms Elmslie: Yes. The Population and Public Health Branch of the department, in conjunction with key partners across the country, is involved in a number of prevention strategies.

The Chairman: In partial response to Senator Cohen's question, the Institute for Women's Health is appearing here on May 9.

I want to understand the decision-making system. Suppose that a new drug or procedure is developed and then the cost-benefit analysis shows that the drug or procedure is very expensive and that it only helps one in ten people. Also suppose that the conclusion is that Canada's publicly funded health care system will not fund that process. How is that decision made? Who are the players and what is the process? Does it mean that Canadians cannot get that service or drug in Canada, even if they agree to pay for it? I believe the answer to the second question is yes.

Senator Morin: If it is one death out of ten, who will turn that down?

The Chairman: I am happy to keep lowering the odds until I get to the point where someone says that from a cost effectiveness standpoint it does not work. I come at this from the standpoint of a mathematician. The reality is that those decisions implicitly put a value on human life. In the way in which we structure medical care in this country, we have always ducked the central issue, which is that we make decisions that absolutely place a value on human life by virtue of what we decide not to do. I have never been able to understand who makes those calls. I would like to understand as well the criteria by which they are made. Also, is it true that, if that decision is made, people with money are prevented from buying that service as well?

Ms Elmslie: Your question is outside my area of expertise. I am not trying to duck it.

The Chairman: You happen to be the victim of the department who is here today, so we can send you back to get the answer.

Ms Elmslie: That is right.

The Chairman: The question is a crucial one, with regard to whether certain things will be provided out of public funds. If so, are they therefore to be prevented from being purchased out of private funds?

Senator Morin: First, this decision is never made federally.

The Chairman: It is exclusively provincial?

Senator Morin: Yes, it is exclusively provincial. Second, it is never made officially in an open way.

The Chairman: Of course, because no one wants to accept the responsibility for having made the decision.

Senator Morin: They will strike a committee and they will delay. Senator Keon implants artificial hearts that cost $85,000. Who will say that he should not implant them?

The Chairman: I agree with you that it is deliberately obfuscated so that no one has the responsibility for making the decision. I assumed that. Nevertheless, it does seem to me, since there is an implicit valuation done in this process, that it would be useful for me to understand how it is done.

Thank you very much for being the victim of our questions.

Ms Elmslie: It was my pleasure. I have some homework to do and I will be pleased to do that for you.

The Chairman: Senators, our last witness today is Scott Murray.

It is not only at Senator Fairbairn's pleading that we have asked Mr. Murray to talk about the impact of literacy on health; we want to explore factors that impact on the cost of the health care system that one does not normally think of as being a health care problem.

Please proceed, Mr. Murray.

Mr. T. Scott Murray, Director General, Institutions and Social Statistics Branch, Statistics Canada: Thank you for the invitation to appear before you. By way of introduction, I will say that I am focusing on the health of older Canadians, but what I say applies to the health of the rest of Canadians. The basic thesis is that the literacy skill of Canadians will act as a retardant on the speed and the equity of Canadians to absorb all of the interesting things that the health research system is going to turn out. The context within which this takes place is that individual behaviour is the biggest agent of social change. It is also, from a government point of view, the cheapest one, so we should be concerned about literacy as a retardant.

Senator Fairbairn mentioned that 42 per cent of adult Canadians do not possess literacy skills that allow them to deal with everyday reading tasks, including health reading tasks, and that goes well beyond decoding the printed word. It means using the printed word to accomplish the tasks that face us.

The population is getting older, and this is where we get into the dynamics of literacy. Canada is rather unique in the fact that, at about age 45, we see a rapid deterioration in skill that, even when adjusted by educational attainment, does not go away. There is something in the way that we have conceived Canadian economy and society that causes people to lose their skill in mid-life rather than in late life, as is the case in Sweden, for example.

The structure of the Canadian population is going to be dictated by a number of demographic trends that I understand you have already heard of, one being immigration. Over half of the population growth will come from people outside of Canada, many of whom are not perfectly fluent in our official languages and are not able to use literacy to deal with everyday demands.

The most troubling aspect is illustrated on the slide entitled "Forecast Share of Literacy." We have taken the current relationship of literacy to education levels, immigration and age and forecast the proportions of the adult population that will be at each level.

The Chairman: Just to clarify, am I correct that on the literacy level scale 1 is low and 5 is high?

Mr. Scott: That is right. About 5 per cent of the adult population is in levels 4 and 5; 40 per cent is in levels 1 and 2, which is the level that is determined to have problems dealing with the economic and social demands that are implied in everyday reading.

From this graph, you can see that the proportions stay roughly the same, despite increasing education, because the gains from education are being absorbed by the losses associated with aging, at least in Canada. Therefore, a large fraction of the population will, in the absence of any extraordinarily large investment, remain with the same skill levels.

