Proceedings of the Standing Senate Committee on
Agriculture and Forestry
Issue 24 - Evidence, May 3, 2007
OTTAWA, Thursday, May 3, 2007
The Standing Senate Committee on Agriculture and Forestry met this day at 8:09 a.m. to examine and report on rural poverty in Canada.
Senator Joyce Fairbairn (Chairman) in the chair.
[English]
The Chairman: Good morning, honourable senators and witnesses, and good morning to all of those 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 we released in December, just before Christmas, and which, by all accounts, really struck a nerve.
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 Western provinces and made one excursion into rural Ontario, where we will be doing more. We will also be going into Quebec and the Northwest Territories. Along the way, we have met a truly wonderful and diverse group of Canadians who have welcomed us with open arms into their communities and sometimes even into their homes.
However, the committee still has work to do. We still have to visit rural communities in Quebec, Ontario and the Territories, and we still want to meet as many people as we can here in Ottawa, because we need to get this right and understand rural poverty in its core.
This morning's witnesses are here to discuss rural health. It is an issue that certainly has popped up as we have moved across the country. As research has repeatedly demonstrated, poverty and health are strongly related. The poorer you are, the more likely you are to suffer from all manner of health problems.
With us to tell us more about this and other facets of rural health, from the Public Health Agency of Canada we have Dr. David Butler-Jones, Chief Public Health Officer, who has been helping us on another committee of the Senate; and Marie DesMeules, Director of the Evidence and Risk Assessment Division, Centre for Chronic Disease Prevention and Control. From the Canadian Institute for Health Information, we have Jennifer Zelmer, Vice President of Research and Analysis; and Elizabeth Gyorfi-Dyke, Director of the Canadian Population Health Initiative.
We have two hours this morning to cover a wide array of issues. As Dr. Butler-Jones can be with us only until 9:30, I would ask him to start off the morning and then we will carry on.
Dr. David Butler-Jones, Chief Public Health Officer, Public Health Agency of Canada: It is a great pleasure for me to be here this morning. I think you all have the deck that we will be speaking to. Rural communities, as this committee probably knows better than anyone, are going through tremendous transition, and the changes have led also to changes and impacts on health.
The Public Health Agency of Canada is just over two and a half years old now. We were formed in September 2004, and our legislation that brings everything into force came just before Christmas. My role in government is a bit unique because I am both a deputy in terms of public service activities, as deputy head of the agency, but also Chief Public Health Officer, with responsibilities to speak to issues of health, both to governments and to the public.
The report we are speaking to has been very useful in outlining some of the changes that have taken place. It provides a new body of knowledge that will help us as we move through understanding the impacts on health and the kinds of things that we can do about it.
We know that, in general, Canadians are among the healthiest people in the world, but we also know that that is not uniform across all groups, all areas and all geographies of Canada. Understanding that is particularly important as we move into figuring out the differences. In this report, in the first phase, the objectives were actually to describe whether being rural, or living rural, is in itself a determinant of health. Are there inequalities, what are they, what do they relate to, if possible, contributing to addressing our general knowledge gaps as well as identifying key factors in terms of the differences and similarities between rural areas and urban areas?
The second phase, which looks more at health services, is still in progress, and we hope to report on that before too long. It has been a valuable collaboration between the Public Health Agency of Canada, the Canadian Institute for Health Information and others. It shows how in Canada the ways in which we work give us the strength that many countries do not have around understanding issues and bringing together diverse expertise on problems to help us deal with them.
The committee also recognizes that the vast majority of Canada is rural. The old statistic was that 90 per cent of Canadians lived within 100 miles of the United States border. I do not know if that is still true or what the ratio is, but basically it is a long ribbon of population, with more sparse populations above that and some large urban centres as well.
The rural area is home to close to 22 per cent of Canadians and very diverse populations. When you think of rural Newfoundland and the outports versus the Prairies versus the West Coast and other communities, you can think of the diversity not only of the economies but also of the cultural backgrounds and activities in which people engage.
Moving on to slide 5, the challenges of the transition are not unique to Canada, as you know. The whole world is moving to more urban areas, some more so than others. That has created a challenge for rural infrastructure and for the character of those communities. Many people around this table grew up in smaller communities and remember the vibrancy of that in decades before, and you are aware of some of the challenges now, whether around BSE or drought or floods or other impacts on farming and other rural activities, and the issues that are raised.
When we look at the health of rural Canadians, we recognize that, in general, rural Canadians are less healthy than those who live in more urban settings or close to larger urban areas. That is not always for the reasons we may think. Some of it is pretty obvious in terms of access to emergency services, but, for example, when Saskatchewan closed some 50 very small, rural hospitals, we looked at the situation in Saskatchewan some time later, and while health improved in all regions of the province in terms of reduced rates of death, the greatest improvements were in communities that shut their hospitals and the least improvement was in those that kept them open. It is not simply an issue of hospitals and access to medical care but the type of medical care that you have access to, as well as other factors within the community.
We also know that suicide rates for young people are much higher in rural communities. Yet the work that Chandler and Lalonde did looking at different reserves — and you may be familiar with this data — showed that where communities had greater control over their future or their lives, for example where they were engaged in land claims settlements or where the band had control over education, police, health services, and so on, the suicide rate in teenagers disappeared. There were virtually no suicides in that group. Yet in communities that had none of those factors, the suicide rate was four or five times that of the general population.
Again, these other factors have a tremendous impact on the quality of life as well as the ability of people to be healthy and to improve their health. We also know that clearly the most remote areas have the lowest life expectancy overall in the country.
The graph on page 6 illustrates the magnitude of the issue, particularly when you think of the most rural areas versus urbanized areas. In the most rural areas, Canadians in the age group of 20 to 44 years have almost twice as high a rate of dying as those in the cities. In the group aged 45 to 64 years, there is about a 20 per cent increase.
We have to take into account who grew up when and in what kind of community, because a few studies now have shown that if you are poor as a child, you have a higher rate of stroke as an adult, even though you are no longer poor. The impacts of early childhood around nutrition, education, nurture and support actually have a lasting effect on health. We are still discovering what all of that means.
We do not have as recent data for this, although Ms. Zelmer may have some intuition on it, but if you look at people who are well-connected to family, friends, community, work colleagues and so on versus those who are very poorly connected and isolated from community and other people, you find that those who are poorly connected at any age, whether they are male or female, have twice the risk of dying, at any age, than those who are well-connected. Having connections, being part of something that is bigger than us, has tremendous impact.
