Proceedings of the Standing Senate Committee on
Agriculture and Forestry
Issue 21 - Evidence - Meeting of March 22, 2007
[Editor’s Note]
CORRECTIONS
At page 21:28 of the printed Issue, third paragraph, first line, the text reads:
Poverty has three aspects: economic, intellectual and spiritual.
The text should read:
Poverty has many aspects: economic, intellectual, artistic, spiritual and so on.
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At page 21:31 of the printed Issue, sixth full paragraph, lines 10 to 13, the text reads:
For example, in cancer of the breast, one option is to take the cancer out and then have radial therapy. Radial therapy is given in the cities. It is usually five weeks away, one day a week for five weeks.
The text should read:
For example, in cancer of the breast, one option is to take the cancer out and then have radiotherapy, which is given in the cities. It is usually five weeks away, five days a week for five weeks.
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At page 21:36 of the printed Issue, first paragraph, line two, the text reads:
. . . that an obstetric operating room . . . .
The text should read:
. . . that an operating room . . . .
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At page 21:36 of the printed Issue, seventh paragraph, line six, the text reads:
. . . you are in heart lock . . . .
The text should read:
. . . you are in heart block . . . .
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At page 21:40 of the printed Issue, sixth paragraph, lines two and three, the text reads:
. . . Colin Hanson, the mayor of Prince George, . . . .
The text should read:
. . . Colin Kinsley, the Mayor of Prince George, . . . .
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OTTAWA, Thursday, March 22, 2007
The Standing Senate Committee on Agriculture and Forestry met this day at 8:14 a.m. to examine and report on rural poverty in Canada; and to give consideration to draft budgets.
Senator Joyce Fairbairn (Chairman) in the chair.
[English]
The Chairman: Good morning, honourable senators, our witness and to all of you who are watching our Standing Senate Committee on Agriculture and Forestry.
Last May, this committee was authorized to examine and report on rural poverty in Canada. Last fall we heard from a number of expert witnesses who gave us an overall view of rural poverty in Canada. On the basis of that testimony, we wrote an interim report which was released in December, and which by all accounts really struck a nerve throughout the country.
We are now in the midst of the second phase of our study where we meet with rural Canadians in rural Canada. So far, we have travelled to the four eastern and four western provinces. Along the way we have met a truly wonderful and diverse group of rural Canadians who have welcomed us with open arms and generosity into their communities, and sometimes even into their homes.
The committee still has a lot of work to do. We still must visit rural communities in Ontario and in Quebec and, we hope, in the territories. We still want to hear from as many people as we can. In short, we must ensure that we get this right and that we understand rural poverty at its core. To that end, the committee continues to hold meetings in Ottawa with expert witnesses.
As we know, on average rural Canadians are less healthy than their urban counterparts and consequently, we are told, do not live as long as urban residents. We learned in our travels that rural Canadians often face major obstacles in accessing even the most basic of medical services. Dr. MacLellan will shed some light on those obstacles and related issues. Thank you for coming here this morning, Dr. MacLellan, please proceed with your presentation.
Dr. Keith MacLellan, Past President, Society of Rural Physicians of Canada: Thank you for this invitation to appear before the committee. I will present in English but I can answer any questions in French or in English. I have submitted a report from the Society of Rural Physicians of Canada on the subject-matter before the committee. I will not go through it in detail because I have been given just 10 minutes this morning so, to paraphrase Voltaire, I do not have the time to be brief.
The Society of Rural Physicians of Canada is a national organization that represents rural physicians across Canada. Doctors working at the "coal face'' come into contact daily with many of the problems of rural poverty in Canada. Our society has been in existence since 1992, and we have approximately 2,000 members. Most of them work in rural areas but some physicians and non-physicians elsewhere who have an interest in rural health are also members. The twin goals of the society are sustainable working conditions for rural practitioners and equitable treatment for rural communities in health matters. The SRPC produces policies and makes suggestions at various levels of government. The main goals and activities of the SRPC lie in helping our members in matters of education and working conditions.
I have put up on the slides three maps of Canada and the world taken from satellites on cloudless nights. These are the actual lights of the world shining out into space. Later on, I might go through these slides with you but they are mostly to illustrate the true nature of Canada's demography and geography. I will make some general statements and then more specific comments to the wonderful interim report of the committee. Few studies have come out in recent years on rural Canada, so it is heartening to see this kind of interest and the resulting report.
