Proceedings of the Subcommittee on Population Health
Issue 2 - Evidence, March 28, 2007
OTTAWA, Wednesday, March 28, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:21 p.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: Honourable senators, we are truly privileged today to have outstanding witnesses with us who have given their time to come and educate us and help us along our way to getting this study done. We will begin with Dr. John Lynch who is a Canada Research Chair in Population Health from McGill University.
Please proceed.
Dr. John Lynch, Canada Research Chair in Population Health, McGill University: Thank you very much for the invitation to appear before you. I am a public health scientist and epidemiologist. I am not a policy expert nor am I a policy advocate. My comments come from someone who has worked in the field trying to determine the most effective interventions to improve population health.
I think everyone agrees that social conditions in general affect health. Factors such as education, income, housing and working conditions may affect most but not all health outcomes. Why is that important? It is important to know that they do not affect all health outcomes because that means there is nothing inevitable about those things, that they can potentially be changed.
I would suggest that policy frameworks exist to build a coherent and comprehensive approach to improving population health through the social determinants. I would also suggest that there is a fairly poor evidence base on what are the most effective and the most cost-effective interventions. I do think we can build a better policy-relevant evidence base, and that should be an active research priority in Canada. However, one area where better evidence does exist is the benefits of investing in early life. I am sure you have heard that message before and I will hopefully show you some different angles on that today, but building human capital in children will pay off in the development of health capital.
You may have seen this before. It is the sort of evidence that people use to suggest that broadly defined social conditions affect health. Here you see what is called the Preston curve and countries arrayed by their GDP per head. Canada is somewhere up around where U.K. and Italy and France are. The richer countries have longer life expectancies. The implication of this evidence is that as countries get richer, their health improves. In general that is true, but you also see a great deal of variation around those lines. Some countries do better than they should for their average wealth and some do worse.
If we look within countries — this is an example from Canada — again we see a variation in health around income. This time it is income of individuals. You will see fourfold and fivefold differences across the income gradient. In this case, we are talking about the prevalence of cardiovascular disease. Perhaps the implication here, like in the previous slide, would be that if people with low incomes had high incomes, they would take on the CVD prevalence of the better off. That is probably fair to suggest. We do not know, if we did that, how much better their health would be. It would improve. Would it approach the health of the rich? We just do not know that for sure.
The policy framework I would like to show you is one that has been used extensively in the Nordic countries, developed by a colleague of mine, Finn Diderichsen. The basic idea is that social conditions, broadly defined, affect the levels and distributions of risk factors in populations. By risk factors, I mean smoking, being overweight, hypertension, et cetera. Those risk factors, in turn, predict the onset of ill health. Once ill health has set in, there is the process of living the consequences of that ill health.
At a base level, this suggests three kinds of policy interventions that we could think about in terms of building a comprehensive approach. There would be policy aimed at changing the social conditions: employment, education, poverty, housing, transport, the sorts of policy decisions that are already being made by the Parliament.
I also believe there are opportunities in public health policy to intervene on the mechanisms that link social conditions to health. Mechanisms are very important and give us extra opportunities to intervene. In this case, we could be reducing risk factors like smoking and obesity in the population. We already do a great deal of that, but we do not know much about the equity effects of those kinds of interventions.
Finally, it is important what we do in medical care because the consequences of living with chronic disease are more and more likely as life expectancy goes up. The fact of having chronic disease is almost assured. The issue will be: How well do we live with it and what are the social differences in that quality of life? To my mind, health care and medical care are crucial here as well.
Let me just quickly walk you through a selected bit of the intervention evidence base. I am just giving you selected examples to highlight, in terms of effectiveness and cost-effectiveness, that we do not know all that much. Part of that is a failure of the research community to generate policy-relevant evidence; I think that is a priority area.
Here you see a title, ``Evidence for public health policy on inequalities'' and the conclusion is that this study reinforces the view that there is a lack of information on effectiveness and cost-effectiveness of policies.
Other examples relate to studies of urban regeneration programs to improve public health and reduce health inequalities. The conclusion here is that there is little evidence of the impact of national urban regeneration investment on socioeconomic or health outcomes. Where impacts have been assessed, these are often small and positive. I should say that it is not that these programs do not work; it is just that it is very difficult to build an evidence base; and if the government is looking for evidence to inform policy, that evidence base could be stronger.
There are other selected examples here. A range of housing interventions was considered in 2000 in the British Medical Journal. There was a lack of evidence. There have been studies on the impact of new foods. One particularly interesting study related to large-scale food retail interventions in diet. The idea was that one way we can change people's eating habits is to give them better food choices. Unfortunately, if there was any effect, there was not much effect. The reason was people did not buy it. We need to think about why it is that people develop these food habits over time in their lives. Simply giving them different food did not seem to make a difference, which makes sense. These tastes develop from families and backgrounds and over time. We need to think about early life.
If I can put a little plug in here for building a better evidence base, Canada is well placed to take a leading role in developing policy-relevant evidence. Some of you may have heard of the StatsCan program LifePaths. No finance ministry in the rich world would propose policy initiatives without using simulation models to test different policy options. We should be doing the same thing in population health. Those tools exist right down the road at StatsCan. We are well placed to do that. We are one of the few places in the world that has that kind of technology, and I think we should be doing a better job at trying to bridge this link between epidemiologic and public health evidence into policy-relevant options that can inform policy choices.
I know you have heard a lot about investing early in life and I, too, would push that idea. To give you some examples, this is from an OECD report released a couple of years ago. These are the percentages of children reporting less than six educational possessions. Those are things like a desk, a quiet place to study, a computer for school work, et cetera. In Canada, 20 per cent of kids aged 15 have less than six educational possessions.