We can look around the world at the issue of income. In studies, there is consistently a relationship between income and health. For the most part it is a question of having adequate income for housing, being employed, having enough and appropriate food to eat, having clothes on your back, and being able to engage in community. Beyond that, most of the improvements in health relate to other factors, such as issues of inclusion. From our perspective, when we talk about poverty, it is not simply an issue of money. It is also an issue of poverty of connections, poverty of relationships, poverty of education, and poverty of being able to engage in and be part of a community.
Those two factors, having a sense of control over your destiny, where and how you live and the work you do, and having connections, where someone loves you and you love someone, link all other factors around the impacts on health.
It is a complex mix. We know that the healthier communities tend to do well economically. Also, if you do well economically, you tend to be healthier. Again, it is a complex and important thing to try to understand the various factors, because there is no simple solution. However, we can see communities spiral up or spiral down, depending on how these various factors interact.
I have worked now in Northern British Columbia, Saskatchewan, Manitoba, Northern and Southern Ontario and in outports in Newfoundland. I have observed that you can tell whether a community is healthy when you drive into it without knowing any statistics. The way the houses look, how the people interact, how they greet you can give you a sense of the health of that community. There are exceptions, obviously, but in general it is quite amazing how those factors interrelate.
What do rural inequalities mean for public health? Many of these factors reside outside of public health, outside of the health system. How do we interact across societies? Public health traditionally is the organized efforts of society to improve health and reduce inequalities in health. It is not just a matter of the roles that I and other medical officers, nurses, inspectors, health promoters and others have, but how we function as a system. Many of the basic issues of public health have been taken over by other sectors. Clean water, safe food, housing, and a whole range of influences affect health.
Place matters, but it is not just a matter of income and education alone. We do not understand it completely, but — and this is probably your experience as you go across the country — rural life is clearly changing. Some communities we think of as rural are prospering and doing well in terms of health while others are suffering. Some of them are very close together. In Southwestern Ontario and in different parts of the Prairies, there are towns that are thriving while others are in some ways fading away. What does that mean? In Saskatchewan, many services we took for granted have been changed. The school is closed; the rural development office is closed. The only thing left is the health facility. What does that mean in terms of the economy of that community, the kind of expectations they have and what actually will make a difference for health?
The focus of the agency is to be value-added. Public health is a local activity fundamentally. People get sick locally, disasters happen locally, and outbreaks and epidemics happen locally. It could be in 100 places at the same time, but it is still a local event. It is important that public health and health services are focused locally.
They must also be connected regionally, provincially and internationally so that we can bring the best perspective, idea and resources. At each level in public health there are lines vertically to the different levels of government and organization, as well as horizontally across the various sectors.
Some of the things we do focus increasingly on rural issues. For example, in the Canada Prenatal Nutrition Program, 254 communities in Alberta, about 58 per cent of the province, are served by the program. When you think of the Community Action Program for Children, almost half are in small rural communities of fewer than 10,000 people. Again, providing services and engaging and working with communities on some of those fundamental issues can help to make a difference.
It is the same with community capacity building and the work we do around chronic disease prevention, health promotion, et cetera. It is one of the exciting advantages of being part of a national organization that has connections across the country. We work with the provinces and territories to help fill in some of those gaps. We have specialized expertise that small provinces would never be able to have access to or be able to afford; we can help with those kinds of issues.
Slide 10 addresses looking forward. I think about working together across sectors. There is no one level of government, there is no one government, there is no one non-governmental organization, no one private-sector entity, no one community that can do it on their own. It really is about how we think through these issues and come together not only to recognize the impacts of our economic and social policy but also to be able to adjust or engage or think it through. Life in rural Canada is not the same as it was 30 or 40 years ago. What is it that we aspire to today and how is it that we can get there in the environment in which we now live?
The policy issues around this are interesting. I will give you two quick examples from Saskatchewan, where I worked for nine years before coming here.
One of the two things in policy that had probably the biggest positive impact on health in Saskatchewan in the last decade of the last century — and it is not about closing hospitals — was when Saskatchewan implemented a program where low-income families would still have health, prescription and dental benefits for their children. In most jurisdictions, when you go off welfare you lose these benefits. Under those circumstances, is getting off welfare a logical decision, no matter how much you want to work? Your income may be only slightly more but you lose these plans for your kids. In Saskatchewan, if you go off welfare, you still maintain those plans. When we look back at the impact of that, not only are there more people working in that province — and you think of the benefits of being able to work and being engaged in the community and feeling part of a working community — but also you see changes in the way people use the health system. They use it in ways that we think are probably more effective. That is one example.
The second example is where, if you are on social assistance, you can have a phone, but if someone calls Hong Kong and you cannot pay the long distance bill, you lose your phone. You could get a long distance cap so that only local calls can go out without paying directly and calls can come in, but it was a $200 deposit. People worked to remove the deposit. Suddenly, you have thousands of phones in households that did not have phones before in Saskatchewan. Think of the impact of that in terms of social isolation, in terms of an emergency and the ability of social services or health services — public health nurses or whoever — to follow up and contact people.
These two simple things are low cost but they have a tremendous potential impact on health and on people's sense of community and well being. I will stop there.
Jennifer Zelmer, Vice President, Research and Analysis, Canadian Institute for Health Information: Thank you for the invitation to be with you today. I look forward to sharing with you some recent information from the Canadian Institute for Health Information that we hope will be relevant to your deliberations on rural poverty.
For the benefit of those who may not be familiar with CIHI, we are an independent, not-for-profit organization that aims to inform health policies, support the effective delivery of health services and raise awareness of factors that affect good health.
With me today is Ms. Gyorfi-Dyke, Director of the Canadian Population Health Initiative at the Canadian Institute for Health Information. As Dr. Butler-Jones mentioned, CPHI examines patterns of health in Canada as well as evidence about what works to improve our health.
This perspective reminds us that patterns of health and disease are largely a consequence of how we learn, live, work and play. As Dr. Butler-Jones said, although Canadians are among the healthiest people in the world, not all of us enjoy equal chances for a long and healthy life.
Many of you are familiar with the report that Dr. Butler-Jones mentioned that we worked on together with the Public Health Agency of Canada and Laurentian University. We have copies of the summary today in English and French, if anyone is interested.