Poverty has many aspects: economic, intellectual, artistic, spiritual and so on. These kinds of poverty play out more and more in rural Canada. One has only to look, for example, at the suicide rate among farmers to see a different kind of poverty at play. Any community is supported by three pillars: economy, education and health. In any community, if one pillar is lacking, the entire structure falls down, and in rural Canada it often falls down quite quickly. Health is one of the three main pillars holding things up in communities across Canada. Any examination of matters such as poverty in rural Canada must consider the health of rural Canadians and the health care system and what they can access in a major way.
What characterizes "rural'' in Canada, as well as throughout the world? Two characteristics of rural hold true: the importance of the community and the way in which the community acts within the social system of rural Canada. That is not to say that in urban Canada the community does not play a big role, but in rural Canada it holds true that the more rural you get, the more the community dictates what is going on in many areas, including how rural poverty is addressed.
One of the problems in rural Canada is that each community is different. When governments are looking to make an intervention, whether it be funding, expertise or plans, it is difficult for them to do so in rural areas because each community has its own characteristics, needs and capabilities.
Another distinguishing characteristic of rural is generalism, or jack-of-all-trades. I will address that in more detail later in my presentation. Almost no one has one job in rural Canada; people hold down different kinds of jobs. The more rural you get, the more this is true.
Those facts of poverty, including the health care system as one of the three legs that hold up a sometimes fragile community and the importance that that community plays, and the generalism factor combine to form the backdrop of what I will speak to. The committee might want to take these into consideration when making its recommendations. I read the interim report of the committee and found it to be excellent and was heartened to know that someone was examining these issues. I will speak to three areas that the committee might want to examine more closely and then I will speak to the health care system.
The first area is local resources. These are faith-based church organizations and non-faith-based community organizations such as the Lions Club, the Women's Institute, the Rotary Club, the 4-H Club, et cetera. In the past, these organizations have always provided a fair amount of excellent service when dealing with issues such as poverty in rural Canada. Currently, they need a great deal of support, particularly in the areas of administration and implementation. They do not have problems with the vision for their respective communities because they know well what the needs are. However, they do have problems with getting it done and putting it into the bigger picture.
These faith-based organizations and nongovernmental organizations play a significantly important role in relation to poverty in rural Canada. I would argue that there is a strong role for the federal government in supporting these organizations. That would be more effective than large government programs coming into rural areas with lots of bucks to spend on CD-ROMs and posters.
The other comment I have about the interim report concerns broadband access. It was mentioned in the report. I cannot underline how important broadband access will be to rural Canada. It is being facilitated by the federal government. I have no way of judging whether that is enough or not, but in view of the three previous background characteristics of rural, it would be good if, along with the roll out of broadband access, there was an accompanying way of ensuring that it is being rolled out to support and encourage local initiatives.
Third is the matter of generalism of the workforce. This holds true very much in health human resources and in the health system which I will talk about next. In rural Canada, everyone is a generalist, and that is one of the characteristics and strengths of the rural workforce. It is not so much globalization that threatens rural Canada as the specialization that comes along with globalization. When one talks about seasonal workers or the way work is done in rural Canada, there may be a role for the federal government in looking at jacks-of-all-trades and how to support and encourage that type of practice. This may have an effect on rural poverty.
As Senator Fairbairn said, rural Canadians — and good studies now exist that are well accepted — are sicker, older, poorer and more accident-prone than their urban counterparts. The care of these rural Canadians is given to generalists. It is not just general practitioner doctors, because only about 3 per cent of Canadian specialists work in rural areas, but it is also nurses, who must be complete jacks-of-all-trades, physiotherapists, lab and radiology technicians and social workers, who cannot specialize just in one aspect of social work but must cover the whole spectrum.
Another functional definition of "rural'' to add to the others in your report is where the bulk of health care is given by generalists and not by specialists. The issues of rural health care basically come down to issues of access, and access of the rural populations to health care. There have been numerous reports, and the latest series has been the so-called Kirby report from the Senate, which documented very well the issues of rural health care and the challenges involved. The Romanow report, which devoted its entire chapter 7 to rural health care, went further and suggested, as one of the five immediate priorities, that $1.5 billion of federal government money be spent in rural health care.
This was closely followed by the federal Ministerial Advisory Council on Rural Health which brought out its report Rural Health in Rural Hands and suggested broad, strategic ways for the federal government to spend $1.5 billion without stepping on jurisdictional toes. This has gone absolutely nowhere.
My thesis about rural health care is that the problems really have been analyzed extensively and fully. The role for the federal government in rural health care has been argued successfully. A way for the federal government to actually act in consort with their provincial counterparts has been suggested. A budget has even been put forward for the National Health Commission, and absolutely nothing has been done. The reasons why nothing has been done, I suppose, are quite complex.