It is no surprise that health is very related to education level and, by extension, to literacy. I have used as an organizing framework Health Canada's own nine determinants of health. I will go very quickly through how literacy relates to each of those determinants.

The first one is income and social status. Research sponsored by HRDC and Statistics Canada and done by UBC shows that over half of the difference in wages paid in the Canadian economy are attributable to differences in literacy. This is an astounding impact and points to the importance of literacy to both the economic and physical health of Canadians.

The Chairman: Since education and income correlate so closely, is it reasonable to assume that what really drives that is income and not education?

Mr. Scott: No, it is a combination of the two.

The Chairman: In other words, if you were uneducated but rich that would not help you as much as being educated but not as rich?

Mr. Scott: That is right.

Senator Morin: Education is more important than income.

The Chairman: I thought income was more important than education.

Mr. Scott: Income is the product of having access to the labour market and having access to a good job in the labour market. When you look at what determines getting access to fulltime employment and higher wages, literacy explains about half of that. It is a fundamental underlying determinant. There is an economic price to pay for people without literacy, and their social status is reduced.

Fortunately, in Canada, we have a transfer and tax system that attenuates many of those differences, so it is somewhat adjusted.

If we look at the literacy levels of recent graduates from the Canadian education system, we see big differences in literacy outcomes from province to province. The differences are driven mostly by what happens to children from disadvantaged backgrounds. The effects of literacy are intergenerational. About 15 per cent of the literacy-skill distribution in the current population can be related to the literacy skill and educational credentials of their parents.

The second determinant is social support networks. Literacy plays a strong role in this area, but its effects are somewhat second hand. We have a number of social trends that result in people spending more of their life with fewer social supports. More people are living alone, particularly at an older age. More people are retiring earlier. They tend to be self-employed to a much greater extent. Hence, they have impoverished social networks and no one they can depend on for needs they cannot meet themselves. Robert Putnam of Harvard University refers to this phenomenon as "bowling alone" and attributes it to a decline in social cohesion.

If we turn to the subject of demand, there is a slide that shows that seniors, particularly at level 1 of literacy, require assistance in a broad number of everyday activities, many of which relate to making health choices and acquiring information related to healthy behaviours.

Canadians have a relatively high level of education, both in terms of the stock of educational attainment in the country and in the current flow coming out of the educational system. It should have positive effects on health, but we do have this phenomenon where those educational investments seem to evaporate and we do not understand the social and economic processes very well.

There is a strong correlation between people who rate their health as fair or poor and lower educational levels.

I shall now turn to the fourth determinant, employment and working conditions. Literacy acts as a determining factor that selects you into the labour market and determines your income. People with lower skills are selected into occupations that have lower social status. They are paid less and at far more risk from a health point of view, with much higher rates of accident and exposure to occupational hazards. Lower levels of literacy greatly enhance probability of exposure to unemployment, particularly in countries like Canada that have open labour markets, where it is easy to lay people off.

If we turn to the subject of physical environment, literacy levels also play a role here. People with lower incomes tend to be geographically segregated in neighbourhoods that tend to be less desirable and, as such, are exposed to more air- and water-quality issues as well as problems associated with density in urban environments. That not only applies to Canada, but also to places like Poland, where the World Bank has used our literacy data to show that there are community effects where poverty and unemployment act in a negative way, synergistically, to make things worse overall.

The sixth determinant is biology and genetic endowment. We have not found any relationship of literacy in this regard, but perhaps our colleagues in the health research areas will find one.

The most important area where literacy plays an key role is in the issue of conveying health information to Canadians. Literacy enables people to acquire information on their own. We think that a significant fraction of the Canadian population do not have the skills to do that reliably. Demands for reading instructions on medicine bottles are very high, with over 60 per cent of seniors doing that kind of task on a daily basis.

There was a presumption that the Internet and health information on the Internet would be a panacea to save us all. Over 50 per cent of Canadian homes now have access to home computers. This figure differs from province to province, so there is a regional equity issue. However, the utilization of computers in older age groups, 55 to 64, and 65 and over, is very low at present. That raises a problem of whether, even if you build it, they will be able to come.

With respect to the impact on the health of older Canadians, people with limited literacy, according to information published by the Ontario Public Health Association, tend to smoke more, have poorer nutrition, are less likely to engage in physical activity, use seatbelts infrequently, do not do breast self-examinations, drink too much coffee and are less likely to have a fire extinguisher or smoke detector. We are dealing with a group that has, of their own volition, made unhealthy choices or find themselves in circumstances where unhealthy choices are forced on them.