Since Dr. Butler-Jones and I are both here this morning, we agreed that he would present some of the more detailed findings from the report. However, just as a summary and reminder as I start my remarks, the report shows that Canadians living in rural and remote areas have higher death rates than their urban counterparts — both overall and for many specific causes of morality. For example, death rates due to motor vehicle injuries were two to three times higher in the most rural communities in Canada compared to urban centres. Rural Canadians are also more likely to smoke, to be exposed to second-hand smoke and to be overweight or obese.
On the other hand, it is also important to note that the report highlights some health advantages for rural residents. They tended to report lower levels of stress and a stronger sense of community belonging than those in urban areas. They were also less likely to be diagnosed with a new case of cancer.
The report shows that there are important gaps in health between rural and urban areas. However, some other health indicators work that CIHI does in partnership with Statistics Canada highlights the fact that health and health care are not the same in all rural communities. As Dr. Butler-Jones said, in some cases, communities right next door to each other may have very different situations in terms of their health.
As an example, let us take life expectancy. The indicators project clusters health regions into peer groups with similar demographic, living and working conditions. Overall, life expectancy in the group with five northern and remote regions was about eight years less than in Canada's largest metropolitan centres in 2001. Even within this group, there was a 10-year difference in life expectancy.
The same is true for many other health indicators, such as arthritis and rheumatism rates. Overall, about 22 per cent of teens and adults in a peer group of rural regions, mainly in Saskatchewan and Manitoba, reported having been diagnosed with these conditions. Two of these 10 regions had rates that were less than 20 per cent, while two had rates over 25 per cent. There are differences from one rural community to another.
Some interesting work that we have supported recently looks at the question of why some communities are healthier than others. Many of the determinants of health — such as income, education, literacy and employment — apply in both rural and urban areas. For example, as Senator Fairbairn mentioned in her opening remarks, Canadians with the highest incomes are more likely to say that they are in excellent or very good health than those who have middle incomes, who, in turn, are more likely to report positive health than the lowest-income Canadians. This pattern is repeated across the country at the neighbourhood level.
Interestingly, in some cases, characteristics of rural areas may interact with these determinants. I would like to share four quite different examples with you this morning.
First, many resource-dependent communities are subject to employment and economic cycles. Two CPHI- supported researchers, Alex Ostry and Paul Demers, looked at the health of thousands of workers and their families in 14 sawmill communities scattered across British Columbia. They found associations between working conditions or job characteristics and the health of sawmill workers, as well as, in some cases, the health of their children. As Dr. Butler-Jones mentioned earlier, this is not necessarily just about one generation; there may be multigenerational effects as well.
My second example this morning also focuses on the unique characteristics of work environments in rural areas. Farms are workplaces certainly, but they are also often where people live, work and play, making injury prevention complex.
For the last several years, CIHI data show that over 1,100 people per year have been admitted to Canadian hospitals with farm injuries, not including any injuries that might have occurred in homes on farms. About one third of all of these farm injury admissions were related to unintentional falls. The next most common causes of injuries were natural and environmental factors — such as the weather or being bitten by an animal — and machinery-related injuries. Farm injury rates for those under age 20 and age 60 and over are more than twice the rate of workplace-related injury admissions found in other sectors. It is interesting to think about that as one of the key health questions in rural areas.
The third example, which Dr. Butler-Jones has already touched on, explores determinants of health beyond the workplace. It is the work by Drs. Chandler and Lalonde in British Columbia, who asked why some First Nations communities in the province had no youth suicides over a 14-year period whereas others had rates much higher than the provincial average. They found that rates tended to be lower in communities with band-controlled schools, health, police and fire services, as well as community self-government, culture facilities and control over their traditional land base. We are now in the process of working with these researchers, First Nations and other partners to explore whether other health outcomes beyond youth suicide are also associated with these types of factors in British Columbia — and also to extend and adapt the research to Manitoba.
My final example this morning looks at health services use rather than health status. As you know, health services are often organized quite differently in urban and rural areas. For example, in 2004, 16 per cent of family physicians were located in rural and small-town Canada, where just over one fifth of the population lives.
That said, interestingly, the percentage of residents who reported having a regular medical doctor varied significantly between rural regions, just as it does in urban areas. Overall, rural family doctors are more likely to say that they are accepting new patients and tend to offer a broader range of health services than doctors in cities. For instance, one third of family doctors in Canada's least populated areas delivered babies, compared with less than one tenth of those in the largest cities.
Detailed regional health indicators data also show many other variations in health care use between urban and rural Canada. For instance, in Canada's largest metropolitan centres, more than 70 per cent of women aged 50 to 69 had a mammogram in the last two years. Some mainly rural regions in Eastern Canada did not reach this level, but several had much better results. For example, rates were above 75 per cent in Western Newfoundland, as well as in three regions in New Brunswick. Similar variations exist in other parts of the country.
These examples show that geography need not always be destiny, so what is it that actually makes a difference? A Manitoba study that we co-funded with the Canadian Health Services Research Foundation provides clues about some options. Two researchers showed that the rate of poor rural women undergoing mammograms more than doubled when a breast cancer screening program was brought directly to them. Cancer Care Manitoba created the program in 1995. In addition to permanent sites in urban areas, they set up mobile screening mammography vans that travelled the province to reach many smaller communities each year and had an active outreach program to accompany that effort. Within a few years of its introduction, screening rates were almost equal for women at the top and at the bottom of the income scale in rural areas. Similar gains were not seen for two other prevention services, child immunization and cervical cancer screening, which did not have the same kind of outreach efforts over this period.
In conclusion, I would like to return to my opening statement that patterns of health and disease are largely a consequence of how we learn, live, work and play. There are gaps between urban and rural Canada in terms of both health and the determinants of health. While there is still much that we do not know about how to improve health in rural communities, these variations may help provide some opportunities to identify clues for moving forward by learning from our collective experience, just as I understand this committee is learning from experiences across the country in its current undertaking of visits to various communities across Canada.
Senator Callbeck: Thank you for being here today. I come from a rural area in Prince Edward Island. Over the last 10 years many initiatives for rural health have been announced by the government. I want to go through two or three of these this morning to learn what is taking place and whether they are still in existence.
In 1998, the federal government created the Office of Rural Health under Health Canada. When the Public Health Agency of Canada was established, it was my understanding that the program went to the new agency. Does the Office of Rural Health still exist?
Dr. Butler-Jones: The funding for that focus program ended but we have incorporated rural elements across the program activities in which we are involved. The structure of what you need organizationally in order to keep that focus varies depending on the time. Having it woven through is one way of accomplishing that. If that is not happening, then having a focused area, in particular with a new initiative, is often helpful. There are the two tensions — everyone is doing it means no one is doing it. That is the one extreme. The other extreme happens when everyone defers to the area that is doing it but the issues cross over a whole range of programs and activities and so it cannot be done by that one area. When the funding and the program ended before the agency was formed, I believe it rolled into the ongoing activities.