From the same report, these are children who report eating fruit each day. We still have 35 per cent of children in Canada reporting that they eat fruit every day. We can surely do better.
If you look at the social distribution of some of these health outcomes in kids, they relate to delinquent behaviour by income in Canada. Here, again, you see the social gradients that affect these outcomes in kids.
I would recommend a report to you that was released in the last month by the well-known Brookings Institute in the United States entitled Success By Ten. They make the following statement:
People make decisions in the face of uncertainty all the time: which job to take, how to invest, whom to marry. Government policy makers similarly are forced to make policy decisions before the available science is perfect.
I have indicated to you that there are some imperfections in that knowledge.
Based on the available evidence, we think that present knowledge strongly favours our proposal of stepped-up investments in early education from birth to age ten.
I find that report quite compelling and I would recommend it to you.
Another area where we can do more is child poverty. Here, I have arrayed the European countries, the Australian states, the Canadian provinces and the U.S. states according to the levels of child poverty. You see the Canadian provinces in red. You see that most of the European countries do better than we do in Canada, Australia and certainly in the United States.
Let us break that down by family structure. This is the amount of child poverty in lone-parent families. I have highlighted Canada at 12 per cent, the U.S. at 17 per cent and Sweden at 21 per cent. Sweden actually has a higher prevalence of single-parenting. The question is what happens to poverty in those families? In Sweden, they have their 21 per cent of lone parents, but only 7 per cent of those families have children in poverty. In the United States, 55 per cent of their lone-parent families have children in poverty and, in Canada, the figure is 52 per cent.
These are policy choices we make. There is no inevitability about this. You can see the enormous range across these countries.
If we look at child poverty taxes and transfers, you see Sweden at 23 per cent. This is poverty generated by the market, basically through salaries before taxes and transfers. There is 23 per cent child poverty in Sweden; 24 per cent in Canada, which is quite similar; and 35 per cent in the U.K. Sweden drops that to 3 per cent by taxes and transfers. In Canada we drop it to 17 per cent. In the U.K. it is dropped to 20 per cent. Again, this is an example of policy choices we make about how we expose children to poverty.
Colleagues in the U.K., I think, have written powerfully:
. . . it is by ending childhood poverty that the greatest proportional improvement in inequalities in health can be made.
Ending child poverty may be the most difficult goal to achieve, but it would have the greatest effect.
How much would that cost? The Innocenti Centre, the UNICEF Centre in Florence, estimates that it would cost less than half a per cent of GNP in Canada.
Another aspect that we should think about in terms of investing in early life is how we spend our money on education. Again, from a different OECD report released in the last couple of months, they make the point that countries do not always spend a great deal on pre-school education, leading to potentially wasted opportunities for children's early development.
Well-known Harvard economist David Cutler recently wrote something for the National Bureau of Economic Research that quite struck me.
The monetary value of the return to education in terms of health is perhaps 50 per cent of the return to education on earnings, so policies that impact educational attainment could have a large effect on population health.
No one would deny the importance of education for earnings. Here they are estimating that the returns on education to health are about half of those to earnings. That seems like an important effect.
In conclusion, I do think it is possible to develop a comprehensive and clear policy framework within which to deal with the social determinants of health and health inequalities.
The Chairman: Thank you very much, Dr. Lynch.
Our next speaker is Dr. Jody Heymann, a Canada Research Chair in Global Health and Social Policy.
[Translation]
Dr. Jody Heymann, Canada Research Chair in Global Health and Social Policy: Mr. Chairman, I thank you for the opportunity to address this committee today.
The central social determinants of health are poverty and social inequalities. Policies aiming at reducing their incidence will have the greatest effect on the health of Canadians. And among these policies, those that lead to long term sustainable change are programs that deal with improving the quality of work and education.
As you can see and hear, unfortunately, my French is not yet elegant enough to do justice to this great language. So I will continue my presentation in English, but the text is available in both official languages.
[English]
My experience with the social determinants of health runs deep. Over the past decade and a half, first at Harvard University and now at McGill and Harvard, I have led systematic studies involving over 55,000 households globally in order to understand the impact of social conditions on the health of individuals and their families. Among other roles, I have served in an advisory capacity with the World Health Organization, UNESCO, UNICEF, the International Labour Organization and the United States Senate. We have examined public policies in 177 countries around the world. Within Canada, I have had the great pleasure, for five years, to participate in the Population Health Network of the Canadian Institute for Advanced Research before continuing, with relationships built during that time, to edit a volume with leading Canadian researchers on the social determinants of health. I have been in Canada now for the past two years, founding this new institute at McGill on health and social policy. Thank you for inviting me here to testify on ways to move forward on the social determinants of health.
Most nations spend far more time and resources treating illnesses and injuries than addressing the conditions that give rise to poor health. At this stage, Canada is among most nations in that regard. However, Canada has long been a leader in the research on social determinants of health, and it has an opportunity now to become one of the leaders in taking action. It is a great honour to speak with you as you try to launch these efforts.
The case I want to make to you today is that you will be able to make the greatest difference in the health of Canadians if you reduce poverty and inequalities, the central social determinants of health. You have heard a similar message from Dr. Lynch, and because we come from the same university you might think it was a coordinated message. I have also had the pleasure of working with Dr. Frank over the years. If he says something similar, you might think it was coordinated. In fact, we have independently come to these same conclusions.
I will lay out some of the evidence as to why I think you need to focus on poverty. If you agree that you need to focus on poverty, then there are only three routes that you can work on to lift families, children, individuals and adults out of poverty. Those are: first, improving working conditions and wages; second, improving educational opportunities so people obtain better jobs; and, third, transferring income. Of these, improving the quality of work and education are the only ones to lead to long-term sustainable change for most working-age adults and children around the world.