In regard to healthy child development, about 15 per cent of today's literacy is determined by the previous generation's literacy. Thus, there is a vector for intergenerational transmission of inappropriate health behaviours. HRDC is spending a significant amount of time thinking about literacy strategies that focus on both generations at the same time as a way of trying to reduce this intergenerational effect.

Health services involve educational programs delivered by a variety of modes but are increasingly reliant on the Internet as a delivering mechanism. The basic summary is that large fractions of the Canadian population do not have the literacy skills to deal with the kind of information that will be provided on those systems. One must then think about several things to get around those problems. Statistics Canada is not in the business of providing those kinds of solutions, but I can give you three general directions.

First, we recommend using the same technology used to determine what makes adult reading tasks difficult to very carefully analyze the level of difficulty of material that is put in the public domain by our health agencies and providers. We can explain 85 per cent of difficulty and so you could reverse engineer the information to make it more accessible.

Second, we recommend using the power of the Internet to provide alternate means of access, the sort of things that Industry Canada is doing to make Web information accessible to disabled Canadians and Canadians with low levels of literacy.

Finally, we recommend programs, albeit expensive ones, to increase literacy levels in the current generation coming out of school and in the total population.

Making those investments, given the relationship to individual economic success, one could expect to see both an increase in economic output and a decrease in health expenditures at the same time.

The Chairman: Right now in this country, health care expenditures are assumed to be things spent on physicians, drugs and hospitals and so on. You spoke about potential economic output because people would be more educated. We are interested on the impact on health care costs.

Is it possible to do a calculation, however crude, that would in some sense indicate that "X" amount invested in literacy over a period of time would ultimately induce the following savings into the health care system? Where my mind going is to ask if we can encourage expenditures in other areas on the grounds of what they would do to help control health care costs in areas not now typically thought of as health care.

Mr. Murray: Yes and no.

The Chairman: You are a statistician, not an economist.

Mr. Murray: It depends on whether you want to, as my boss says, be close enough for government work. The technical answer is that there is not a database that puts health outcomes and literacy on the same people to make those micro-linkages longitudinally to establish cause and effect that would let you do that kind of calculus.

That being said, there are enough second-order things that show the relative relationships between those variables that you could come up with a good-enough-for-government-work kind of calculus that would, I think, come up with very positive health reductions on top of the economic ones, which would be strong in and of themselves.

The Chairman: I do not know whether you are the appropriate person to say this to, but can you do that for us? I am happy enough to have it close enough for government work.

Mr. Murray: There is a group at Statistics Canada that does this kind of modelling. They are just about to publish a paper on smoking and its contribution to average years of lifespan, and of disability- and disease-free lifespan. It is a short step from that kind of a modelling, by adding numbers to it, to come up with a first order of proximation of cost and benefit.

We are considering doing the same thing for basic literacy investments where, because we can attach economic costs to various literacy levels, we can come up with a cost-benefit analysis.

The Chairman: That would be helpful to us. I do not know if I am looking at you or Senator Fairbairn. If there is anything this committee can do to get that project moved up the working list of Statistics Canada, I would be happy to write a letter or phone someone. Maybe you and Senator Fairbairn can talk about it. I hope it can be done before we finish this study, before the end of this year. This is a great illustrative example. One can look at other things, but this is the perfect illustrative example. To the extent that we can get some ballpark quantification, that would be very helpful.

Senator Fairbairn, do you want to comment on that as well?

Senator Fairbairn: I would certainly be glad to talk with Mr. Murray to see if we could propel something.

The Chairman: My objective is to try to get government to understand that if health care cost is your problem, to entirely focus on a narrow definition of areas of spending is not the way to solve it. You may be able to help control health care costs by doing something that is not naturally thought of as a health care expenditure. That is what I am thinking.

Senator Fairbairn: The only thing I would like to find out, and you could let us know in writing if there are any other thoughts, is related to the statistic that you show that in Canada, for some reason, despite our education system, whatever its limitations, being relatively good, we start dropping off at age 45 in comparison to other countries such as Sweden. What are other countries doing, and what are the influences that we are aware of that make that happen in Canada?

Mr. Murray: We are going into the field with a second literacy assessment internationally in 2002. One of its prime objectives is to answer that question. There are two hypotheses. One hypothesis is that Canada suffers a deficit in the factors that support literacy in adult life. Those determinants have to do with the kinds of jobs we have and the kinds of reading demands that are placed on workers in those jobs.

Swedes on the job read twice as much as Canadians do. This has an impact on maintaining their literacy level. They also tend to read more than Canadians at home. That has a positive effect. They participate in adult education at a level that is twice the average for Canadians, and they do so throughout their working life, whereas we see the same kind of reduction in adult education participation in midlife as we see in literacy levels in Canada.