We are open to and interested in the committee's perspectives and recommendations as we move forward to continue to work in this area.
Senator Callbeck: Was that office phased out because it was not effective?
Dr. Butler-Jones: No. It is my understanding that basically the funding for that program as a focused entity ended and we incorporated elements into other activities.
Senator Callbeck: In June 2000, we announced a national strategy of rural health with eight broad objectives. Is that strategy still in existence? Is either of you involved with any of these eight strategies? One of them, for instance, was to develop health information technology. Is the Canadian Institute for Health Information involved with that? I would like to know whether the strategy still exists.
Ms. Zelmer: Health information technology is actually Canada Health Infoway's mandate, which has a greater focus on that. They have a specific program on telehealth, which is part of that effort.
We work with regions across the country. For example, we have an initiative with sparsely populated regions to look at their specific needs. We found that in the area of health information and the way that it is used, the needs might not be the same at the local level for those in a big city compared to the needs of those in a sparsely populated region. That is one of the initiatives currently underway.
I am not familiar with the national strategy. That is the work we are doing.
Dr. Butler-Jones: I will turn to my historian.
Marie DesMeules, Director of the Evidence and Risk Assessment Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada: To give you some background, the national strategy for rural health was very much linked with the Office of Rural Health, which you mentioned in your previous question. The Office of Rural Health and the national strategy were meant initially as a time-limited initiative. The initiative funded the Office of Rural Health and some community programs administered by Health Canada at the time. Some significant funding also went to the Canadian Institutes of Health Research, which was dedicated funding for rural health. The initiative lasted approximately three years until the funding ended. After a transition period of about a year, the Office of Rural Health became less active and took on a more generalized focus across the department. At that time, the Public Health Agency of Canada was not yet in existence. Clearly, the Office of Rural Health and the national strategy had a significant role in two key areas: raising capacity for rural health research and programming and raising awareness across public health practice and research to do more in this area.
New researchers went into the field and people in practice became more knowledgeable about the needs of rural health. Currently, there is a strong awareness within the Public Health Agency of the need to consider the rural aspect of our programming. Some of our programs, if not fully dedicated to a rural perspective, certainly consider a strong rural focus. That includes health promotion, chronic disease prevention, infectious disease, child health development and surveillance activities. We do that collaboratively, and we have seen a difference over the years in the level of activity in this area.
Senator Callbeck: That strategy was in place for only three years. It is gone and the Office of Rural Health is gone.
Ms. DesMeules: Yes.
Senator Callbeck: Our briefing material says that the word ``rural'' does not appear in the Public Health Agency of Canada's 2006-07 Report on Plans and Priorities. That concerns me.
Dr. Butler-Jones: Can you say why, as opposed to other words that do not appear there? Rural runs through all of what we do.
Senator Callbeck: It says that the word does not even appear.
Dr. Butler-Jones: I am not sure the word ``urban'' stands out in the report either. We take the approach that you bring the resources, tools, perspectives and programs to wherever they are most needed. I do not think it reflects an attitude that the word ``rural'' does not appear in the report.
Senator St. Germain: The question of native communities jumped out at me in your presentation. Senator Peterson and I sit on the Standing Senate Committee on Aboriginal Peoples. You talked about self-governance or their ability to take control of their own destiny, which, according to your studies, has produced positive results as far as reduced suicide rates. You mentioned that if the band council controlled schools and various other aspects of their life, it seemed to improve the standard of living in these particular communities.
Are you linked at all with Indian and Northern Affairs Canada in your work?
Dr. Butler-Jones: We are linked not only with INAC but also with the First Nations and Inuit Health Branch in Health Canada, as well as working with various national Aboriginal health organizations and other Aboriginal organizations. On the Standing Senate Committee on Social Affairs, Science and Technology, we have been involved and will come back with a follow-up report regarding some of the questions that were raised about how we are incorporating and raising awareness of those issues within the Public Health Network, which is the organization that provides oversight to federal, provincial and territorial services to public health services. We have ongoing dialogues with other departments in government on these issues.
Senator St. Germain: For about 18 years there has been a self-government proposal in the Senate that cannot see the light of day and it does not matter who is in government.
I have had meetings recently with Aboriginal leaders from some of the remote areas in Northeastern Ontario and Northwestern Manitoba. It is a nightmare. In the wisdom of this committee, our chair decided to travel up North into some of those remote areas. I was told that there are four communities and 10,000 people. The only remarkable thing about the community is that they have a dialysis machine because of the high incidence of diabetes.
This is rural poverty at its worst. We do not seem to be getting anywhere. We have all these departments going in different directions doing various studies, but there is no marked improvement in the lifestyle of those people. As a matter of fact, it is deteriorating. In many of those communities, the gangs are taking over because of the breakdown in the social fabric.
Do you have any comment from the perspective of your department and the studies you conduct? Is there a light at the end of the tunnel?
Dr. Butler-Jones: I think, yes, there is a light at the end of the tunnel, but exactly where the end of the tunnel is and how to get there are much broader and more difficult questions.
A large percentage of First Nations people are living off reserve in urban centres. Independent of one's background as Aboriginal or not, issues relating to the social conditions of poverty, unemployment, lack of connection and so on are the same. Whether you are European, Aboriginal or African, you have much poorer health. The challenge for many First Nations and other communities is these factors; it is not an issue of simply being Aboriginal. These factors are particularly profound in many First Nations communities, but that is not because they are First Nations, although clearly we recognize the issues of discrimination and racism where they exist.
In terms of the organization of those communities, there are also other communities that are thriving and doing very well. The challenge for governments and for First Nation governments is to figure out the elements and the changes that can be made in order to improve that. It is not always the first things we think of. It may not necessarily be a hospital. For example, the high rate of diabetes is related to change of diet, obesity, inactivity, et cetera; diabetes then leads to kidney failure and the loss of circulation in the legs, which in turn leads to amputation, and so on. All of that is compounded by the high smoking rates that also interfere with circulation. Those are just a few factors.
On the health side, there are a number of factors. Clearly, communities and individuals who have a sense of control — and it is not just one form of government over another but a sense of control over their lives and how those communities function — will, in general, be much healthier.