So why poverty? From my standpoint, having looked at social determinants for a long time, I have a simple answer. People can give you a long list of social determinants and so can I. Many of them operate through poverty and probably nothing is more important as a single determinant than poverty and inequalities. In Canada, adults from the highest-income households are twice as likely to report being in excellent health as adults in the lowest-income households. Those marked health effects of poverty are well-documented in other high-income countries. In the United States, living in federally-designated poverty areas increases mortality 1.7-fold. Even in Finland, with a strong social welfare system — to name one other country — a large nationally representative study found that those in the lowest income group have 1.7 to 2.4 times higher death rates than those in the highest income group.
These disparities are true for a variety of indicators. In fact, there are 31 health and development indicators for children's outcomes in the U.S. and Canada, all of which are worsened by family income level. It is not true for every single health measure you would find, but it is true for the majority.
Poverty acts directly on health; it also mediates other social determinants of health from safe housing to good nutrition.
Given the central impact of poverty on health and welfare, Canada's current profile is deeply troubling. Despite economic growth, little progress since 1989 has occurred in how many families and individuals in Canada live in low income.
There is a good news part of the story, and I think that is what should encourage us about action. Canada has done well when it comes to seniors. Seniors are reduced from 59 per cent in poverty to 8 per cent after taxes and transfers. Compare that to other OECD countries and you find Canada outperforming Australia, Austria, Belgium, Finland, Germany, Ireland, Italy, Norway, the U.K. and the U.S.
However, Canada has not done so well when it comes to children. In fact, out of 24 OECD countries, Canada ranks fifteenth below the midline for its rank of children living in low-income households. Moreover, although average incomes of Canadians have increased during the past decades, not only are we not making progress on poverty, but the gap between rich and poor in Canada has continued to widen.
Given that poverty has such a dramatic impact on health, such a central role in mediating other social determinants, and that Canada has not gone as far as it could in addressing poverty in children and in working-age adults, what can we do about it?
That brings me to these three policy areas. I know you are at the earliest stages of your committee work, but I want to give focus to these areas because ultimately, as you move into the next two years, you will have to decide where to focus and where to spend most of your efforts.
The first of those three areas is better jobs. A number of things can be done in terms of better jobs such as ensuring that the minimum wage is a living wage; ensuring that there are decent working conditions and basic benefits available for all Canadians, a high-enough floor for all working Canadians; providing incentives for companies to create career tracks for low-skilled workers. High-skilled workers have them and low-skilled workers rarely do. They need them if they are to exit poverty through work. We could also provide access to training for low-skilled workers and incentives for employers who come to Canada to offer good working conditions, the kind of incentives that bring the best jobs to Canada. All those efforts that can be made in the area of work.
The second major area is education. In particular, we need to address improving educational quality, attainment of skills and completion of educational programs at advanced levels. Particularly important is the percentage of Canadians who complete high school and who go on to complete post-secondary education. This is an area where Canada deserves to have a lot of pride. The best universities in Canada are, by and large, affordable. They are public universities. There have been great efforts made in that area. At the same time, we have to be aware that reductions in government funding leading to relative increases in tuition fees are affecting access to post-secondary education.
Moreover, less on the rise has been adult education. Adult education is the chance for this generation of working adults to exit poverty. It is crucial. About a quarter of Canadians participate in it, but those who need it the most, those with only a high school degree or less, are the least likely to participate right now in high school education, which has a lot to do with cost availability and family responsibilities, another area that can be addressed.
I said there were two main areas, but in fact there is a third, and it lies at the intersection of work and education. You could put it in either one, but it is important because it benefits both. It makes it so that adults who are working can help exit poverty and children who are in poverty have the best chance. It has a multigenerational impact. I am speaking of early childhood care and education. Because it works on both levels, there is probably nothing more important to do than to address increased access to quality early childhood care and education from zero to five years old. The benefits of early childhood programs have been well shown in terms of cognitive outcomes, social outcomes, primary school, secondary school and work outcomes beyond. We know there are vastly too few spaces for children aged zero to five. Quebec is the only province that has made substantial progress in this regard, but, Canada-wide, hundreds of thousands of children who could benefit from it are not currently benefiting.
Having outlined those areas, I want to urge you to think about one thing, which is that in addressing poverty and targeting programs at the poor, such programs should be made universal. I hope I will be able to convince you that it is not paradoxical and that you should support universal programs. In terms of a wage floor or a benefits floor, in terms of offering universal accessibility to children aged zero to five or to adult education, we know that any universal program will disproportionately benefit the poor. They are the ones who have the worst working conditions and who have the least access to education. Universality will benefit them.
Why make programs universal? It is important to note that substantial international research on policies shows that countries with targeted programs for the poor do less well at alleviating poverty. We know why that it is. Those programs are less likely to be financed in the long run by governments; they are less sustained; and they tend to be lower quality. I hope you will give a lot of conversation to whether such programs should be universal.
In summary, I urge you to focus on the central social determinant of health, poverty and inequalities. In doing so, the only long-term effective means are through improving work and educational outcomes and their intersection. Second, I urge you to make sure that, while being aware of heightened needs of certain sub-populations, these needs are addressed within the context of universal programs.
I understand that the committee's efforts will continue through the remainder of this year and into next year. At the Institute for Health and Social Policy at McGill, we are also actively engaged in a program of how to translate what is known about social determinants of health into effective policies and programs. That is at the core of our mission.