I am not here to argue one way or the other for $1.5 billion, although that would make a huge change to rural poverty as well, if for nothing else than to have a way for large governments to flexibly evaluate community needs and to respond to them. We have put forward, as examples, some eight suggestions on how the federal government could intervene in some of the problems of rural health and health care which would not cost $1.5 billion at all but much less. I will take you through these slides; there are only three.
This is a picture of the world taken on a series of cloudless nights. These are the actual lights of the world shining out. I am sure some of you have seen this. It is really quite fascinating. You can see North Korea and South Korea; North Korea is completely dark. You can see across Russia and the Trans-Siberian railroad; you can see the Nile coming down through Cairo; and you can also see these large dark spaces. These, of course, are the rural areas of the world.
This is a closer look. You can see the heart of Africa and South America, and then you see Canada. Of all the so-called developed societies in the world, only Canada and Australia, if you accept that Australia is developed, would share this enormous area of geography.
The problems for the populations in these dark areas are all the same in terms of health care. They are all, in every rural area of the world, older, sicker, poorer and more accident-prone. There are also huge problems in delivering health care to them.
This next slide shows Canada itself. In the United States, the eastern seaboard and almost all across the U.S., there are dense populations. The health care system in place there is very orderly and suits dense populations. If prevention fails, the patient is seamlessly, one hopes, brought into the primary care system where they are evaluated and coordinated. If they need a secondary care level then they are transferred up to secondary and tertiary care.
That is a system that works well for dense populations but it falls apart when you get into Canada with our type of demography and geography. In Canada, we do not have specialists. Should a woman want to deliver in or close to her own community, which is part of the definition of a healthy, vibrant community, that would depend on having an obstetrical team present. If a caesarean section were required, an operating room and people with specialized skills would be in order to ensure that the woman could deliver in a rural area.
In Canada, we are following the model of the densely populated areas. This is the model that is seen to be the best. That is true also in Europe, in Great Britain and elsewhere. It is the model that everyone aspires to. It is one of ever increasing sub-specialization. If you break your arm or need to deliver a baby, have cancer and live in rural Canada, most of the specialized services — that is, the secondary services — are being transferred to urban areas. That means patients must travel farther and farther for this treatment. There are many examples of this. For example, in cancer of the breast, one option is to take the cancer out and then have radiotherapy, which is given in the cities. It is usually five weeks away, five days a week for five weeks. The other option is to have the breast removed, to have a mastectomy. Rural women are increasingly choosing mastectomies.
I can give all kinds of examples where it is becoming increasingly more difficult — much more so than it was in the 1940s or in the1930s — for rural patients to get fairly simple care close to home. This is because of the natural specialization that happens. The federal government, not just Health Canada but also the department of Human Resources and Social Development and others, can look at supporting generalization, that is, jack-of-all of trades. That is how health care has been given informally in rural Canada, and it is exactly the type of team needed anywhere in the world. That is, a team of generalists, each of which have certain specialty skills.
There is a bit more background, although I will stop there. Before doing so, what this committee might consider is, given the rural characteristics of a community, and each community being different, and also the generalist nature of the workforce, this committee might make a difference in suggesting ways for the federal government to act locally and flexibly from community to community. It could look at community strengths that are there, evaluate them and support them. This would allow the rural communities to use their natural resources on hand, that have been there for decades and centuries, to help in dealing with poverty in that area.
The Chairman: Thank you very much. That is certainly the first time that we have had an outline of this nature before this committee. It is something that each one of us, in our minds, worry about. I listened to you and I thought of my corner in south western Alberta where in the small communities it is very difficult to find doctors and their families who are willing to come out into the land area. Nonetheless, it happens. When they get there, everybody is so excited to see them that they are not likely to get out very easily, either.
Senator Callbeck is from Prince Edward Island.
Senator Callbeck: As you know, Prince Edward Island is pretty rural. I certainly identify with what you have said here this morning.
One of the areas on which I wanted to ask you a question was the church and non-government rural organizations. You talk about those and the great work that they are doing, and have done. I certainly know that as I come from a rural area. You go on to say that they need support. In other words, some of them are really struggling. You state that there is a role for the federal government in supporting these important local methods to deal with rural poverty, youth opportunities and employment initiatives.
You must have given a lot of thought to how these local organizations and our churches can be doing more in the communities and how they can be assisted to do that work. I would like to hear your thoughts on that.
Dr. MacLellan: I just read in the Ottawa Citizen a few days ago how the town of Winchester, which is a small town south of Ottawa, got together and planned a $60-million expansion to their hospital. That is fantastic. What must have happened there is that they had a few resource people get together and harness all of the energies of the community to do that. What I do not know is how those resource people started off. In our area too, all the time, the Lions and the Rotary are coming to me and saying, "We would like to do fundraising of some sort. What do you need?'' I then give them my priority list, which may be completely different from the priority list of a nurse or of a social worker.