No one of us will solve those challenges faced by the communities. What is important is working closely with communities, rather than doing things to communities.
Senator St. Germain: I hear what you are saying, doctor, but the more things change the more they stay the same with our Aboriginal peoples. I have been on that committee for 14 years. I think I know a bit about it. I do not consider myself to be an expert, but in the 14 years I have not really seen any change. In some areas, the situation is getting worse.
I am not blaming your particular department, but the fact is that we have all these various departments, for example Health Canada, Industry Canada and your department. We had a study last night on safe drinking water. We have not even been able to provide that. We have 97 communities still at risk. There were about 190 a year ago. That situation has improved. I think those studies are credible. Yet, this is so blatantly obvious but nothing seems to be done. This is scary. The statistics they are giving us on young children, like the people from Northeastern Ontario in my office yesterday, are worrisome. There are thousands of young kids under 25 not being educated properly and they do not even have proper health care.
The object of this exercise is not to pick on anyone. Somewhere along the line there is light at the end of the tunnel, but how long is that tunnel? That is the question.
Dr. Butler-Jones: That is a fair question. It is a tremendous challenge. I think we all wish it were not so.
Part of the challenge, including for governments, is that money has been spent but we still see these problems. As an agency, we are involved in a range of activities off reserve. The services on reserve are with the First Nations and Inuit Health Branch in Health Canada. Off reserve, we have the Aboriginal Head Start Program in communities across the country, the children's action plan, and a number of programs that work to reduce the risk of fetal alcohol syndrome, to improve nutrition, and to improve other things. Still, we are not seeing that profound change you are talking about. I think it is a challenge faced not only by Canada but by governments and communities around the world. It really does require concerted action. My point before was that no one of us can solve it alone but it does require that collaborative focus and working with communities in terms of how they get to where they want to be, because it is a tremendous problem and challenge.
Senator Mercer: Ms. Zelmer, in your presentation you referred to an interesting study in British Columbia. I think this relates exactly to what Senator St. Germain said regarding youth suicide rates. According to the study:
. . . more than half of First Nations communities in the province experienced no youth suicide over a 14-year period; several others had rates well below the provincial average. Rates tended to be lower in communities with band control over schools, health, police, and fire services, as well as community self-government, cultural facilities, and control over their traditional land base.
This links the problem with what appears to be a bit of a solution. It does not seem a great leap of logic to figure out that if it is a problem in communities that do not operate this way and it is not a problem in communities that do operate this way, one and one seem to make two.
Ms. Zelmer: That is one reason this study was so interesting. There was basically a step function. They looked at each of these individual factors. In communities that had more of these factors, the suicide rates went down. It is an interesting piece to look at. It may not always be things that are just about us as individuals; characteristics of the places we live may have a profound impact on our health. One reason we are following up is to see if this applies outside youth suicide and to other parts of the country, like Manitoba, to really be able to understand what is happening.
Senator Mercer: It does not seem like rocket science, does it?
Dr. Butler-Jones: The challenge is not recognizing those relationships, because they are very real. It crosses over all kinds of groups. People in the British civil service all have reasonable incomes. Those who have the most control over their lives and their work have much lower rates of death than those who do not have much control. You find that everywhere you look.
The challenge is in terms of that relationship. That is why the research is being done. I am sure it will show the same thing. It is not just about Aboriginal suicide, but it will relate to a whole range of health impacts. If you added other factors such as control, people's connections within a community, all those things I alluded to would lead to better health.
The challenge for governments, band councils, leaders and community members themselves is to know what kinds of things that can achieve it. As we are learning, some communities that were unhealthy have, in the space of 10 or 15 years, become healthy. The economy has not changed, but the way people have taken charge over their own lives has then generated a kind of ferment that you spiral up in health.
What policy changes will do that? I gave two examples from Saskatchewan of the kinds of things governments can do. There is the kind of work being done with band councils in terms of self-government and the work being done around education control in Manitoba and B.C. All of these measures are clearly in the right direction. That is why I say there is light at the end of the tunnel, but it has taken us generations to get to this point. It will take us a few years to get out of it. We cannot lose focus, and we have to bring the evidence to bear leading to good programs and outcomes. Much money is being spent without the kinds of outcomes we would hope and expect.
Senator Mahovlich: I want to thank the witnesses. It was an enlightening presentation. Can you tell me where in Canada is the most disturbing rural area? Which province?
Dr. Butler-Jones: I would not pick on a particular province. The reality is that we have gaps. When you look at the difference between rural and urban, between different provinces and territories, and even within them, there is a big gap. The worst off in one province may be as good, better off or the best compared to somewhere else. It is really mixed up based on individuals.
Depending on which community or area you are talking about, there are different problems. In many rural areas, particularly in the North, homelessness is not an issue of people on the street. Homelessness is three or four families living in one house without adequate sanitation and water.
In another part of the country, even within walking distance to the most sophisticated hospitals in the world, we have infant mortality rates that are many times the average, again because of those conditions of poverty and inclusion and those things we have talked about.
To say it is a province or district or region is not fair. In the city of Saskatoon, with about 200,000 people, there are parts of the city where the mortality rate of infants is twice that of another part.
For me, that is one of the values of thinking not only as a nation or as a province but also thinking locally and having organizations, social services, public health, that are thinking about what we need to do with this community as opposed to that community. Because these determinants that underlie health and well-being tend to coalesce, it becomes even more challenging. It is not like you can just pull one string and everything will be better.
Senator Mahovlich: I came from a Northern Ontario town called Schumacher. You mentioned closing schools. It was a sad and emotional day in 1968 when I went up there and they were closing our high school. You grow up with your buddies, and all of a sudden they are closing the school for economic reasons. People were going to bus to another town. On the day we closed the school, an ambulance went by. We were out taking a school photo. One of my schoolmates had committed suicide on that particular day. The closing of schools does have an effect on people.
I have a question regarding the Northern Ontario School of Medicine. If a doctor is from an area, we find it is more likely that he or she will stay in that area. If a student from Schumacher studies to be a doctor, there is a good chance he will come back to that area. If we could get Aboriginal students to go into medicine, would that be an answer to keeping doctors?
Dr. Butler-Jones: It improves the odds; it does not guarantee it, even for non-Aboriginal rural physicians. There are programs that work to encourage that engagement. On the public health side, the agency has bursaries for training in public health that help to facilitate training and employment.