We have undertaken two multi-year initiatives, the findings of which may become relevant to you, so I want to mention them briefly in closing. In the first, we are examining the public policies in countries around the world in the areas of working conditions, education and addressing inequalities in 180 countries. We have selected these areas because we think they are core to social determinants. We will be looking at their impact on health outcomes, on economic outcomes and on other national well-being and success outcomes. Second, we have a multi-year initiative in which we are carrying out case studies of the most effective national and provincial policies which aim to improve working conditions for the worst off, expand educational opportunities and decrease poverty. I would be happy to provide further information on these initiatives to the committee and to learn more about how what we do can be most useful to your efforts to improve the health of Canadians.
Thank you for being committed to addressing the critical ways social conditions shape the health of Canadians.
The Chairman: Thank you very much indeed for that excellent presentation.
We will now hear from Dr. John Frank, the Scientific Director of the Canadian Institutes of Health Research. He is here today representing the Institute of Population and Public Health, so he can be tremendously helpful.
[Translation]
Dr. John Frank, Scientific Director, Canadian Institutes of Health Research, Institute of Population and Public Health: Mr. Chair, I am very pleased to be here to present to you some very important ideas relating to population health, an area I have been interested in for more than 20 years, either as general practitioner, public health doctor, professor, or researcher.
[English]
I will make the rest of my remarks in English but I am happy to take questions in French. I will be able to avoid using all my slides because of the significant degree of overlap and, in fact, convergence amongst us. We decided not to engineer that, as Dr. Heymann said, but rather we thought it valuable for us to think about the most important messages to give you and we converged without much consultation.
This is a conceptual framework which, although simplistic like all diagrams, I commend to you as a way of thinking about determinants of health as the key set of ideas inside the field called population health, which is developed as much in Canada as anywhere. It simply points out that as we go from womb to tomb, we end up with a set of exposures that affect our biological, genetic and epigenetic endowments. We end up with the health outcomes shown on the upper right. I know, after doing general practice in many different settings around the world for 20 years, most of health care is hard-pressed to get upstream. Dr. Keon was agreeing with us on that earlier. No matter how committed the practitioner, 95 per cent of the patients you see every day have complaints, problems, drugs to review. You will not get much prevention out of that system. However, upstream, the forces you see there conspire to change the exposures inside those families, neighbourhoods, communities, provinces, countries in which we live, and that is changing in a way that policies need to address to get upstream. That is not a new idea, I am sure.
Where do health disparities fit in? There is a somewhat busier version of this graph on the CIHR website. It shows that disparities go back into the page because they are the ways in which patterns of health outcomes are determined differentially by race, ethnicity, by socio-economic status, by geography and, indeed, by gender, to name just a few.
The first message I have is the one that you have already heard. I will use two slides from longitudinal studies that tell us how much early life does matter. We sometimes say that there is such ``a long reach'' of early life on our health and function. This is the famous 1958 British birth cohort, the work of Chris Power. It simply points out that people at the age of 33 should be in peak health before the decline of middle age sets in. Then you graph the frequency with which they have common problems, the most common of which at that age are mental health. ``Self-rated health'' is a general questionnaire of how well you rate your health compared to other people your age, but it predicts serious health problems later. This graph also shows the percentage of those who are obese.
You see this strong differential rate, ranging from about 5 per cent for people whose parents' social class was the best, was the highest. This is a U.K. study, so they use the Roman numerals I through V. The people who exhibited the lowest rates of these problems had privileged parents, which is not something that people pick? This has nothing to do with babies but rather with parents. It is the parents' social class that is depicted here. The rates of these adverse health outcomes range from being double to triple. In some of them, there are large absolute differences.
For the rates of mental health problems, largely depression and anxiety sufficient to interfere with function, the differences are quite significant. For women, there is a difference between 1 in 12 women having the problem, to 1 in perhaps 6 having the problem if they come from the most disadvantaged social group.
Of course, I hate to say it, but it is all downhill from there. Age 33 is as good as it gets, really.
This is a very old study. I am sorry about the colour, but there is a middle line that is yellow that sits between the green line at the bottom and the red line. This is very old data, but it is compelling because it is the work of Emmy E. Werner, who followed a lot of children on the island of Kauai. There were socio-economic differences despite the fact she worked in a plantation environment. She showed that when there was a biological impairment in the form of perinatal stressor events, such as partial asphyxia or low Apgar scores, the effect on the developmental quotient — that is on the vertical axis — at 20 months of age was strong. The effect of social class was so strong that children in privileged families were so stimulated by paternal interaction — verbal, being read to, social skills, being stimulated to develop fine motor and gross motor skills — that the perinatal effects were almost completely mitigated. In other words, social class can buffer even relatively major biological disadvantage in early life.
As my colleagues have said, there is no point in talking to you about things we cannot change. Let us zero in on two things we can change, one of which people often say we cannot, which is poverty. I will pick up from where they left off.
The poor are not always with us. Indeed, we make tax and transfer decisions every year in every Western country that massively change post-tax and transfer income distribution. We do so largely for fiscal reasons without much attention to the social and health consequences because health scientists are never involved in Treasury Board discussions. The people who are there come from another discipline that we will not name today.
The second remediable factor is lack of cognitively-stimulating environments. This factor is so important that it has actually been listed at one of the top four causes of suboptimal child development in the entire world. A wonderful series of papers — which Dr. Keon can make sure you get through the staff — was published in The Lancet on January 6 of this year. It shows is that even at the global level, although you may think that in poor countries there would be big impacts of malnutrition and infection and there are, the number two cause of suboptimal human development is still inadequate cognitive stimulation.
How are we doing on health and equality by socio-economic status in Canada? This is data from Russell Wilkins at Statistics Canada. The red line is life expectancy. This graph sums up the death rates at every age after birth; in other words, life expectancy at birth. The top line represents the wealthiest folks by neighbourhood income, and the bottom line is the poorest women by neighbourhood income. You will notice that the gap has not declined at all over a 25-year period. He will soon publish updated data for the subsequent five years.