I think there is a role for the federal government to play in making needs assessments, characterizing the community and helping the community to characterize itself. They could work with town councils on plans for the future, look at the social needs of a community that are local to that community and identify how to harness all of the organizations that could pull together and accomplish this. That is one thing.
The Ministerial Advisory Council on Rural Health had the same issue. How do you take $1.5 billion of federal money and really make it work at the community level? What we are lacking at the community level is this type of method of defining what the community is and then accountably taking funding or planning and making it happen. Generally in health care, money is given to the universities in urban areas to spend and do programs in rural areas because in rural areas there is not the infrastructure to actually take in big plans. The Ministerial Advisory Council on Rural Health suggested that the federal government fund, at least in health care, about 200 of what they called rural health innovation centres. These would be staffed with maybe three or four people who could take the pulse of the community and be a connection between the community and the larger federal government in terms of training, needs and research. Each of these would have perhaps $1 million, for a total of $100 million or $200 million, to provide at the local community level some organized research, needs assessment and also coordination of initiatives with church organizations and other nongovernmental organizations. There may be other ways, however.
Senator Callbeck: In many rural areas, one of the things that seems to be missing nowadays is leadership. Of course, that goes with the decline in population. People may still live in a rural area but they are working in a town or in a city, and in that city they join the Chamber of Commerce and the Rotary Club or whatever. They get involved in activities within that city. That is where their spare volunteer time goes rather than to their rural communities.
Dr. MacLellan, you talked about innovative centres and their efforts to develop leadership within their communities.
Dr. MacLellan: That is correct. They set up the infrastructure and leadership in the community so they are able to handle things themselves. Rural is about local issues. One of the suggestions in the committee's interim report is tagging rural communities to urban areas. In health matters, that has led to, as you said, the regionalization of health, which means that most of the health budget for a region is sucked up by the urban centres, which have big needs. Therefore, we need to promote the ability for rural areas to act locally and independently.
Senator Callbeck: That is one way. In your report, you talked about the four ways, I believe, to distribute $1.5 billion.
Dr. MacLellan: You would need to read the report of the advisory council, Rural Health in Rural Hands, in which they looked at aspects such as broadband technology and how best to implement that at the local rural level rather than just bringing it in and leaving it there. They were looking at how to encourage the use of broadband for local development in various ways. They also looked at health human resources, not only physicians but also nurses, who are in short supply in southern Alberta as is also the case in western Quebec. In part, it is because the nature of the work is so broad. It is becoming increasingly easier to be a specialist in any health field. The report also spoke to using some of that money to support generalism and generalist training.
One of our eight recommendations is the development of a way for rural health issues to be addressed nationally so that they are not talked about as just an addendum to any of the national meetings. There needs to be a way to bring together nationally our licensing authorities, training institutions and professional associations to identify and discuss the rural problems that can be sorted out on a national basis. There was a bit of that as well.
Senator Gustafson: I found your presentation most interesting. I have two questions on educating doctors. Doctors from other countries immigrate to Canada. Are we placing enough emphasis on educating our own young people to become doctors? I will go back to the Tommy Douglas days when there was a big fight over medicare in Canada. At the time, Tommy Douglas brought many doctors to Canada because there was a kind of doctor-versus-the-system, undeclared war going on.
At the same time, there were young people wanting to get into medical training but could not do so because the margins had been lowered so much that they could not get in. It seems to me that we have never really picked up on that issue since that time. There has been an emphasis on trying to take rural young people and educate them as doctors in the hope that they would return to their communities after graduation. That does not seem to have worked too well, either.
We live in southern Saskatchewan where we are 100 miles from Regina and 100 miles from Minot, North Dakota. Many people around there travel to Minot for treatment because they have far superior equipment, such as MRIs. Saskatchewan might have only one or two machines, but North Dakota has them everywhere. That comment raises the subject of private care, and I am familiar with this aspect. When my grandson broke his arm playing hockey in Minot, we could not believe the speed with which that young man went through the system of having his arm diagnosed and set. Another boy was hurt in the same game and chose to go back to Regina for treatment. It was hours before his arm was set. I have laid out the problems to which I do not know the answers.
Dr. MacLellan: The arm should have been set locally, and quickly.
Senator Gustafson: Sure it should have been.
Dr. MacLellan: It would have been done that way 40 years ago.
Senator Gustafson: That is right.
Dr. MacLellan: The first issue on Canadian rural education is something that we have been harping about a great deal. In this report, we say that the university that has been the most important in providing doctors for rural Canada is arguably the University of Johannesburg in South Africa.
