Proceedings of the Subcommittee on Population Health
Issue 1 - Evidence, February 22, 2007
OTTAWA, Thursday, February 22, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:46 a.m. to examine and report on the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chairman) in the chair.
[English]
The Chairman: There are a few senators still to come, but the time of our witness is extremely valuable. We want to get as much as we can in, so we will start now. We are deeply honoured to have the Honourable Monique Bégin here this morning, who is the Canadian Commissioner at World Health Organization. She has been involved in health for as long as I can remember, and has contributed so much to our country, including the Canada Health Act.
Ms. Bégin, please begin.
Hon. Monique Bégin, P.C., Commissioner, World Health Organization Commission on the Social Determinants of Health: Thank you very much for your generous introduction, Mr. Chairman.
I was going to say "colleagues," but I have never reached the level of the Senate. Members of the committee, I thought that for my first presentation on the topic I would use PowerPoint. I understand you have copies, and I will go more rapidly through some slides than others. There are 41 slides in total, but I will skip some of them.
I want to present the first scientific observations that led to the theory or the conceptual framework of the phrase we now use a lot, namely, "social determinants of health": where it comes from, its creation, and then the work of the World Health Organization Commission on the Social Determinants of Health, of which I am the only Canadian commissioner.
I made my presentation in English, but is it practical if I speak French at times? Mr. Chairman, please direct me. I have no problem if people interrupt and want to ask questions during my presentation, or is it preferable to do so at the end? What do you suggest?
The Chairman: As far as possible, we will try to let you make your presentation uninterrupted. However, if someone wishes to pinpoint something, they are certainly free to do so. We will reserve questions for the end as far as possible.
Ms. Bégin: As I could not figure out through your Internet site exactly what you were, I copied the mandate the way I found it on Google. This is the way I want to start.
I entitled this slide, "The "Classless" Society?" because all of us in North America think we are egalitarian — Canadians maybe even more than others. We hate the notion that we have social classes. I am a sociologist by training and I know that every society in the world has social classes. When I was Minister of National Health and Welfare, we would never speak of "poor people"; we would say "low income" or "socio-economic status." We masked the words to make them neutral and easier to digest so that they would not move us.
The British acknowledge that their society is a well-entrenched class system. They have a long tradition of research into this system. Two famous British studies — and some your witnesses will mention them in passing, as if everyone was born knowing their names — are the Black study and the Whitehall study. Sir Douglas Black was a physician with a great and important role in Great Britain. He did not interview people or follow individuals. He used existing statistical and other documents, and tracked patterns of inequalities of health across Britain. He made a recommendation and his report concluded that, despite the National Health Service, big inequalities still existed in Great Britain. It was so shocking to the then government that Mrs. Thatcher tried to suppress the report. It was not permitted to be published. It was finally published only in 1992, which is surprising in today's world.
The existing publication, which we can find easily, has an added section written by Margaret Whitehead in a book entitled The Great Divide. Margaret Whitehead was a great researcher into social determinants of health. Almost parallel to that, the chair of my international commission, Sir Michael Marmot, started a study called Whitehall, which is far better known than the Black report. Mr. Marmot studied a great number of civil servants. Whitehall is the name of the street and the buildings where they work. He divided them into social class groups or social professional groups and studied them. I will come back to that study in a minute.
The Black report stated that during the first 35 years of the National Health Service, there was definite improvement in health, but a correlation still existed between social class and infant mortality rates, life expectancies and inequalities in the use of medical services. Sir Douglas Black concluded that if the mortality rate of the wealthiest social classes had been applied throughout the population of Great Britain during 1970-72, 74,000 lives of people under age 75 would not have been lost. We have difficulty believing that, but it is a fact that I hope will be taken into account in the work of your committee.
Why should we use the Whitehall study? As I said, that study was undertaken separately. In the slide, the yellow text is for those of us who are laypersons. In terms of non-medical training, the general assumption, even today in the minds of many people, is that people with big jobs and big responsibilities have heart attacks. I say that in front of Dr. Keon, but that cliché is believed to be true by a great number of people in the population. That was the starting point of the study. If you read the Black reports you begin to wonder if that is true. That doubt was the starting hypothetical situation of Michael Marmot and his team.
We are not talking about soft science; we are talking about cardiovascular functions, smoking, and then some socio-economic data, for example, car ownership, angina, leisure, diabetes, et cetera. The study was a mix of solid economic indicators as well as solid health indicators.
Whitehall II is an ongoing longitudinal study that tracks a number of civil servants. The first conclusions of Whitehall II confirm conclusions in Whitehall I. That is, people at the bottom of the hierarchy have a higher risk of heart attacks, and the lower they are in the hierarchy, the higher the risk. The same applied to all the major causes of death, and I listed them in the slide. This shocking reality is backed by statistics — not only in the U.K. but also in Canada, where research shows the same thing.
Whitehall also observed that men and women with low job control have a higher risk. The importance of the psychosocial work environment — job stress, lack of skill utilization, tension, lack of clarity in tasks, household income and factors such as a socially cohesive neighbourhood or the opposite — are both positive and negative factors.
The next graph shows, "Long Spells of Sickness Absence by Grade." We see, age adjusted or fully adjusted, how people in low social professional jobs, people in lower positions, have a much higher absenteeism than people in the top category of employment.
Do socio-economic differences in mortality persist after retirement? That question was studied in a 25-year follow-up of civil servants from the first Whitehall study. Relative differences in mortality between low and high employment grades are less after retirement, suggesting the importance of work in generating inequalities in health.
On the lighter side, but still scientifically demonstrated, people with Ph.D.s live longer than those with a master's degree; those with master's live longer than those with bachelor degrees; and, going down the scale, those with bachelor's degrees live longer than those who left school early. Of course, there are always exceptions.