In men the gap appears wider. This is a bit of an artifact of how well women's real social class is captured by family income of their neighbourhood. There is some mistaken identification there of women's real social class in my view. However, even where we have a clear picture of it in men, it has not reduced at all. The life expectancy gap in the 25 years under observation here did not change at all.
Of course, as Robin Hood knew, the rich get richer and the poor get poorer. This next graph from Canadian Population Health Initiative report entitled Improving the Health of Canadians — and I was privileged to co-chair the advisory board two years ago — simply shows that that is even more true in Canada than one may have thought. Over a 29-year period, the poorest 10 per cent, the second-poorest 10 per cent and the third-poorest 10 per cent did not gain any wealth at all in the period. All of the wealth gained was concentrated in the top few deciles of folks at the beginning of the period.
Maybe you think we cannot do much about that and, indeed, I am not proposing a wealth tax, but income is something we change all the time. However, a recent report from the U.N. Commission on Human Rights — and I can send you the reference for it — basically castigates Canada for having one of the worst records, particularly in respect of child poverty, compared to any country at its level of wealth and any country with its apparent values.
I said ``apparent values.'' Let us pursue that a little bit. We may say that this is a given, the way income growth occurred at different levels of income. In 2004, we reached an unenviable state. This graph shows the average earnings of the richest 10 per cent. We moved away from wealth. Wealth is a little bit harder to deal with. However, the earnings were 82 times that earned by the poorest 10 per cent. In terms of income, we are now the most unequal we have ever been as a society. This data is from a report by Armine Yalnizyan of the Canadian Centre for Policy Alternatives released a few weeks ago, and I commend it to you for a very clear and thorough discussion of the wealth and income in Canada and the trends and disparities. The point is that we change after-tax income in profound ways every time we issue a budget.
The next graph has already been depicted by Dr. Lynch, and he commented on it. It is a bit too busy. It points out that without even really trying to, we managed to reduce poverty in seniors from something like 60 per cent of all seniors before taxes and transfers, to a good deal less than 10 per cent of seniors afterwards. It varies with the exact year of the data. That is a wonderful accomplishment, but it is not very deliberate. I admit there were a few moments on Parliament Hill, which some of you may well remember, when some tough seniors confronted various Prime Ministers and others and said, ``You better not do us in, because at the polls we are increasingly important group.''
Unfortunately, no one was there doing the same for children, or at least the incredibly large and sophisticated lobby of well-intended children's rights people did not have the same effect. As you heard from my colleagues, we are ranked about fifth worst in this graph in terms of how much we reduce poverty in children by the same range of taxes and transfers. We could only get it from around a quarter of children to about a sixth of children, and it has not improved.
There is something missing; there is something wrong. I submit to you that it is about our values. We do not think that the problems of poor children are everybody's problem, but we will think that once we think through the entire lifetime cost of dealing with the consequences that you have already heard about.
It is not as if these issues are not fixable. You have already seen the evidence of on tax and transfers. If other countries like Sweden can get child poverty under 5 per cent, what is wrong with us?
There are indeed new moves afoot, particularly in the province of Ontario, to do something about housing. However, if you count up the total dollars in these initiatives that Ontario announced last week, it is pretty small potatoes. All they plan to build is 1,000 homes with the money they announced, in a province of over 10 million people.
What about cognitive change? Let us have a quick look at something that Fraser Mustard and Margaret McCain made famous in their report a few years ago. We need to have regular monitoring on how we are doing, not only the level of people's human development indices, including literacy, but on the gradient. This is the mean level to show that Canada does pretty well in terms of life expectancy, but not as well as it should, say, compared to the Nordic countries in the upper left corner, Sweden and Norway. The bottom of the graph represents the percentage of people at very low levels of literacy. We have over 40 per cent of people at very low levels of document literacy. They would not be able to read the fine print on a form on the Internet to purchase something through PayPal, for example. You may say that perhaps this is not important, but I would submit that it is indicative of a society that now expects that of you or your rights will not be protected.
Sweden has virtually half that percentage of people at such low levels of document literacy. We need to understand how they achieve that level. We must stop using the excuse that we have the immigrants and they do not. That is really a rotten excuse. Children are children. It can be fixed. We see that this data is strongly correlated with life expectancy; something about societies makes that the case.
The graphs that Fraser Mustard and Margaret McCain put in their report, the Early Years Study and the sequel — self-published because the government did not want to draw to the public's attention the failure to actually do enough about that report — highlight the notion that we need to follow not only what is the mean level. Here we have Sweden with a mean level of literacy on an internationally standardized test that is higher, the blue line, but what is the gradient? How much is the slope of the line across the x-axis that represents the parents' level of education? How are the kids' scores on a standardized test in this case of document literacy? We see that our gradient is not bad. It is not much steeper than Sweden's, but they overlap at the top. If you come from a highly educated family in Canada, your scores will be on average the same as the Swedish high socio-economic status family.
If you think about the yellow line, Canada, and the blue line, Sweden, who are we failing? We are not failing anyone who is privileged. They are doing as well as the Swedes. We are failing the people at the bottom, and it is their children we are talking about. We are failing to achieve levels that surely we could achieve.
I think the point that my colleagues made deserves repetition. It is the third point here. Poverty is not the whole story. We need to do better in the area of ending childhood poverty, but I will finish with one or two slides in terms of cognitive stimulation before school.