Senator Gustafson: I read about that.
Dr. MacLellan: That might not be strictly true, though. The moral, ethical issue of poaching doctors from other countries or from other jurisdictions in Canada aside, there is no reason for us not to produce our own physicians in Canada, provided there is the will to do so.
A report on Canada's health system about 10 years ago contained many different recommendations, only one of which was to reduce medical school applications or admissions by 5 per cent to 10 per cent. This recommendation was cherry-picked by the then ministers of health. It had a disastrous effect because other parts of the recommendations were not put into effect. In the eight recommendations of the SRPC, we have given a great deal of consideration to education for rural areas. Although the suggestions of the SRPC are quite modest, they could be quite effective.
On the issue of private versus public health care systems, in general rural practitioners believe that a private system would make rural health care even less accessible. In general, practitioners cannot make a profit in a rural area so a private health care system would lead to even more centralization and urbanization of health care.
Having said that, some of our practitioners point to the fact that an operating room located about one hour from the city is often not being used. We could look at ways to make use of it in a private field, perhaps, during its down time, although I do not know that that could be done. Frankly, the issue of private or public is small compared to the problems that people are having just getting any health care at all.
Senator Gustafson: Going back to the question of education and importing doctors, it seems to me that it is almost immoral to take the brightest people from some of these countries that so desperately need that kind of support in their society. Comparing the possibilities for educated young people in our country, I do not see that the emphasis is being put in that direction.
Dr. MacLellan: No, I would say in your province, senator, in Saskatchewan and in Newfoundland, upwards of 60 to 70 per cent of the doctors in rural areas are international medical graduates.
Senator Gustafson: In regard to specialized care, I know that if I get really sick, I want to go to Regina; I will not fool around in Weyburn. I want my doctor to say, "I do not know what is up here so I want to send you to a specialist.'' I will take my chances and the two or three extra hours to get there.
There is just not the expertise in rural areas. So many hospitals have been closed in Saskatchewan and turned into nursing homes. This is a good thing. It is about all they could do with it because they could not man the hospitals with the types of doctors that were necessary to give the service that is so needed.
You said you did not think that private care was a solution. Did I hear you right?
Dr. MacLellan: Compared to the problems we are having in just getting any kind of care, I do not think it is a big issue. It is a bit like wait times now. It just has not played out in rural Canada as being an important issue, in terms of rural health. You cannot get your arm set in a rural area, or if you have a heart attack and you are in heart block and very unstable, the only treatment for you is to be transported by air or bumpy ambulance for two or more hours. These are the real issues here. There may be a role for privatization, but it is just not that big an issue.
In Saskatchewan, every little town at a crossroads had a hospital. Before the days of medical care, having a hospital was almost a way of minting money. I have no trouble with closure of that type of system, but there is no system to replace it, other than centralizing it. There is just nothing to support that.
I am not arguing to have a heart surgeon or a neurosurgeon in every town in Canada that is huddled around a mill or a mine, but it has got to the point where if you have a child who is sick with croup, someone will have to take care of that child, and transporting that child is not the way to go. You need to bolster up local capabilities. That means issues of training and standards of care that the system is not looking at at all. It forms a very big part of any examination into poverty in rural Canada.
Senator Gustafson: I was just reading an article, and I think it does apply, that stated that if you are to get sick, do not get sick on the weekend.
Dr. MacLellan: That depends on where you are, but if you are to get sick in rural Canada, do not be poor, because you cannot go then.
Senator Gustafson: In Saskatchewan, most of the serious cases are taken to Edmonton.
Dr. MacLellan: I really do not think it is necessary to do that. We have very good studies showing that if you close local obstetrics wards because they only deliver 100 babies a year, say, and make all the women — the high risk women would have been sent out anyway — go to a regional centre, the outcomes are worse. Of course, if you are to have neurosurgery, you need to see the neurosurgeon in the city.
I point out, too, that when they close down local care for economic reasons, they say it is just more cost-effective to have all of this taken care of in the city. They never factor in the cost to the patient nor the loss of jobs that happens locally.
How will you plan for an economic development in a town when the hospital is just a triage centre or even just has a telephone, which is what is happening in some parts of Saskatchewan? It factors very large, but there is no political will amongst our federal or provincial politicians to champion rural health care.
Senator Gustafson: I am dating myself, but I lived in the day when I remember the rural doctor coming to the home. Those were the days when we did not have snowploughs and we did not have the advantages we have today. In fact, our doctor built a snow machine before snow machines were built commercially. He took a Model A car and put some tracks under it. The number of things that he was able to do was unbelievable. He was just a country doctor.