Similarly, actors who have won an Oscar will live on average three years longer than those who were nominated but missed out.
I have nothing about politicians and the results of electoral victories.
Senator Eggleton: Senators will definitely live longer.
Ms. Bégin: That is because senators have a clarity of task.
Sir Michael Marmot says that our health and longevity are influenced to a high degree on our social standing. Status, it seems, is more important than genetics. If we ask the question, the first basic question, of why some people live longer than others or are in better health than others, the vast majority of the population would have said genetics and biological endowment. Fundamentally, genetics is only one determinant of many other determinants: The sum total of the others is far more important. Status is more important than genetics, smoking or even money. Position in the hierarchy relates to how much control we have over our lives, and not just to have control but to perceive to have control. This means that if a clerical employee in a relatively modest job in an office — and that person will be a woman most of the time — has a clear definition of what she is expected to do, and has a good boss, good colleagues and a good working environment, that person will have a much better health score than one in a bad environment who does not know what is expected of her.
It is unbelievable how life around us influences our health, which has nothing to do with genetics.
I wish to speak now to inequality. Wilkinson, one of the great names in research on social determinants, argues that what matters most is not whether people have a smaller or larger home, or better or lesser care, but what these differences mean socially. I used life in an office as an example, but life in one's society is also fundamental, and what society makes people feel about themselves and the world around them.
The British have completed a lot of work in this field and this slide gives a chronological list of studies. I have extracted two concepts from those studies that I think are fundamental.
The gradient theory states that we know now that social classes or socio-economic status predict health status. One of your witnesses, Dr. Louise Lemyre of Institute of Population Health, has doctoral students who recently finished their Ph.D. theses on Canadian samples of people. The research confirms the theory of the five gradients, from the 20 per cent at the top of our social classes to the 20 per cent at the bottom and the three classes in between. At every different gradient we have a difference of quality of life and of health.
The conceptual framework itself, the social determinants of health, is the raison d'être of your work.
I want to add a personal observation. All the years I was in health and welfare, I remember signing and protecting the budget of many projects on — at the time, a subject called health promotion and disease prevention — basically health promotion. I liked those community-based projects that delivered good things different from what the health care system delivered.
However, I always worried how all of that work fit together with the health care system. At the time, we did not have a conceptual framework explaining it. From health promotion, it seemed to me that slowly we moved to population health, using epidemiology to inform us. From population health we moved to the social determinants of health. For the first time, from the work to put together these various socio-economic factors and some health indicators, I could see where these health promotion projects were supposed to fit.
I will keep slide 37 for later.
I will give more history, but Canadian history this time. In Canada, when did we start talking of social determinants? I never heard the words "social determinants" in the eight years I was in the Ministry of National Health and Welfare, and today I still see many people who do not understand what the words mean. "Determinants" is not as clear as "factors," for example.
We can trace "ancestor" to the so-called Lalonde report in 1974, which was known worldwide. I still hear about the report regularly, which was not written by Marc Lalonde but by others: I want civil servants to be recognized when they do great work.
The report started putting things together. However, if you have Sholom Glouberman or Dennis Raphael as witnesses, they will both tell you how bad that framework was, because in today's knowledge we see that what was extracted from the Lalonde report was the box called lifestyle. We had all those health promotion projects, but lifestyle, which is do not smoke, engage in physical activity, eat well, et cetera, are all individual behaviours. They mask societal and collective behaviours. Social determinants tell us that besides lifestyle and individual behaviour that must be "corrected," far more determinants are societal in nature and do not have much to do directly with the ministry of health. Although the word "environment" appears in the box, at the time we did not pay much attention to it. In fact, it took almost 25 years to see some movement on societal factors.
Jake Epp succeeded me in health and welfare. He was the minister when the Ottawa Charter for Health Promotion was launched. Perhaps the people at the Public Health Agency of Canada can give you the exact reference; I discovered it too late to put it in my presentation.
Jake Epp's report is a milestone as well. The report entitled Achieving Health for All was launched at the same time as the Ottawa charter. I thought they were one and the same but they are not. The Epp report is their way of expressing the social determinants of health. It is interesting to see how the report moves on from the Lalonde report. It adds things such as creating supportive environments, reorienting health services and developing personal skills. We can see a beginning of the model.
Dr. Fraser Mustard, a great Canadian, then conceptualized the social determinants — and I was on the same committee when he presented it — in about 1989-90. Again, factors include not only the biological endowment and individual responses but also the social environment. The framework is still not complete but we are getting there.
Then there is Margaret Whitehead. She came to Canada to present last year, and I had the great pleasure of hearing her. There is also Dr. Gören Dahlgren, who I do not know. I use the model developed by Dahlgren and Whitehead a lot because it is a simple one. It goes by layers and is not from one individual but from several. It explains how inequalities are the result of various layers.
There are numerous other models. Dr. Louise Bouchard of the Institute of Population Health of the University of Ottawa is an expert on all the conceptual frameworks that have been developed. I like the Dahlgren and Whitehead model because I have spoken of Great Britain up to now, but what about between countries or within countries? I took this example. If one catches the train in downtown Washington to a suburb in Maryland, life expectancy is 57 years if one lives in downtown Washington at the beginning of the journey. At the end of the journey in the suburbs, life expectancy is 77 years. That is a 20-year difference between the poor, predominantly African-Americans of downtown Washington and the predominantly wealthy suburbs around the capital of the United States.
The next slide from down south indicates the probability of survival from age 15 to 65 years among U.S. Black and White males. The light green and the yellow represent the total population of White males or Black males, and the poor are represented by the two other darker boxes.