Smaller communities with 10,000 people, such as you were referring to earlier, are a different setting, but with the very small communities, it probably would not work to have a physician go back to the community, although it could work to have people — nurses and nurse practitioners, community health workers and others — go back to the region. I am looking forward personally to the northern medical faculty. It is true that people who have trained or worked in rural and Northern communities are more comfortable going back, not just because the school is situated there but also because of the practical opportunities. A guy like me from Toronto, who worked in Northern B.C. and in Northern Ontario, found that I love rural and Northern areas. Again, those opportunities are very important for nurses as well as other professionals as part of their training, and not just in the northern medical school but in schools across this country.
Senator Peterson: We have heard many statistics this morning that identify problem areas. My question is how much emphasis we should put on them and why. You talk about rural health being less than urban because of many issues — lack of public transportation and facilities, mainly, and the inability to access a doctor — so most of their care is corrective and not preventive.
We have also talked about rural car accidents. Well, rural people have to drive everywhere. If you have seen the roads in Saskatchewan, you understand the statistics. As well, we talked about farm injuries being on the rise and that is because they cannot get help to get the crop in so they work long hours and are overtired. The why of so many of these statistics can be readily explained. Do we continue to try to identify the why in your report more than just the statistics?
Dr. Butler-Jones: You are absolutely right. There are multiple factors. In Saskatchewan, for example, even if you live in the town where there is a physician's office, getting there if you are no longer mobile and able to drive is a serious problem. You see that even in cities. One of the challenges when I worked in Newfoundland was at the outport clinics. Once a week on a regular basis, one of the physicians would go to one of the outports to hold a clinic. Between those times, if an unemployed fisherman needed treatment, he had to take a $50-cab ride to access a hospital. Yes, there are tremendous issues in terms of access to medical treatment but, at the same time, some of these communities were very healthy. It is that blend of getting a base of good health and having the connections so that you are less likely to be ill in the first place but, if you are, you have a mechanism to access the right place.
Although we do not know all the details, one of the issues around small hospitals is that they do not have the capacity to do critical care work because they may have a physician who does not know how to intubate in an emergency situation. Closing those small hospitals simply meant that people would travel the extra 20 minutes to the next hospital that had the capacity and they did not waste time with not getting good care.
The public health system needs not only the basics such as hospitals and ambulance services or other emergency connections, but also transportation for seniors to access services, public health programs, day care for single moms so they can attend programs, and transportation to get them there. We need to think about all of these things if we want to make that happen. It is a bigger challenge in rural areas because of the distances, infrastructure and other issues that you have mentioned. Those are part of the solution.
Senator Peterson: In many small communities, people deal with first responders who then phone the ambulance that takes them to the hospital, where they cannot get the necessary treatment so they have to move on to the next hospital. A lot of time is being lost while all of that is happening. Do you think that public health care, right across the country, is in danger of collapsing under its own weight? The funding of it is difficult and it seems to be suffocating.
Dr. Butler-Jones: A number of initiatives have looked at how we can better organize what we have. The Romanow report indicated less concern about the need for more money, although it is necessary, than it indicated a need for better organization.
The other point is the focus on what we do and the small investments necessary that can make big differences. For example, over the last 15 years, the rates of obesity in young people have gone from low to high. The current young generation might be the first generation to not live as long as their parents. That has crept upon us over 10 or 15 years and is preventable. That change can be the difference between picking up a can of pop and picking up a 20-ouncer. We have not had that kind of strong focus.
Look at waiting lists for surgery on hips and knees. If it were not for polio vaccine, we would not even think of doing hip and knee replacements because all orthopaedic surgeons would be dealing with polio victims. Today, about 90 per cent of the need for hip and knee replacement is because of excess weight and is not because of other wear and tear on those joints. If many of the people on waiting lists were to reduce their weight, they would no longer need the new knee.
That is what we are seeing in just one area; take that across the remaining chronic diseases and even the infectious diseases. In the healthiest areas of the country, look at the kinds of things that people are doing and you will find that it is a mix of all the factors that we have talked about as well as having an organized system of health care. If we think comprehensively about all of the factors then we can get ahead of the curve.
Senator Mercer: In his presentation to the committee, Dr. Keith MacLellan, past president of the Society of Rural Physicians of Canada, argued that rural Canada needs generalists, not specialists, which is the reverse of the status in urban Canada. Do you agree?
Dr. Butler-Jones: Yes. Any good system anywhere in the country needs good basic public health and generalists and proper access, whether to nurse practitioners, to family physicians or other. From that point, you escalate.
Not to advocate for the health care system in Cuba, which is a much smaller country, but one thing they do well is make the right connections. Everyone is connected to a nurse and a family doctor at the local level or in their region, and the family practitioners are connected to a poly-clinic attended by specialists to see the patient. At times, the doctor will attend the clinic as well and it becomes a teaching session. If the patient needs hospital care, the levels of health care are connected. The doctors and nurses there think about the needs of the community and of the family and whether chronic disease is involved. People do not get lost in the system with respect to the management of their chronic disease. There are connections through the system, as opposed to just sending patients off.
The short point is that generalists are key to making this work. If you do not have the generalists, the specialists cannot do their part because they deal with only one part of the care. The generalists look at the whole and help to make the connections to other things in the community.
Senator Mercer: All that being said, what should be done to bring a better balance to the geographic distribution of doctors in both rural and urban areas? How do we get doctors to work where we need them? That does not necessarily mean the very small communities only, because the need might be a smaller regional area. How could we accomplish that?
The argument has been made that a big, dark secret of provincial health ministries is that they are not interested in graduating more doctors from medical schools because more doctors would mean more billing of the health care system. Do we need more doctors or are they simply in the wrong place?
Dr. Butler-Jones: It is probably a combination of the two. Certainly, more generalists would be beneficial to the system because they can deal with the vast majority of problems. Then we could utilize the specialists more effectively for the things that require specialized care. It is a complex issue that governments around the world struggle with. No one has found the answer yet. As Senator Mahovlich said, it is about people having experience and comfort working in a rural area.
In the 1970s when I trained, it was the early era of CT scans. I was planning to work in Africa. I asked what you do if you do not have a CT scan. I was told, well, you get one. I said, no, no, if I you do not have one for 100 miles, what do you do? I was told, you get the patient to one. I said, that is not good enough. That exchange did not give me much comfort in my training.
Part of it is the training so that people are comfortable working in rural areas without all the toys and fancy tools, as important as those are when they are needed. It is also about remuneration. It is about the style of practice. Group practices are much more supportive and appealing because you have other colleagues to talk to. It is a mix of nurse practitioners, physicians and other professionals working together as a team in a region, so there may not be a doctor in every town but you have a cluster of doctors nearby and a couple of nurse practitioners and other caregivers in each small community who then link back in so that again you have a system of care.