It seems, somehow, that we have lost some of that enthusiasm for dealing with health care.
The Chairman: I have a thought on how you can encourage young people to try to do this. In a small community in the area that I come from in southwestern Alberta, they had two terrific doctors. They got to a certain age and, with all the will in the world, they knew that the time had come. It was not a question of retiring; they did not want to retire, but the time had come. They could not get anyone here in Canada, but had an opportunity to hire a young man who was in Africa, so the town got right behind it. It is always complicated. There is family, and the issues of who can come and who cannot come. He was practically on the way when they found out that his mother, who was alone and with no one to care for her, would not be part of the party, so that meant that they would miss having that doctor.
Some of us worked very hard here in Ottawa to see if something could be done. The reason that this became urgent was the fact that the doctors, who had been there and loved what they did, had reached an age where they were the ones who made the decision that they needed to have a newcomer. This young man turned up. Often you hear that when younger people, younger doctors come into rural areas, they stay for a while and then they leave. This young man and his whole family have been there now for several years and it has changed the whole community. The community will not let them out of town. The doctor and his family are having an experience that they would not otherwise be having if they were in a larger urban system. I am sure he has been pursued to do that but he is quite happy where he is.
Why is that when younger doctors have the opportunity to practice in a very welcoming place — and it is always a welcoming place — why would that not be viewed in their mind as a terrific opportunity, at an early point in their career, to learn things that they would not learn in a city? Is it money?
Dr. MacLellan: Most of the international medical graduates provide invaluable services to rural areas, and most within ten years are in urban areas. Many of them are indentured. They are on special permits that extend only to that local area, and spend much of their time trying to get a general permit so that they can leave. Still, they have held up rural health care in Canada. It has not been our own system that has done it.
I alluded to generalization and specialization before. In the universities the training is, with few exceptions, oriented towards the specialist and specialized training. Being a generalist is thought to be second best. When you get out into rural areas there are also licensing authorities. They are sort of the sheriff in town and make it very difficult to have what we would call clinical courage. This is not being a cowboy, but really grasping the nettle and taking responsibility for the condition and healing, if possible, and certainly treating.
What happens now is that care is fragmented amongst four or five specialists. It is very difficult to ask an international medical graduate, never mind any graduate, but it is even harder to ask an international medical graduate to take on the responsibility of caring for complex conditions.
I think that, again, we need to get the federal government on side. We have been arguing this, as has Kirby, as has Romanow, that there is a role for the federal government to support broad-based, generalist practice, not just in the community but also starting with the training and the licensing and so on.
With regard to this graduate of yours, I really wish you all the best. I hope he or she joins the society of rural physicians because we are there to try to support that type of person in the practice they are doing. We are the only national group that is trying to support someone locally like that.
The Chairman: Whatever it is, and maybe it is just that it is a great area, but it has succeeded so far. This is much to the advantage and happiness of both he and his family. The doctor himself is enjoying it tremendously, as I understand, but he has just become an icon in the community. This one is a very happy story.
Dr. MacLellan: It has probably helped to bring the community together.
The Chairman: Totally.
Dr. MacLellan: It is to define who they are, what they are, what they want, and that is so important these days.
The Chairman: It really is. For my colleagues, the community I am speaking of is Picture Butte, and they are pretty happy how all of this has turned out.
Senator Callbeck: I wanted to ask about the federal solutions you have listed here for rural health care, to make health care more accessible for people in rural areas. In the notes you have given us, you mentioned Australia. They have a strategy for rural health care, and it has been successful in getting more doctors into the rural areas and also keeping them there.
Are these federal solutions you are suggesting here based on that Australian experience?
Dr. MacLellan: The Australians really saw the need for a pan-Australian national rural health strategy, as did Kirby and Romanow. It is something we have been pitching for quite a while, as do many of the other consultants. We need a national rural health strategy, and that is what the Australians did. They, however, do not have the federal-provincial jurisdictional issues that we do. I do not know enough about all of the federal-provincial issues that happen, but health care, I guess, is a provincial responsibility. If Canadians keep throwing themselves or falling off the cliff of life to dash on the rocks below, it is the provinces that have to care for them on the rocks below. I suppose the federal government must build a fence on top, or give people parachutes or whatever. Whenever the federal government comes to a provincial government and says "We want to help with health care,'' it becomes an issue, whereas it was not an issue in Australia. The Australians were able to, first, just recognize that they needed a national rural health strategy and then actually get one, and they did that.
Canadians have not got there yet. What the Australians did with their national rural health strategy is quite broad. I do not think we have the time to talk about it all. Some of the things we have taken have been similar to certain smaller programs within the Australian system that we think the federal government could do right away without getting into any federal-provincial squabbles.