The Chairman: We know from the old 60-year-old Swede advertisements that they are also in better shape than we are.

Mr. Murray: Not only are they skiing better, they are reading a book at the same time.

The second hypothesis is that the younger generations replacing the older ones will bring with them better behaviours. They in fact will create more literacy-rich jobs and we will not see this pattern of skill loss continue. For now, it is an open question.

Senator Graham: Thank you, Mr. Murray, for a very interesting presentation.

I am compelled to ask a question related to slide 9 and, generally speaking, to all of us. You talk about the relationship between the availability of preventive and primary care services and improved health, and this is under the heading "Literacy's Impact on The Health of Older Canadians." You use the example of Well Baby and immunization clinics.

This document deals with older people and their relationship to the relative health of Canadians. I wonder, Mr. Chairman and Senator Fairbairn, under the general heading of literacy and the health of Canadians, whether we should consider at some point the importance of literacy and the relationship between literacy and health at a very early age, and the importance of reading and encouraging our children to read. The formative years are, comparatively speaking, the most important years of a person's life, whether the years are between the age of two and five, or three and six, or whatever. While this is a most interesting document and very important to us, at some point we will have to focus on the beginnings.

The Chairman: By the way, that was the real purpose of my question. In the sense, you hit it exactly. There are two issues. First, there are the people who are now illiterate or not sufficiently literate. Second, how do you stop the next generation from following the curves that Mr. Murray put on the table?

Mr. Murray: We do have a series of surveys. We have been approaching this in exactly that way. There is something called the National Longitudinal Survey of Children and Youth that looks at kids from zero to 12, originally. We have been following them longitudinally. It includes direct measures, tests of their reading ability, and relates it to a variety of social, economic and health characteristics.

Senator Graham: And habits.

Mr. Murray: And habits, including interaction with their parents and the parents' reading behaviours. That is complemented by a study launched in the last year that looks at a big sample of 15-year-olds and tests their literacy in a very elegant way, using the same kinds of tests we have used to test the entire adult population's skill level. We will follow those kids and see how much of their skill level can be related to their social and economic characteristics, looking backwards, and how much that skill conditions their access to the post-secondary system and eventually into the labour market, whenever they happen to get there, whether they go directly from high school or after some post-secondary career. That data system is happily mostly in place to explore the issues that you suggest.

The problem is that the skill demands in the labour market are going up so quickly and we have so few children relatively as a proportion of the population that there is an economic worry that there are not enough kids to fix the problem fast enough. The solution may lie in doing something with adults.

Senator Fairbairn: If I may, just for the interest of senators, this issue of early childhood has been directed to us from the ground rather than from the top. In the last few years, family literacy has probably become, in terms of those on the ground who are involved in this issue, the hottest button of any in Canada. We heard Dr. Mustard a while ago, and his paper of several years ago startled many people in this country. He showed not only that children were able to be imprinted with an interest and a love and an ability to learn from about 18 months on neurologically, but that if they got to the age of five or six and none of the stimuli had been available some of those windows would close and would never reopen. This is a very big consideration. When you hear about early childhood enhance ment, that is part of it.

The Chairman: Thank you, Mr. Murray, for attending. I loved having another mathematician before the committee.

Senators, I have three quick announcements. Some of the committee members had to leave, so I will also send these to you in memo form.

Particularly for all of those from the Atlantic, we are working on the changes in the EI bill aimed at seasonal workers next Wednesday. The minister will be here, along with several other witnesses.

Thursday, we are considering the health information highway. You have received a memo that we circulated today but will send out again and follow up with everyone. The memo asked to confirm August 22 and 23 as the two days we would meet in the summer to finalize the fourth report. It will have to be in the last several weeks in August. We need two consecutive days. Please let us know if those dates do not work. I will have the clerk follow up on that with you, because I really do want to lock that in.

Finally, and I will send this out in a memo as well, you will recall that we agreed to meet on Mondays to do the international teleconferences, because it was the only way to do it, and we agreed on the four Mondays. They are in the schedule sent out to you. I should inform you that on those four Mondays we will do Sweden, the Netherlands, Britain and Germany. We will do the U.S. in a regular time slot because we are in the same time zone. We will have to do one Tuesday night, because that is the only way to do Australia.

When I chaired the Banking, Trade and Commerce Committee, we did a two-hour videoconference with the governor of the central bank of New Zealand. We found that the only way to make it work with his schedule was to have us start about seven at night, which is eight in the morning his time. Therefore, we will add a Tuesday night in late May or early June. Between now and the middle of June, we will have one session devoted to each of six different countries.

I am setting all of that out just so you know what we have ahead of us. I would hope that we have a full agenda, particularly for all of us from the east, for next Wednesday.

The committee adjourned.