Ending child poverty would be a significant step and is entirely affordable. In case you did not follow the mathematics in Dr. Lynch's slide about why it is affordable, it is affordable because each year only 1 per cent of the population are babies. In some provinces, the percentage is not even that high. That is why it is so cheap to end child poverty. It is not like 1952 when the birth rate was three times as high. It is cheap to end child poverty. What is our excuse? The will has to be there.
My last point is about cognitive interventions. Because this material is so widely circulated, I do not need to spend much time on it, but there are some important, almost-apocryphal studies. I want to remind you of a ridiculously small study that we have all seen Dr. Mustard use. It is randomized. It should not have been able to show the effects it did, but it was done in the Black ghettos of Ypsilanti, Michigan, in the early 1960s. They wanted to improve kids' outcomes in school. They gave them a couple of hours several days a week after school of social skills, conversation, fine motor skills, game playing, particularly involving the parents. They ``role modeled'' for the parents ways to stimulate kids' brains as well as their bodies. They hoped to see big impacts on school success and retention. Those impacts were only evident for a few years, and then the environment around the kids drowned out the effects of the program and nothing was visible after the first half of primary school.
Dr. Lawrence J. Schweinhart would not give up. He kept following people and 27 years later showed enormous differences in favour of the group who had that very modest intervention at ages three and four in that little school, the Perry Preschool. I admit that those changes are not in health outcomes, but they are changes in what I would call citizen success markers, mostly financial. There were some criminological outcomes, which were horrifyingly bad in the control group because it was a ghetto, but they could be expected to predict, as we have already pointed out to you, your health in later life when we all start to become more expensive in Canada to the public purse.
This little study has demonstrated the long reach of intervention. It is not a fatalistic story. Childhood conditions have a long reach. Interventions also have a long reach, but they must include the right elements, such as the parent and cognitive stimulation. They must be of sufficient duration and dose, a couple of years, particularly ages two through four, before kindergarten.
Have you had Dr. Clyde Hertzman speak to you, Dr. Keon?
The Chairman: Not yet. He is coming.
Dr. Frank: The one thing Dr. Hertzman has proven beyond the shadow of a doubt at the Human Early Learning Partnership at the University of British Columbia is that you can very inexpensively measure every kid's readiness to learn when they enter kindergarten. You just have to get every school board to give you the kindergarten teacher's time to fill in that little form. It makes a difference. He goes all over B.C. He shows them how their kids are doing compared to communities of the same level of income and they say, ``Oh, my goodness, we have to do better than that for our kids.'' We could do this. We could determine how kids are doing when they all come to kindergarten. Of course, that means we have to act earlier. We would do some remedial work. You would want to see school boards' head in that direction. You have to work on the earlier period. You get communities to say, ``Yes, look at our record.'' Dr. Hertzman will give you the full story.
That is the story I came to tell. Early life matters. We can fix at least two bad things, cognitive stimulation and family poverty. We are in a state ourselves of arrested national development because of our failure to follow through on what Canadians hold to be commonly held values but do not act on politically. There are interventions that would make a difference.
The Chairman: Frankly, it has been a real treat. I would like to thank all three of you.
I would raise a couple of points. I notice that none of you talked about maternal health. The last time I heard Fraser Mustard talk, he said that getting to a child after it comes out of the womb is a little too late. You have got to get to the child while it is in the womb, and you have to be sure the mother is healthy. He had some figures. I think he put out another report yesterday, and I am trying to get my hands on it.
He has data showing that not only are kids from an unhealthy mother behind the eight-ball from an intellectual point of view, but they have a higher incidence of cancer, congenital heart disease, you name it. They have a poorer life expectancy and a tremendous bit of morbidity ahead of them. Since none of you commented on that study, I wanted to ask you something that you were not prepared to answer. I would appreciate it if you would have a go at that comment.
Dr. Heymann: When we address poverty, we should not frame it as just child poverty, although I think child poverty does have particularly long impacts. We should be equally worried about adult poverty for two reasons. One, I hope we do not give up on the social determinants of health of people who are already adults. Large among those is adult poverty, and we can do a great deal about adult poverty. There are more adults than there are kids, but we know that work interventions and education interventions will matter for their health and for their kids' health.
That brings me straight to mothers. There is an income gradient in relation to how women get access to prenatal care. There is a gradient on how people do during their pregnancies that is related to income, poverty and inequalities. When we address family health, adult health and the health of mothers, the poverty conditions therein affect overall health.
Should there also be public health interventions to ensure that people are receiving good prenatal care? Absolutely. All three of us have focused on the social determinants, and important public health measures need to be there at the same time. However, if you want to do one thing for mothers, make sure that they, too, are not living in poverty and you will help their pregnancy and help how their kids are faring.
Dr. Frank: One of the other findings of The Lancet series of articles on the most remediable causes of poor human development in the world is that there is pretty good evidence that we should be intervening on maternal malnutrition and depression. How to do that well, particularly before pregnancy — and Dr. Keon is right that the current thinking is that this would be optimal — is not simple because, of course, many of the people who are at the highest risk will have babies soonest, unplanned babies, and it is tough to intervene. I do not think we do as good a job as we should do in early high school, because if we wait into middle high school, it is actually a little too late to help people prepare for unplanned parenting. I think we need to think that through, despite the protests of some in the community who will argue that that might increase teenage birth rates. I am less worried about that, actually.
We certainly are not good at providing universal parenting training for people in the age group who need to be prepared. The evidence is not totally in that those kinds of programs make a big difference, but I would argue that when someone is parenting at the age of 17 or 18 and has not even finished high school, almost any program would be better than no program if it contains sound psychological content on helping someone prepare for parenthood. As we all know, the most significant challenge we face in our personal lives is parenting. It is the one job we all find the hardest and the one job we cannot mess up.
Senator Cochrane: It will always be hard.