Training and recruiting from rural areas could be done. It would not be very difficult for the federal government to set up chairs of rural health and fund them. Research is a huge issue. We need to characterize, for example, how well we are taking care of heart attacks in southern Saskatchewan. Do they need to be transferred or not, or is it cheaper to boost up the care locally? Research is a massively important thing that the federal government can do.
Why not reactivate the ministerial advisory council, which is made up of 20 rural citizens of some prominence, that could give some feedback to the federal government and serve as a link to their communities as well?
Senator Callbeck: When did that council become non-existent?
Dr. MacLellan: Right after it produced its first report.
Senator Callbeck: Which was?
Dr. MacLellan: It was when the Romanow report came out, 2002. It was chaired by Colin Kinsley, the Mayor of Prince George, and had 20 members. Four of them were doctors. I was on it as well. It had about four meetings with very little budget, mostly for meetings; no research budget or anything like that. It produced its first report and was shut down.
My feeling or my view on this is that it was seen as potentially a problem from a federal-provincial point of view. The bureaucrats in Health Canada thought it was better just to let it go. It still exists in theory, buried somewhere in the healthy communities side of the Public Health Agency of Canada, but that council has not been brought back together.
Senator Gustafson: I would like to hear about your approach to the mental health situation. In our area last year we had four suicides. You mentioned in your report that suicides are much higher in rural areas than in urban areas. I would say that farm people are proud people. They can go through very difficult times and not want to talk about it; they just keep it all inside. Finally, the whole thing explodes. Women and men seem to react differently to depression. A man seems to hide it more. I do not know if I am right in saying that. My question is: What could be done in rural communities to deal with this mental health problem?
Dr. MacLellan: Act locally. I will give you an example. The 4-H Club in my area asked one of the local country doctors to speak to their members about farm safety. I got in touch with the Canadian Federation of Agriculture and some other people and asked if they had any material on farm safety to give to me. There is no plan to really empower or to give rural doctors or nurses a little package to talk to kids about farm safety, but I did get a video on depression and suicide in farmers from an agricultural organization, and I played it for the kids. Much of it was about the wife of a farmer who had committed suicide. It talked about the few days beforehand and it talked about farm credit, which is becoming more of an issue now in rural Canada. I hope that it had a profound effect on the kids.
You need to do things like that. We cannot simply say that we will combat depression in rural Canada by increasing farm incomes. The last suicide in our area was by a dairy farmer who receives a cheque every two weeks. We cannot combat depression and suicide in rural areas by issuing posters and CD-ROMs, by creating focus groups, and by having campaigns worth hundreds of thousands of dollars on aggressive or violent men, or some such thing. We truly need to work with the local clubs like the 4-H and with church groups.
Foxwarren, Manitoba, which is a small town that once had four grain elevators, has no elevators today. The population is elderly and they got together and talked about what to do. The Anglican Church in Foxwarren has a full kitchen, as has our church in Shawville, Quebec, with two professional ranges, and it is used only three times a year. The people of Foxwarren hired a cook for that kitchen so they could set up a free-hot-meal program provided once each day to the elderly people who signed up for it. They did that without government help at all, without any funding, and started using that kitchen every day. People signed up and kicked in $5 for the week so that they knew how many to cook for. It has served as a restaurant, as a social club, and as a way for elderly people to get out, because suicide and depression, as you know, are most common in the rural elderly.
Senator Gustafson: The last suicide in our area was just last week. It happened to be a boy in Grade 9. Whether that was the result of a difficult home life, I do not know. It was just shocking.
Dr. MacLellan: In my area, when we see a boy in Grade 9 having some trouble, I draw on a host of informal connections and hear about it. I can involve the minister if that seems useful or I can involve a social worker or other people. However, I do not have a large, multidisciplinary mental health team, and that is not what I need. Rather, I need to get my informal network working a little better.
Senator Gustafson: The committee had an opportunity to visit Steinbach, Manitoba, where we met in the church basement. They said that they were getting more food from their congregation than they needed to accommodate their operations. It was all gifted to them and they were doing a tremendous job of servicing about 30 people each week. Steinbach is a pretty affluent community and yet some people were falling through the cracks, so people were trying to help them.
Dr. MacLellan: They need a little help. There is a role for the federal government in that area.
The Chairman: Senator Callbeck, do you have a question?
Senator Callbeck: No, I have finished.
The Chairman: I have one final question. First, thank you so much for coming today. Certainly, we have not had any opportunity to hear this kind of testimony previously, and it is so important that we hear about this.
In your work, do you have to deal frequently with government? If so, do you have a tough time being heard and being appreciated for what you have to say?