This next slide shows trends after the implosion of the USSR. Immediately following the implosion of the USSR, the society was differentiated into social classes in a special way — not that there were no elites of people before, but now socio-economic classes are far more differentiated. With a university degree, we see immediately how the trend towards longer life expectancy rises in comparison to those with only an elementary education.
Differences also exist between countries: this slide shows the probability of dying between age 15 and 60 in different countries. Look at Lesotho and Russia. Russia should have indicators as good as our country but it does not. It is damaged. Look at Sri Lanka. It is not a particularly rich country, but is has a relatively good marker. The father of independence and the first President of Sri Lanka immediately made education mandatory for all, including girls, with no user fees. In Africa, user fees for the elementary school level exist for many schools today and are a deterrent, even if we speak of relatively little money. The great success of Sri Lanka, in comparison to India, which is far richer today but has much worse indicators, is attributed to universal education that is mandatory for all. Things follow education such as much better family planning control, et cetera.
Another indicator is the "Under 5 Mortality Rate per 1,000 Live Births." The slide shows Sierra Leone, one of the poorest countries in the world; Sri Lanka again with a good indicator; and Iceland at the top. This information comes from UNICEF and it is based on the UNICEF administrative regions. It has a story to tell. The story is that inequities between countries are growing. In blue, we have 15 years ago; in red, we have five years ago. Yes, there is a decline in those 10 years. The size of the decline, however, is shocking. The poorest countries, namely Sub-Saharan Africa followed by parts of South Asia, have a smaller reduction than the industrialized word — that is, Europe, North America, Japan and Australia: the Organisation for Economic Co-operation and Development, OECD, countries, basically — where the difference is 32 per cent. This situation is the opposite of what we should aim for. The change for the poorest countries appears to be peanuts when compared to other countries.
I will now talk about the commission, of which I am a member. It was created in March 2005. We should finish our work by April or May 2008. The commission is independent from the World Health Organization. We are supported by WHO to an extent, and by contributions of some countries, additional to their annual contribution as members of WHO.
We have 19 members now. We have a small secretariat in Geneva and smaller scientific team in London with Michael Marmot. We meet in person about three or four times a year. The next meeting of the commission is in Vancouver on June 7, 8 and 9. We usually meet outside of Geneva, with the theory that social change takes work both from the bottom up and from the top down. We need the two elements for change to occur, so we usually meet with top government people, for example, presidents, prime ministers, some ministers, and so on. We do some field observation. For example, in July we stayed almost a day in one of the worst urban slums of the world, Kibera in downtown in Nairobi.
With respect to the four pillars of our work, for the first time, the world commission has included civil society. They come to our meetings, they have regional consultations and they report their viewpoint on how to bring about social change. Their viewpoint is important, a viewpoint which is far from being captured by all official statistics and reports from everywhere.
We have the civil society. We have started to engage other countries into adopting social determinants of health. You will explore that more with the Canadian government.
The big international players are another one of our pillars. How do we move the World Bank, if their policies are not acceptable? They inflicted great damage on health and education all over the developed world, but they seem to have moved away from that approach of the 1990s.
With respect to value, the commission uses an official description of what we are supposed to do. We are also supposed to discuss health inequality and health inequity, which are two different concepts. I adapted those definitions from several different readings. Health inequality is something nobody should question because it comes from an observable and often measurable difference in health status among individuals and among subgroups or groups in society, whatever its cause.
I call health inequity a "moral category" because it has to do with choice. One can observe health inequality and put it on the shelf. Then one can decide, after having observed health inequality, to move and do something. That is the role of any government, and that is why I described it as a choice. It is a moral category rooted in social stratification that is embedded in political reality and the negotiations of social power relations. There is no way we can hide from that.
I like the definition of "health equity" as "the absence of unfair or unavoidable or remediable differences in health among populations or groups defined socially, economically, demographically or geographically."
Our knowledge networks are teams of researchers who competed at the beginning of the commission to be included. The commissioners had nothing to do with choosing these teams. It was a bureaucratic process of the WHO secretariat, and advertisement was directed at whoever wanted to take on research for the commission. Eight knowledge networks were chosen. They are academic, and unfortunately, they are from countries in the north, which is normal, but the teams were required to add people from countries of the south, including people from civil society.
One of the knowledge networks is entitled "Social Exclusion." From discussions with some First Nations in Canada, I quickly realized that our own Aboriginal population refused to be lumped together into the category of social exclusion. They say the roots of their marginalization are unique, and they have a point. However, you will certainly want to explore that because if there is one pocket of Canadian society that experiences inequality of health status, it is the Aboriginal people.
I worked on that issue as much as I could. With my colleague from Australia, who did a tremendous job, we organized a first meeting last September and an important conference at the end of this April for people who have similarities in context, history and so forth, namely, Aboriginals of Canada, Australia and New Zealand. I want to undo the polarization in Canadian society as much as we can. I am struck by the strong adversarial relationship between Aboriginals and the Canadian population in general, with many misunderstandings on both sides.
Aboriginal people in Canada will have a chance to form alliances with others who live in similar situations. Although neither the situation in South America nor that of the Aboriginals in India is the same, there are many similarities between the Aboriginals of those three countries, Canada, New Zealand and Australia. The conference will be in Adelaide, Australia, at the end of April, and a few Aboriginals, will join probably from the United States, where contacts have been made, and South America. The group is relatively small budget-wise, and the job I gave my own friends in Canada is, if you are not comfortable with being labelled "cases of social exclusion," tell us why. Of course, the answer is self-determination, and I say, "Self-determination is a political word, and it is loaded. Tell me what the roots are behind the need for it."