Dr. Frank: You are right, but it is much harder for people who do not have those personal and material resources.
Dr. Lynch: I think everyone would agree that maternal characteristics are extremely important in terms of the health of babies perinatally, but that importance continues in terms of the values, dietary habits and the whole complex of parenting that we transmit both socially and biologically to our kids. Having said that, my interest would be, what is the best buy? If we are trying to improve the health of the children, certainly we need to think about the health of the mothers.
If we had to look at the actual effect on the health of the child, my bet would be that the best buy in terms of the effectiveness of interventions would be postnatally — the conditions in which the child grows and develops — and not prenatally. That does not mean we would ignore the mother. I am not saying that, but I think that the biggest effects are postnatally.
Dr. Heymann: I want to add one other piece of information to the postnatal issue. The age of zero to one is a crucial period. We have talked a lot about the big picture issues, but we have to get the details of the laws right. I want to mention two examples.
Employment Insurance in Canada does not cover millions of Canadians because they are involved in doing contingent work, part-time work. As a result, they do not have paid family leave. This affects, in particular, low- income parents who cannot afford unpaid leave to care for children during that vital first year.
The second example is breastfeeding breaks. Of all the interventions that mothers undertake in terms of children's health, breastfeeding reduces sickness and death three to five fold. This happens in poor countries and in rich countries. Our level of mortality and morbidity starts lower, but breastfeeding still has a dramatic impact on health and on cognitive development. The biggest difference in whether a mother breastfeeds is whether she get maternity leave and breastfeeding breaks. One hundred seven countries around the world guarantee their workers breastfeeding breaks. The United States does not; Canada does not. This could be simply and very cheaply addressed. There are some small, specific interventions, but they are hugely effective.
Senator Fairbairn: I have to say that I am virtually speechless. I have never been in a meeting where I have heard the story of why, in a country like Canada, we have difficult health situations and difficult learning situations. I wish that the three of you could be sent around to speak to every level of government and every political group in this country because what you are saying is the foundation of how we can change a system that is keeping people out of work. It is keeping people in bad health. It is keeping young people from receiving the encouragement they need to learn. It is making certain adults very uneasy about letting people know they do not have the learning skills that are fundamental requirements to raising children and getting a job, all of the things that make for a decent life.
All of us around this table have been involved in the issue of literacy for a long time. It is probably one of the most frustrating areas to which an individual can commit.
You spoke of Dr. Mustard, who is an icon to those of us who have been involved in these matters. I am glad to hear that he has issued another report, but his report many years ago really became the foundation of the notion of family literacy, how absolutely imperative it is that the very youngest get a head start basically before they are even born.
In your travels to talk to groups and people like ourselves, do you get much in the way of negative response in the sense that what you are saying is so hard to believe it could not be true?
Dr. Frank: I think people mean well. As long as you stay at the level of what should be done, it is a pretty easy conversation, but when you start talking about actual costs and how money would have to be largely raised from taxes in order to be bearable for those at greatest risk, you do run into some backlash.
I was struck by the way in which the Government of Ontario, a couple of governments ago now, dealt with Dr. Mustard and Ms. McCain's first report, the Early Years Study. The report was crystal clear about what was needed. It said that we need one centre per neighbourhood where, at no cost, women at highest risk, both in pregnancy and before pregnancy, would feel free to come regularly with their friends and to be with peers who have extra training, as well as a few supervisors with real ECE — early childhood education — training. There would be lots of interaction and zero barriers. If the centre were more than five blocks way on a Canadian winter day and you had a toddler, you would have to forget it.
What did the government do in Ontario? They built centre one per riding, mostly giving out pamphlets, as far as I can tell. What was that all about? It was about looking good and spending nothing. That government had a little ideological problem about spending money, so maybe we should forget it. It is gone. That era is over, but what is our excuse now?
This is not about daycare. Do not get these two things mixed up. Daycare is an important and separate issue that many of you would have a lot more to say about than I. It is a crucial issue and we have dropped the ball on that one, too.
This is about stimulation. This is about getting the brain to reach its optimum potential in the whole of society so that we are internationally competitive.
Senator Fairbairn: Absolutely, and when we look at your various charts, we note that if it does not get done during the very early ages, then we have a major problem later in that adults are not able to take advantage of available opportunities and live decent lives for themselves and their children. With all of the good things we have in Canada, it is difficult to understand why we are not at the top of the list but well down in the pecking order internationally when it comes to how our adult citizens stand in terms of what they can do well every day of their lives. As I say, it is difficult to understand why we are at 40 per cent in a country like Canada, but it is also real.
Can you give us some advice on promoting what everyone around here believes is fairly obvious? How do we explain, encourage and excite governments to respond in a positive way? We have had ups and downs over the last 20 years, and at the moment we are in a down all across the country. Do you have advice on how we can create the social stimulation required to make this a foundation issue of any government, any Parliament or any group that makes policy decisions and laws throughout this country?
Dr. Heymann: That is a very difficult question to answer, but I will give it a try.
I want to start with your original question of how people react because that is part of the answer to how one gets action. In talking about this issue, my experience is that the public gets it. Wherever I go, people get it. I have talked at forums where folks who are cleaning the room at the beginning stay and listen because they understand that I am talking about their lives. You talk to the bus driver and they understand that this is about their lives. You talk to the professionals in the room who are moderating, and they understand that it is about their lives. Reporters experience it day by day. There is not a problem in getting the information out there so that the general public has an understanding. That is important and is a great asset to us.
The challenge is in thinking about the political reality. It is important to realize that you will have at your fingertips a few different interventions. There are the cheap, easy ones, those with no cost. Let's make them happen. Those have very low barriers. They are not all in place. Ensuring that every woman who works has a right to breastfeed is an important one, and it is inexpensive. It should be straightforward and should happen.