Dr. MacLellan: Yes.
The Chairman: We would like to know about that.
Dr. MacLellan: Regularly, we deal with our regional health authority. I have already alluded to the problems experienced with the fact that our rural area is tagged to an urban area. Therefore, most of the budget and funding decisions and consideration for what we do are taken in the urban regional office. We have a great deal of trouble convincing those officials of our mandate, which is to provide general care and secondary level care. Any time that we say we have a problem, their answer is usually, "Well, centralize it.'' That is our immediate government issue.
When we speak with our provincial and federal representatives, they understand instinctively what we are saying, just as I think you understand instinctively what I am saying. Perhaps that is in part because some senators here today come from rural areas, and in part because you have a broader overall view of things.
The problem lies in implementing solutions. It simply does not work well if I say that such and such is the issue, and what is needed is to act locally in a big way. You will say, "How do we do that?'' That is where the answer lies, I am convinced, for rural Canada. We have to be a little bold and recognize that we are not Great Britain or the Northeastern United States. We need to face the fact that this is the reality of Canada. We need to set up some way for governments locally to act in rural areas effectively.
The Chairman: If that were remedied, would money be a problem? I am sure that the solutions require financing.
Dr. MacLellan: Yes, money is a big problem. That is why Roy Romanow thought that $1.5 billion possibly would not be enough. However, we did not get any of it.
The Chairman: You did not get any of it?
Dr. MacLellan: No.
Senator Gustafson: I want this on the record. Transportation is a big challenge but ambulance service has really improved, in my observation, in rural communities. I think that is a good thing, because time is of the essence in any health situation.
Dr. MacLellan: Yes. The ambulance used to be provided by the funeral director because he had the station wagon.
Senator Gustafson: Exactly.
Dr. MacLellan: If someone did not make it, they would just go to the funeral home instead of to the hospital.
The Chairman: It still happens.
Dr. MacLellan: There is no doubt that the transport system is very important. There are lots of studies on this and a lot of them are military studies. From the time of wounding to the time of definitive treatment in Vietnam, the Americans got it down to 35 minutes average with their MASH units. That was a great improvement on World War II, which was, in turn, a great improvement on World War I. In order to do that, however, they needed a core group of helicopters and helicopter pilots that could fly in all weathers. There was a core group of 50,000 to get that time down to 35 minutes.
Anyone living in rural Canada knows that if you rely on a transport system, no matter how good, it does not work in the night time and it does not work when the weather is bad, and that is quite often. Transport times in good weather are nice to look at. However, what happens to you in your local area if you have an excellent ambulance system but you shut down your capabilities? It means that you will lose some people sometimes when you cannot transport them.
Senator Callbeck: I have a brief question on telehealth. How effective is that for rural areas? Are there certain areas where it is more effective than others? Should we be putting a big push on in that area?
Dr. MacLellan: There is lots of promise for it. It cannot deliver a baby yet. You must ask: If we were sending a crew to Mars, a five person crew, and you had to pick a doctor to be on that crew, with all of our telehealth expertise and robotic surgery, what kind of physician would go on that crew? Would you pick a general internist? It is an interesting question. You would have to pick a general, broad-based physician who can use telehealth but also has a number of innate skills.
In certain areas, such as psychiatry or radiology, telehealth is already making a difference. You can put up an X-ray and have it read in Bangladesh, if the licensing authorities agree.
I attended a national conference on telehealth where they discussed having the bureaucratic vision to get it off the pilot project stage and into general use. I got up and said that bureaucratic visions are a bit like meteors: Most burn out brightly in the atmosphere and we do not see them. Those with big funding behind them, however, do make it through. They usually crater out in rural Canada somewhere and cause some damage.
A friend of mine, a very broad-based doctor in Fogo Island, can put you to sleep and perform surgery. He went to Grand Manan to fill in and told me that he was surrounded with telehealth equipment but could not do a simple blood test. There was nothing to support his skills.
Telehealth is excellent, but whenever it is being implemented, you must ask the question: Will this improve local capabilities or will it replace local capabilities? In general, if it will just replace local capabilities it will not be good, whereas if it will make local capabilities better, including the times when the Internet is down and nothing is working, then I am all for it. That is not how it is being implemented now. It consists of just large budgets and a visit from some telehealth person offering to set up monitors so that you will be able to talk to the specialist. A lot of work still needs to be done.
The Chairman: Thank you very much. That was something that we have been missing. We are pleased that you did choose to come down on the slippery roads from Shawville. Thank you for your attendance, patience and passion. We hope there are a lot of Dr. MacLellans around in rural Canada.
The committee adjourned.