Of course, when we say "self-determination" in Canada, we go crazy because we think of Quebec, and the word does not mean that at all for the Aboriginals. What is behind their quest is enough identity to feel good and be of the best health, if I can sum it up that way.
Then I want to ensure that our commission does not suffer what Alma-Ata did, which is a great milestone in WHO history. In 1978, Joyce Fairbairn was the one giving permission in the Prime Minister's office, and she forbade me to go to the conference where the Declaration of Alma-Ata was adopted. She is not here today because I am still a bit angry. Alma-Ata is a major milestone where the idea of health for all by the year 2000 was launched, which, of course, has never been reached. Basically, the conference emphasized primary health care. The northern countries ganged up behind the scenes after the Alma-Ata conference and decided that they had a high-tech medical health care system and did not need primary health care because it was for the poor. Primary health care should not be for the poor, it should be for all of us. I do not want that division to happen. I want to ensure that our report speaks equally to both northern and southern countries, although the situation in the southern countries is shocking in terms of poor social determinants of health.
I entitled a presentation I gave last June in Vancouver, "Canada is the country of pilot projects." I briefly touched on that topic earlier. Over the years — in fact, to this day — we have signed approvals and budgets for so many pilot projects on social determinants of health that it is unreal. Some projects have been evaluated; some have not. They have never been translated into policies and programs. The projects are a one-shot affair. I do not think I am being unfair here, because I hesitated, and waited many years, to say that. Since I have said it, people have stopped me in public health meetings to tell me that it is true. There is something wrong there. I speak about other things, too, for example, gender.
At the first meeting of the commission in Santiago, Chile, there was no knowledge network on women, so we forced one. I still remember the face of our Chair, Sir Michael Marmot. It was his first meeting and he had never been in groups other than academic, scientific or medical ones. He said, "You mean gender." I shouted, "No, I mean women." The official title, however, is gender.
This slide shows the knowledge networks, and their goal in the middle. The one in green represents the knowledge network. The knowledge networks are not undertaking new research as there is neither the money nor the time for that. They collect all evidence-based and quality-based research, including qualitative research work. They analyze and synthesize it and then give us recommendations. They will publish a lot in the coming months. Their final reports to us are due this March or April. They will be a source that you may want to explore.
Our medicare system, for example, is only one social determinant of health in Canada. Globalization and how it affects health, employment conditions, social exclusion and urban settings — that is, not only the existence of urban slums but also the growth of urban slums, which is absolutely unbelievable — are other determinants. I do not know what kind of recommendation we will make, but I will give you an example of what happened in Nairobi. We spent three hours with their young Minister of Finance. Not lacking in self-esteem, he told us not only that Kenya would continue to grow but also that as soon as it reached 7 per cent growth in GDP in two years, there would be no poverty left in Kenya. I do not know where he lives, but that theory is the trickle-down effect of the World Bank. The trickle-down never reached the poor. It created a middle class but it never reached the poor, who are much more numerous. Their finance minister wants to demolish completely that urban slum of 600,000 people and relocate them far away in new suburbs and provide them with public housing. However, that slum is only one of at least three in Nairobi.
Senator Pépin, you are also from Montreal. Montreal tried to do that with its downtown slums some decades ago and it was a complete failure. We know that public housing is never offered in the quantity needed. It is never ready when the demolition takes place and then we have broken the social fabric of these people. Even if it looks awful, it is obvious that there is a social organization. The modest but remarkable projects we witnessed in Ahmrabad, the city of Ghandi north of Mumbai, in India, when we had our meeting there, are projects under something called the Self Employed Women's Association, SEWA. I thought we would see some small family businesses, but we saw associations of women rag pickers, women street vendors, and so on, who were organized and received their training at the Coady International Institute at St. Francis Xavier University. It is wonderful to hear the good that association does.
We are talking about the most vulnerable and the poorest of the poor, who are living in incredible slums, and villages that are a little better but not much. True co-op concepts, union concepts and Ghandi principles have a bottom-up approach that tries to change their lot. They do succeed. There are things to do, but they must mobilize locally. It is extraordinary to see that.
Three knowledge networks are funded by Canada. Two of them are Canadian networks. Early Childhood Development is managed by Dr. Clyde Hertzman — I suppose he will be one of your witnesses; Globalization and Health is the responsibility of Dr. Ron Labonte here in Ottawa at the Institute of Population Health; and the health systems are guided by a South Africa team of researchers with others, of course, but it is funded through the International Development Research Centre, IDRC.
I will finish by borrowing a statement from Professor David Gordon, University of Bristol in the U.K. Roy Romanow was accused that his report spoke only of medicare and not of anything else, especially social determinants. Mr. Romanow then did his homework and adapted this list from David Gordon's work. I think he makes his statement in a way that speaks easily to people: Pick your parents; do not be poor; get a good start in life; graduate from high school; get a job; pick your community; live in quality housing; and look after yourself.
I will finish with this slide. I have many pictures of the slums that I saw but the commission is about this: Social determinants, for any country or any province, is about "What good does it do to treat people's illnesses" — at which we are becoming better by the day, at a huge cost — "then send them back to the conditions that made them sick?"
The Chairman: Thank you very much indeed for enlightening us with this tremendous presentation.
As we move through our hearings, we want to establish what we have on the ground in Canada and then compare successes and failures with other countries of the world. Before I throw the discussion open to the committee, from your observations so far, what examples do you think we could use? Sweden seems successful, as usual, and, of course, there are dismal failures in Sub-Saharan Africa.
Ms. Bégin: I will share with you some personal thoughts on this topic. For all the years I was in National Health and Welfare Canada, Sweden was the perfect country and I was a bit annoyed by it. However, since working in this commission I have realized that all the indicators of the almost ideal situation are present in the Nordic countries, not only Sweden, as a block with some minor variations.