The final point is something we discovered while working in rural Newfoundland around recruitment and retention of doctors, and I think it is true elsewhere. If you have good work to do, if you are valued and supported in that work and if you have a reasonable place to live, then that is 80 per cent of the recruitment and retention. You cannot let the dollar gap get too big, but that is really important. Even for small communities, the way a doctor relates to the people working in that community makes a big difference to whether or not he or she will stay.
Senator Mercer: We hear stories every day of foreign-trained professionals, doctors or engineers or what have you, not being able to work in this country because of their inability to get licensed. I am frustrated by this, and I place the blame squarely on the shoulders of the professional organizations that self-regulate, like the Canadian Medical Association and the various provincial medical associations. I am frustrated enough to suggest that they should stop regulating and that they should turn the regulation of licensing of doctors, et cetera, over to government, which, God forbid, sounds even worse. We have lots of people in this country and others willing to come to this country who could help us solve part of this problem, but they cannot get licences. Do you see this as part of the solution, or is this problem just a figment of our imagination?
Dr. Butler-Jones: There are several aspects to that. Just as a clarification, the Canadian Medical Association and the provincial medical associations do not regulate. They are the professional associations. It is the colleges of physicians and the colleges of nurses that do the regulation. They are self-regulating bodies under statute of the provinces. Their job is to ensure a standard.
That challenge is well-recognized, and there are two aspects to it. The first is how to assess people's training and the second is recruiting internationally as opposed to recruiting those who are already in the country. We have many South African doctors working in the Prairies, for example, and South Africa is hugely challenged in terms of providing health services to populations in South Africa. That creates an international complexity.
I think the universities are looking at the question of people who are trained elsewhere, international graduates working in Canada, and the regulatory authorities, governments and others are trying to find ways to do an assessment. The quality of graduates trained in a Canadian university is pretty well standard. They are all different, but at least you have a very good basic standard of training and experience. That is not true for all medical schools around the world, clearly. The challenge is how to assess that training. I taught international graduates when I worked at the University of Saskatchewan, and we had international graduates from some countries that I would say are on par with anyone, and there were other schools in the same country where they had huge challenges in terms of basic medical concepts. Some Canadians who trained in European countries also had great difficulty with things, yet others did not.
What we need at the end of the day are systems where you can do some basic assessment and the additional training, but there are not many training slots for the graduate medical training that will allow you to then practice in any jurisdiction in Canada. There are multiple levels of issues to be dealt with. Both governmental and professional levels are looking at this. We are not there yet, but my view is that we are closer today than we were three years ago.
Senator Mercer: Have the colleges of physicians tried to speed up the process of assessing new Canadians who were trained in the medical field? If they are not up to our standards, have they been provided with the proper training to bring them up to our standards?
Dr. Butler-Jones: The training is done by the universities in the residency positions. They are talking about it. I will not say I am familiar enough with exactly what they are thinking or planning, but I do know that the various licensing bodies and others are quite seized with figuring out how to do this.
Senator Peterson: In the rural area that I am familiar with in Saskatchewan, the problem we run into is that we get a doctor who is basically on duty 24/7. After a couple of years, they have burnout. Even if we could provide a program with both the provincial government and the health regions providing the funding, are there enough positions graduating or that we can get access to in order to augment the number of doctors so that we do not lose them?
Dr. Butler-Jones: It depends partly on which specialty, whether family medicine or another specialty.
Senator Peterson: All we get is family medicine in the rural areas.
Dr. Butler-Jones: I understand that, but I am referring to whether there are enough. I do not know the right answer to the question of whether there enough, but I do know that how you organize care makes a huge difference in terms of the impact. In Saskatchewan, southwest of Saskatoon, a number of nurse practitioners in different small communities are working with a family physician in one of the communities, and they all link in and then back to the hospital with other health professionals, public health nurses and others. There are ways of organizing practice so that you are less likely as a physician to burn out from being constantly on call as well as providing good-quality care. A good nurse practitioner can cover off 90 per cent or a high percentage and then has access to a good family doctor who has access to good specialists. If we organized primary care that way, not just the medical services but the social and public health and other things that are linked to it, we could create a system that addresses those issues more effectively, reduces burnout and increases job satisfaction.
Senator Mahovlich: You mentioned Cuba. Are you recommending their system to Canada?
Dr. Butler-Jones: No.
Senator Mahovlich: You seemed quite enthused about Cuba.
Dr. Butler-Jones: I usually preface that comment, and I thought I did, that I am not suggesting that we adopt the Cuban system. The element of the system I am interested in is the connectedness and the focus on results. People do not get lost in the system. If this is my group of patients, the nurse and I working together know that David Butler-Jones has asthma and I should see him once every three months, and every family gets a home visit once a year so that we understand the context in which people are living, and I am connected to the poly-clinic, so if my patients need specialty care they can go there, and if they need hospitalization it is available, and so on. It is the activity and the focus on getting the basics right. Even though they have few resources, they had people think through the questions like, ``If we only have this much penicillin, what is the most effective use of it?''
Senator Mahovlich: I have had many friends who have money here, and if they have a problem, they go to the United States where there are no have lineups. If you have money, you do not have a problem because you can go to the U.S. Do Cubans go to America if they have a real problem?
Dr. Butler-Jones: No, not to the United States.
Senator Mahovlich: The buck stops in Cuba.
Dr. Butler-Jones: They will get their care. They have sophisticated care in hospitals in Cuba.
There are long discussions on comparisons between different health systems, but I must leave shortly. That is a convenient excuse, is it not?
The Chairman: One senator has not had a chance to ask a question. We will get that in before you leave.
[Translation]
Senator Biron: I would like to ask you a current and maybe somewhat philosophical question concerning the choices to make to get rural young people interested, namely would you examine the possibility of opening private clinics and of offering better salaries? Could this reduce waiting periods in hospitals? Would a user fee help improve the quality of service and reduce waiting time in hospitals? What is you view about user fees and private clinics?
Dr Butler-Jones: As far as the quality of services is concerned, this is a matter of option for people.
[English]
If I understood the question correctly, there is not a simple connection there. If you get the basics right, the need for hospital is less, and it is independent of who is providing the service or how they are funded.