For years, when speaking in the United States about medicare or the health care system, I would start by saying, "Canada is the Sweden of the Americas." I was sure of myself because I had always heard when I was minister how great we were. I remember working with Senator Callbeck when she was Minister of Social Affairs of P.E.I. I was also minister of welfare so I knew social security as well. We always speak of our safety net. I said that in honesty. Recently, I checked the April 2006 report of OECD on the percentage of total expenditures on what can be called social security in countries of the North, including in the first column what we would call social welfare — social assistance and social services. There we have unemployment, education, training, and one or two more categories. Health is not in that report.
Health Canada for years has found itself in the five countries at the top of the pack in the percentage of total expenditures on health, private and public. We are below or around ten per cent of GDP. One year, we may be second or third. These countries are France, Switzerland, Sweden, Germany and then us. Everyone accepts the United States at 15 per cent, and it does not have a health system; it has a patchwork.
That is our situation. I assumed we would be in the same kind of ranking when it comes to social spending or social security in the broad sense. When studying these columns of figures, I decided not to use education or unemployment insurance because every country is average, so I concentrated on the social security system, meaning social services and welfare assistance, what we call social security usually. To my shock, Canada is just above the United States as the worst of all the western world countries. I did not know we were that cheap.
What triggered my personal research was a text I discovered from Dr. Carolyn Tuohy, the Vice-President of Research at the University of Toronto, a political scientist of great reputation. One of her books from at least ten years ago, which I discovered recently, asks a key question: Why has Canada been so generous towards its health care system, et cetera, and so cheap and mean historically vis-à-vis social security? I thought she did not know what she was talking about. I was insulted. However, I realized that she knew what she was talking about and I did not.
I know that the term "welfare state" has become almost a dirty word for the past 25 years in terms of ideologies. I know that programs did not deliver what was expected. In general, welfare programs were cut dramatically in many countries, including ours. However, I learned through the commission of recent new research taking place right now that is looking at a correlation between good workable so-called welfare programs and the best health outcomes. I think welfare is going in that direction. I am answering your question in terms of where my personal quest is taking me right now. I have identified the Nordic countries. Second, there is the U.K., where the outcomes are only starting to be a little better. The U.K. has done tremendous work on social determinants of health. Canada is working with the U.K. in that area. The Public Health Agency has developed workable so-called inter-sectorial approaches, because there is almost no point talking to a minister of health of social determinants of health because every department functions in a silo. There are millions of inter-departmental committees. I was on the committees as a civil servant and as a minister. In general, I am sorry to say they do not deliver. There is no power to deliver. They speak a lot but do not deliver.
We need inter-sectorial mechanisms, which are often called whole-of-government approaches, that will go horizontally across the ministries needed to work together.
Senator Eggleton: This meeting is our first. I want to recognize you, Mr. Chairman, for having launched us on this journey. It will be most interesting and I hope the study and the results that come from it will be productive for the people of Canada ultimately. I am excited about what I am hearing so far.
Madam Commissioner, professor, thank you for coming and sharing your vast knowledge with us on this subject to get us off to a good start.
In your slide presentation, the Whitehall I and Whitehall II studies in the U.K., slides seven and nine appear to be contradictory. Slide seven reads:
The general assumption was that individuals with big jobs and big responsibilities are those prone to cardiac accidents.
On page nine it reads:
People at the bottom of the hierarchy had a higher risk of heart attacks. The lower you were in the hierarchy, the higher the risk.
The first message suggests that stress is a big issue; the second one indicates the issue is poverty. Can you comment on those differences?
Ms. Bégin: I developed my slides from different documents I work with and I am sorry if I am not clear. It is obvious I have not been clear.
Michael Marmot and his team started with the general assumption that individuals with big jobs have heart attacks: That was the hypothesis. Their study showed the opposite. That is what I did not express clearly. The study showed that it is people at the bottom in small jobs that have — I am lost in my slides now.
Senator Eggleton: Seven and nine are the two slides.
Ms. Bégin: Yes, that is it.
Senator Eggleton: They started with one assumption and the study found something else.
Ms. Bégin: The first assumption is still repeated regularly by many people who do not know. It is a cliché. We say that and we really think that.
Senator Eggleton: It is a popular belief, yes
Ms. Bégin: That is it.
Senator Eggleton: There is a wide range of social determinants: education, working conditions, the physical environment, income and social status, all of these things. However, having listened to your presentation and having gone through the materials, if I had to sum up in one word what the biggest single determinant is, I would say poverty. Perhaps I am stating the obvious or maybe it is not that easy to put into one word, but I would like your comment about that. Also, do you have a hierarchy of determinants?
Ms. Bégin: I was afraid somebody would ask me that.
Senator Eggleton: Sorry.
Ms. Bégin: I asked that myself, in terms of our recommendations. We do not want 300 recommendations that everyone forgets, so how do we prioritize?
I do not have an answer in terms of the relative importance. I am the daughter of an engineer so part of my mind asks if we have one engine powerful enough to start the others and put things into motion but I do not know which determinant it is.
I have also been a teacher in my life so there are days when I think that early childhood development is a key investment, even before poverty, because it crosses all social classes, and in a way it can negate the effects of poor social class. However, I do not know if a hierarchy exists and you will speak to researchers on that who will know more than me.
I sent a recent text by Michael Marmot to your chair. It was published in The Lancet and tries to conceptualize the link between all the various social determinants. Poverty is the one I think of first, but if I do that, I negate that something can be started immediately. That is why I think of early childhood development.
Historically, free universal education has been extraordinary. The president of Kenya told us himself in July that, almost two years ago, he suddenly abolished user fees for primary education. That September, a million and a half additional kids registered in school, mostly girls. That tells us a lot.
The Minister of Health in Kenya is a colleague of mine in the commission and we visited the community clinic. It was modest, dirty and tiny in the slums of Kibera. People pay for community clinics, which include maternal health, reproductive health and all of that; they must pay a user fee. I did not like the Minister of Finance of that country and I told her to consider that it costs more to collect the user fees than it brings to the treasury. It is a deterrent, even if, for us, it looks like peanuts. All those questions come to mind and I do not know the answer.
In Canada, I asked myself when I started, where are the poorest of the poor? I am talking poor health outcomes that are avoidable. Of course, it is First Nations Aboriginal health. It is in pockets of urban poverty across the country and, of course, those pockets are now invisible. They are not like Kibera. They are totally invisible. We do not want to think of it.
I think there are pockets in rural parts of the country, but I am not familiar enough with that so I cannot answer you.
Senator Eggleton: Do you have time for one more question?
Ms. Bégin: May I say one thing? Historically, we were told several times that investing in women — that is a terrible expression — but investing in programs, education, et cetera, have made social changes in many parts of the world.
Senator Eggleton: Both you and I have served at the cabinet table: you in the Trudeau government and myself in the Chrétien government. My first portfolio in the Chrétien government was the Treasury Board. I went in thinking I would create horizontal links across departments. I think I was as frustrated as anyone else who has attempted to do that. As you commented in your opening presentation, the system is a silo one here, which is advanced also by the Parliamentary tradition of ministerial accountability. It strikes me that it is one of the difficult things to do, but it must be done to deal with these wide ranges of determinants —
Ms. Bégin: I could not agree more.
Senator Eggleton: Silos must be dealt with because the health department does not do social services or education; social determinants of health are all over the place. They are not only at the federal level, but at the provincial level as well.
Do you have any further wisdom as to how we might overcome that?
Ms. Bégin: I think you may want to speak with Morris Rosenberg, Deputy Minister of Health Canada, who chairs a committee of deputy ministers that could be called ministers of social determinants, if I understand correctly. That format did not exist in my time. That is one possibility.
I think you have already invited Dr. Sylvie Stachenko, who is one of the number twos of the Public Health Agency of Canada. The public health agency, if I remember well, together with the U.K. and Sweden is working on a project of identifying the best intersectoral approaches. You may want to contact Dr. Stachenko and Mr. Rosenberg. They may be of some help.
Senator Nancy Ruth: With respect to these two diagrams, my question is around the place of race.
Ms. Bégin: Yes, that is well said. We speak of it all the time but we did not identify it as a social determinant of health. It is one of the key factors behind the expression, "social exclusion." A remarkable team is in charge of that knowledge network. In our work, I would say almost that the most important factor of social exclusion is race. However we did not write these words. They were presented to us.
Senator Nancy Ruth: Gender does not exist in this network?
Ms. Bégin: Absolutely.
Senator Nancy Ruth: I am so sorry.
Ms. Bégin: We forced the creation of that network because it could have been buried under social exclusion, and that is wrong because it would have included so many huge subgroups of the population. The commission is definitely extremely sensitive. Race applies to the Canada of today, by the way, as a socially negative or positive determinant of health.
Senator Nancy Ruth: In the Whitehall and Black studies, can I assume in the Black studies, which was the earlier study and the research covered all of Britain, that the study dealt with race?
Ms. Bégin: I do not recall.
Senator Nancy Ruth: In the Whitehall study of male civil servants 20 years ago, would the subjects have been predominantly white?
Ms. Bégin: Whitehall also has women in it. I am sorry, I do not recall right now.
Senator Nancy Ruth: Would the Canadian Women's Health Network have anything to contribute to this study on population health, in your opinion?
Ms. Bégin: The so-called health systems knowledge network from South Africa is headed by two women professors, and they have worked constantly with the knowledge networks on globalization and women and gender, the three together. I do not know how to explain that interaction. It will show through their various reports that will come out in a few months. I can only assure you that the answer is yes.
Senator Nancy Ruth: I was curious, in the Vancouver meeting in June, is it possible for two or three of us to observe your meeting?
The Chairman: We will discuss that in camera.
Ms. Bégin: I would love to have people of civil society from here and from there, now that we are in Canada. By the way, the accent will be on Aboriginal health, and on aging also. A piece was done for us by the Americans on aging, but other discussions will be held as well.
I would love it.
Senator Nancy Ruth: Besides knowing how to change the World Bank, I have one more question. I was in Colombia in November and they told me that $30 million is transferred from North America to Colombia, and it effectively pays for health care and education. In the study that your group is doing, will you deal with the issue of remittances from new Canadians, back to their countries of origin?
Ms. Bégin: I am not sure I understand.
Senator Nancy Ruth: Remittances are monies sent back by, say, a new Canadian, from Colombia, to their family there, which are used for health and education. It seemed like a lot of the health and education system was being funded by our economics.
Ms. Bégin: I am almost sure that Ron Labonte and Ted Schrecker who head the Knowledge Network on globalization have that information. I am reading so many things at once that I do not recall the source. It is covered. This is just the first presentation. Maybe you want to speak to me later on when we have done more work.
[Translation]
Senator Pépin: You tell us to make a distinction between health inequality and inequity. Does it mean that in choosing a population health approach we should make the commitment to develop a social justice dimension in our report?
Ms. Bégin: This is going to put me even more in hot water since this is a question of choice. Inequality, as I defined it after various documents and readings, is a reality of life that is measurable, observable and backed by evidence.