When you look at systems broadly, access is certainly easier in the United States if you have money, but they spend twice as much per person on health care as we do. As well, their outcomes for the same problem are not as good as ours, in spite of spending twice as much money, at least in the areas that have been studied.
It is not so much an issue of private versus public as it is the organization of care, the kinds of services provided and how to make those connections.
Senator St. Germain: Doctor, I just had a knee problem as a result of chasing cows on my ranch.
The Chairman: On horse back?
Senator St. Germain: No, on foot.
I paid $875 for an MRI to find what was wrong and they are fixing it. Had I gone into the public system, it might have taken months to get an MRI. If the facilities are available, those who have the ability to pay are looked after. The WCB and various other organizations use these private clinics to make things flow much more smoothly for the workforce and to mitigate the costs to the workers' compensation boards in the various provinces.
I would like further clarification on your answer to Senator Biron.
Dr. Butler-Jones: To me, the issue is not so much private versus public as it is how the services get organized and delivered, which you can potentially do well in either system. There are incentives and disincentives in each.
To compare the American system with the Canadians system, as I said, the Americans spend much more and, in terms of the end point of the service, on average they do not do as well for the same condition at the same stages as Canadians do. Having said that, you can get things done much more quickly, but that is not necessarily always a good thing in terms of complexity. A less intrusive intervention may be more effective or less dangerous. It has been said that several thousand Americans die as a consequence of having bypass surgery that they probably did not need at that time.
There was a study done in Vancouver on cataract surgery. They found that about 25 or 26 per cent ended up with worse vision rather than better vision. Did those people actually need cataract surgery at that point in time?
You must determine what is essential for health and what is important for quality of life. For example, if someone needs a knee replacement in order to get around, how do you manage to ensure that the waiting list is not too long? On the other hand, many people waiting for knee surgery who get into a weight control and activity program end up not needing knee surgery.
Most physicians working in Canada are private practitioners. The public/private debate masks some of the deeper issues. If we are going to solve problems in the health system, we need to start by understanding it and then we need to address them, whatever methods of payment and organization we have.
Senator St. Germain: The question is not so much what is happening in the United States. Would private facilities make the system more efficient in Canada? I do not think the American example applies here. We are talking about our system.
Dr. Butler-Jones: I understand that, but I am not sure we know the answer.
For example, the Shouldice clinic, which is publicly funded, is a private organization. It is probably one of the best places in the world to have a hernia repaired. It is very efficient, effective and low risk. That is a way of organizing private care within a public system that is very effective. If you tell the private system to do the things it wants to do, they will, as we sometimes see in the drop-in clinics, tend to do the easy, low-risk and profitable stuff and leave the more complex things to the rest of the system. That distorts the system and creates longer lineups in the public system, as Britain found.
Again, there is not an easy answer to this. I personally think it is important to look at all the options and consider all the impacts and not to generalize too much, because that is where we get into trouble.
The Chairman: I know that you must leave, Dr. Butler-Jones. We want to thank you for staying longer to help us out.
This has been a first-class morning. If senators want to ask questions of your associates, would that be possible?
Dr. Butler-Jones: It is only I who has to leave. Thank you once again. It was a great pleasure for me to be here this morning.
The Chairman: We have not focused on seniors who can no longer hop into a car and go and who may not be close enough to family to get assistance from them. This is a problem in rural Canada. Can you comment on that?
Ms. Zelmer: That can be the case particularly in rural communities where there are high proportions of seniors relative to the overall population because young people have left for jobs elsewhere. It is an interesting challenge to think about that. Downtown Toronto is a completely different environment from the community near the farm where I grew up in Northern Alberta.
The solutions may be different, too. That is one of the interesting things about looking at the regional health indicators. It allows you to see that two different communities may have very different outcomes for seniors both in health and in the determinants of health.
What can we learn from those comparisons? We do not have all the answers but we may be able to learn from each other and metaphorically knock on the door of your neighbour and say what did you do differently? Perhaps it is how you worked with local community groups or how you take advantage of the church basement, which was a big meeting place where I grew up. That may not be as easy if you are having problems getting around; it may have to be the main floor.
We have to look at how we are creatively using the resources in communities to provide the social supports that Dr. Butler-Jones spoke of and to address the kinds of access issues we have been talking about as well.
The Chairman: There is also a concern if you do not have the next door neighbour or if you are out on the land and do not have family to take you around. I hear about that in my own area.
Ms. DesMeules: I want to comment on seniors. This is a very important population to look at. Our study highlighted that the ones who are most vulnerable in terms of worse health outcomes in rural areas are the younger populations, especially youth. That relates to accidents, suicide, and so on. When we looked at seniors separately, the differences between rural and urban Canada were very small, indicating that something is going on and that seniors, in a rural setting, may have other challenges about their daily lives, but maybe we need to look at other structures that may be in place to support seniors in a rural setting. They may stay with their family members longer rather than go into a nursing home, for example. That told us that we need to look at seniors separately because there might be some interesting things happening there.
We spent a lot of time this morning discussing health care, and it is a critical issue, but the report that we worked on really highlights the importance of health promotion and disease prevention as well. That is a important role in society generally. Definitely in a rural setting, we need to develop innovative ways of doing better at prevention.
To give you an example, we are just starting a study to address diabetes better. That would certainly help in the rural setting a great deal. We need to do better at diagnosing diabetes. As you know, one third of diabetics do not know they have diabetes, and in rural areas it may take longer before they are picked up. If they do not see a physician often, complications may already have developed by the time they are diagnosed. Currently we are testing new ways of diagnosing early with some do-it-yourself tests in three provinces. The population would receive a kit, a questionnaire and a test to do themselves. You can detect whether you are a pre-diabetic, meaning whether you are at risk of becoming diabetic; then you are aware of it and can do some prevention early.
That is one of the studies we do in public health. These are interventions that would make a difference before you need dialysis. The answer needs to be looked at in its whole span of different interventions we can do.
Senator Mahovlich: Is it difficult to get volunteers to help senior citizens in rural areas?
Ms. DesMeules: As an example, our study indicated that there is a stronger sense of belonging; seniors, as well as the rest of the population in rural areas, can benefit from that. However, there is clearly a need to find ways to improve the social structures. Volunteers may be an answer to facilitate the connections in the community. I think you are highlighting a very promising area, but I also think you are right that there is probably more difficulty.
On the other hand, volunteering is not necessarily popular in the urban setting either. People are a bit more individual in their lives and communities. The community life may be a little less important for them as well.
The Chairman: Thank you very much. If we think of more questions, we will let you know.
The committee adjourned.