Once inequality has been observed, people have to decide whether it ends there or whether they want to move and do something. It is as simple as that. Your committee will decide. And this choice is fundamental, an individual choice, a choice by the committee in this case, a choice by government. This is why I call it a moral category. In my view, it is of no use to study inequalities if this effort does not lead to valuable conclusions.
In recent years, I think we have witnessed a historical movement initiated by the powerful people of this world — including the private sector, people like Bill Gates and others — such as the World Bank and the G8.
They are going to discuss Africa, but the Millennium Development Goals Report has created a movement requiring the United Nations to reach eight goals, and we signed this document. The focus is on development, but there is no development without health and no health without development. Also, Jeff Sax, a great economist, is the author of the Sax Report on Health and Development for the World Health Organization.
However, you will decide by yourselves. We found that he focussed more on the link between poverty and health. We preferred to broaden the definition of health rather than restricting it to its medical aspect. In any case, those are fundamental studies that you would probably want to examine.
Senator Pépin: Medical health comes to mind first when we discuss the subject of health, but we have to adopt a broader view in order to deal with population health, and take global actions.
Ms. Bégin: It remains a matter of choice, but I have made mine.
[English]
Senator Munson: Good afternoon. Being in the Senate is an education every hour. This report is fascinating.
I was struck by your last slide, "What good does it do to treat people's illnesses, then send them back to the conditions that made them sick?" I was struck by what Senator Eggleton said about silos versus horizontal links.
As a reporter, I covered and wrote the story on Davis Inlet. I thought I was doing something to sensitize Canadians to a people's cry and anguish. There were different kinds of sickness, from children sniffing gas to psychological illnesses to isolation. Yet, as a society, we fast-forward about ten years and we move these people to another place on the mainland in Labrador. They are not on an island. It seems to me we are treating the situation in silos, because we now see the same things happen again.
I feel that, as governments and as a society, we failed again because we still are not using the holistic approach to address what is happening in our isolated communities. Do you have any views on that, and any recommendations on how we treat that sort of thing? It is bigger than the one picture of a child sniffing gas.
Ms. Bégin: Yes, I saw that situation in Winnipeg when I was minister. We dealt with pharmacists at the time, and asked them to put all the hair products, and others, on much higher shelves: those products that Aboriginal kids in downtown Winnipeg were sniffing.
One word of what you said remains with me as a critical challenge in Canada. You said, "I thought I was doing something to sensitize" the readers to situations x, y, and z.
The situations described are not the usual cancer or obvious medical situations. They are health situations but they are not captured when we speak of medicare.
For me, a major challenge in Canada is to make the public take ownership: understand, believe and take ownership of a situation of poverty and social exclusion that is unacceptable in one of the richest countries of the world.
When we took the train from Ottawa to Montreal, we used to go through St. Henri. I have been both a student and a teacher there. St. Henri was an extremely poor district of Montreal. It is almost completely gentrified now. Senator Eggleton, you have been mayor of Toronto. You know how we pushed public housing out of Jane and Finch, or wherever. We gentrified the downtown. We do not see poverty. Canadians do not want to know that there is poverty.
I will be even more critical, if I may. I will say that we did a great service to all Canadians by putting our fiscal financial house in order in 1995. We had to do it but there is no doubt that we did it on the backs of the poor. I am sorry but it is crystal clear. All the payments that disappeared, were cut or reduced were in social assistance. Someone will say, it was not us, it was the provinces. It was us.
Senator Munson: In terms of my question, is there a better approach to dealing with this kind of issue? If there was a decade of darkness in 1995, the decade of darkness was on the backs of the poor, not on the military. I am talking about today.
Ms. Bégin: I would be Prime Minister if I knew the answer. I am sorry. I think you should ask those who know the concrete ways of today's world. I have been in charge of the health of First Nations and Inuit for eight years. At the time, we did not recognize Metis populations. Of course, the isolation and economic situation is what stops us. It is the first barrier. We do not know what can be done to help.
I wanted to have Inuit and Aboriginal, First Nations, health professionals of all kinds. The last legislation I tabled and won in the House of Commons, in June 1984, was the Indian and Inuit health carrier programs. Now we have physicians, for example, Dr. Jeff Redding, who heads the Institute for Aboriginal People's Health of the Canadian Institutes of Health Research. We have wonderful people — not enough, but it has started. I am only talking health. These people are all open to social determinants because they know.
I am sorry, senator, I do not know the practical, concrete, operational answer of what to do.
Senator Munson: I guess we have a job to do.
Senator Cook: Thank you for coming again. We will look for the benefit of your wisdom as we ponder the population health.
I turn to the issue of Aboriginal health, which preoccupies me. I am always searching. Senator Munson talks about Davis Inlet. Senator Munson, you may not know the history of Davis Inlet but one day Dr. Padden found a group of Inuit on the high land on the Torngat Mountains and they were riddled with tuberculosis. Dr. Padden brought them to the island and that was the evolution of the nomads of the Torngat. He put them there and no one taught them how to live in a new environment. They were on an island, for goodness sakes, with no interaction with anyone. It was for the benefit of the greater good: tuberculosis was the problem.
When the federal government built the "new tomorrow" for the same people, no one gave them any life skills once again. The government put them in modern homes, with bathrooms, washers, driers, all the modern conveniences and furnaces instead of stoves. I asked repeatedly at home, why? Community health workers and social workers told me that they begged government to send in groups of people to teach them the fundamentals of living in this new environment: a house with a furnace, stove and bathroom.
Somehow, we need to meet those people we care about, and say, "tell me what you need" or have the wisdom to see what is best and work together with them. We are not doing it. We are doing this to them.
I can fast-forward to a community of Mi'kmaq in the Bay d'Espoir area, which is a model community. They have a wonderful education system and good leadership there, but health services are delivered by a nurse practitioner. A Mi'kmaq nurse, who saw the need for her community, went to Dalhousie University. It is a success story. I do not think we know how to listen.
If we go to the fundamentals, I am getting older and more philosophical, it is poverty of spirit. You helped us through that journey of the Aboriginal people in New Zealand, with primary health. Then we went into the mental health, and we embraced some of the practices the Aboriginal people used along the road to wellness. Is that approach a silo? Who knows?
It seems we are always telling the other group what is best for them and we are not listening. How do we move that silo out of the way?
In my own province now, the social workers are so overworked they are on stress leave. They have cannot cope with what is happening in a population plagued with out-migration, the downturn in the fishery and all the rest of it. There does not seem to be any movement. I am sure if you went over to the psychiatric wards, the mental health, you would find the same thing. Is it budgets? Is it turf wars? What is it that is —
Ms. Bégin: It is power.
Senator Cook: How do you disseminate it?
Ms. Bégin: I started with the women's movement way back but now I am seeing it in development and aid. The local people need help with techniques and so on, but they should be in charge of their future.
I am on the council of the Canadian Population Health Initiative. We funded research by Chris Lalonde from the west on Aboriginal communities in B.C., and now he is doing research in Manitoba, and where Aboriginal people have started to take over their own governance, things change for the better. The number of suicides has declined. It is remarkable.
Things are visible and it is good you mentioned a success story because we all need to see a few of them. It is feasible.
Senator Cook: I can share with you only my experiences and where I live. About 15 years ago, we started a modest breakfast and lunch program out of our church for a couple of our intercity schools. We were inclusive.
An envelope went home with the menu, with coupons in it, and every child in the school received it. No one knew who paid, and it worked. Today the program is a foundation sponsored by Hibernia. It is a success story. We started out and said, we will send it to everyone. The interesting thing is, enough money came back that we could always buy the groceries for whoever wanted breakfast. These measures you have to —
Ms. Bégin: That program changed the life of kids, I am absolutely sure.
Senator Cook: Yes, it will. We are thousands of people now in that foundation.
Ms. Bégin: You cannot learn with an empty stomach. It is simple.
Senator Cook: How to find the wisdom to break down the silos if a society —
Ms. Bégin: I should not say that because it looks bad, but I will. When we created the child tax credit — which is now another name and is a huge help, or should be — in 1978, I had a fit when I discovered that the group who opposed it was an organization of social workers. I was shocked, but as a sociologist I should have known better. The money went directly to the mothers, so it was not going through their power relationship over the mother, if I may put it negatively.
Senator Cook: Who knows best?
Ms. Bégin: That is it.
Senator Cook: How do we meet basic human needs? We are back to it every time we start a study in social services.
Ms. Bégin: That movement I mentioned in India, which is becoming well known — it is made up of a million women, members of only the most vulnerable. It is in the state of Gujarat. It has not spread that much more in India. Other similar initiatives exist in India, and the power of the local people is unbelievable when they are helped to organize and do their things.
The Chairman: Before you go, Senator Munson, this is such an incredibly important point. It is one that will permeate our hearings and our report when it comes out.
When we walked through the mental health report, we found that people with mental illness need community: community facilities they could find, people they knew, peers that would help them do their banking and people who would drive them if they did not have a driver's licence. I have been convinced for a long time that we made a terrible mistake in health care in Canada in building many monuments and no community facilities. That is why we have no access.
You have been there, done it; you were a minister of health. In fact, you helped fund my monument when you were minister. What is your comment on that? Then Senator Munson will come in.
Ms. Bégin: May I use the opportunity to say how well received the report of your committee on mental health has been and is all over Canada. Everyone is so pleased that you said in it what you said as a committee.
The top cannot decide what the bottom wants, et cetera. They can only empower and enable them. They can be facilitator, but that does not come from big governments down. There are approaches. Some have worked and are working, but we need a specific orientation and we need to stick to it.
Senator Munson: The two are power and empowerment, right?
Ms. Bégin: At that time, you were the power. If you governed me, you were the power.
Senator Munson: I did not listen enough, I do not think. When I was a reporter, I asked a lot of questions but now as a senator I have to do my homework.
You talked about Mumbai and the Coady International Institute, and I am curious about that. This country needs more Coady institutes, because the poorest of the poor outside of Mumbai in India can be empowered, do we have programs — it might be a naive question — of training and empowering people to take control of their own lives, with impoverished areas in this country?
Ms. Bégin: I no longer know what exists in the general field of community development, I am sorry. I do not know which programs eventually help.
Back to the Coady International Institute, I would say that the vast majority of Canadians have never heard that word, and do not remember Father Coady, the Great Depression and the birth of the co-op movement in English Canada.
I was thrilled to see that today they train, in French we would say animateurs and animatrices, for all those movements in many countries of the Third World. I find that extraordinary.
I suppose some of them, such as the travelling expenses and hospitality expenses, are paid for by the Canadian International Development Agency, CIDA. There must be links, but I no longer know the state of affairs, either domestically or internationally. I am merely signalling the good work they do.
Senator Munson: It is a good model.
Ms. Bégin: One of the five so-called collaborating centres — I hope it is not one more pilot project — and I am not even sure if it is the Public Health Agency of Canada, Health Canada or both, the one entitled Social Determinants of Health, is based at St. Francis Xavier University. The collaborating centre, the academic part and all that are based at St. Francis Xavier University, which is where the Coady International Institute is.
The Chairman: Thank you so much. This presentation has been a real enlightenment for our committee and a wonderful place to start. We are deeply indebted to you. I am afraid we will be back.
Honourable senators, we will go in camera for a few minutes to talk about our work plan.
The committee continued in camera.