The others are things like early childhood care and education, which you have heard from all of us are really important. Implementing them will require dollars up front, but they will save money in the long run. They will at least pay for a good portion of themselves. We can debate the exact numbers. It will not cost as much once we start to see the returns, but it will take 10 years or 20 years for the returns to come in.
That is the bigger issue and I would say a couple of things about it. First, Canada has a head start. I am sure it feels like an uphill battle sometimes, but coming from the U.S. context where they truly have yet to embrace these issues, the level of commitment in Canada to public health and public education is an enormous asset because the country will get direct economic returns.
It is quite clear from our global data that part of what needs to be done is to make the case that it will be the only way to economically compete. Most economists will argue that competition will only occur for high income countries like Canada by having the best educated work force. There is no other way to keep salaries and living levels up. That is what early childhood care and education and the interventions that will require dollars are fundamentally about. That is the approach I would recommend, and I can bring out plenty of data to support it. There are many lessons to be learned from countries already investing in it.
Dr. Lynch: When I do presentations such as this one, the groups I talk to feel embarrassed. There is a great mismatch between what we value and what we do. Sometimes they are not even aware that things are this bad. People get emotional and angry. We should be doing better.
Senator Fairbairn: Do they not believe what you tell them?
Dr. Lynch: They do not believe it. When I give these presentations internationally, I find some incredulity in the Nordic countries. They cannot believe that a country like Canada, which is so different from the United States, looks like the United States or more like the United States in the way it treats its youngsters.
Having said that, some of the models that have probably been put forward to you are countries like Sweden and Finland. They treat education very seriously. You must have a master's degree to teach in Finland. They are well paid. Their schools are well funded but locally controlled. They put their money where their mouths are. What do we find? The Nordic countries are extremely competitive. If you look at OECD numbers, Sweden is doing very well in terms of international competitiveness, and part of the reason is the long-term investments they have made.
This will not be a quick fix, but it will be the right investment long-term.
Dr. Frank: When we talk about competitiveness, it is important to be concrete about the fate of people at the left end of the yellow line, people who cannot perform any jobs except direct manual service jobs. We cannot all serve each other $5 cups of coffee. That is not a viable economy. We do not even grow the stuff. We have to have products and services that the rest of the world wants.
In Sweden, the blue line, they are not carrying all those other people. They are not carrying many people who are functionally document illiterate. We are carrying them and they are not competitive. Every time another car parts plant moves out of Southern Ontario to a country with cheaper labour, there is no work for those people. No one is pumping gas any more in my hometown outside London, Ontario, and that is what those guys used to do.
Let us accept it. There is going to be an impossible clash between our aspirations to be competitive and our approach to flattening that gradient.
Senator Fairbairn: Ironically, I have often said that if there are four adults in Sweden who cannot learn or have not learned, I imagine that their government is trying to find them and teach them. We do not have that same push here in Canada, but what you have said is on our record. Perhaps we, as a committee, can find a way to get your comments around to places where decisions are being made, not necessarily from the ground up, but rather making decisions on the basis of the realities that you have set out tonight. Thank you very much.
Dr. Heymann: I want to make a brief comment about competitiveness. We are putting together a study that will look at all the top-ranked competitive countries in the World Economic Forum and their policies in each of these areas. If that would be useful to you in the future, we would be glad to share it. I think it does have important insights. Some countries are well known, such as Sweden, but other countries that provide these benefits are often less well known. For example, Mexicans, as part of their social security, get childcare with their jobs. It is not just high-income countries that are doing it; it is middle-income countries, and Canada can certainly afford it.
Senator Cochrane: Dr. Frank, I have a question about education. I hope it is at the top of everyone's list, but we are seeing a little problem Alberta in that children are not finishing their high school education because they can get a job in the oil fields making just as much money as if they had a degree.
Senator Fairbairn: Or more.
Senator Cochrane: What should be done there?
Senator Fairbairn: You are absolutely right. In Alberta, something like 35 per cent of people coming into the job market cannot do the kind of reading, writing and productivity that is demanded now.
Senator Cochrane: They are getting jobs in the oil fields making big money.
Dr. Frank: I would like Dr. Heymann to comment on the specific policies that have been tried to keep people in school. Some countries actually pay people to stay in school, particularly in apprenticeship situations where they are learning a skilled trade. It is one of our weak spots in Canada. There will be a bust part to the economic cycle. We have had it every time.
Senator Cochrane: That is our worry.
Dr. Frank: When we get to the bust part of the cycle, most people want to go back to school. The issue then becomes whether they can get back to school easily without mortgaging the house. What are the barriers to going back and getting more training? Much of the programming, although improved in community colleges, still consists of a significant barrier for people. I think community colleges in Ontario, at least, are trying very hard to give people an even playing field to get back to school, but we need to make that an easy route. There should be no personal financial sacrifice. Maybe an individual needs to apply for a loan, but under good conditions. We need to make it very easy for people to go back to school to upgrade themselves. I would submit that the system of patchwork quilt institutions in the educational sector of Canada does not have a coordinated approach to optimizing adult education.
Dr. Lynch: I cannot remember the exact figures now, but I think it has been estimated that the current generation of kids will go through six or seven different jobs in their lifetimes; they do not have the idea of being in a job for life. The bust will come. There is pretty good evidence that people who are better prepared through high school actually find those lifelong learning routines easier to do. We need to think about the development of human capital over the life course, and that means the ability to go back to school and to retrain so as to have those opportunities. That is what the modern economy will be built upon.
The Chairman: Our next questioner is Senator Callbeck, who has a very interesting dimension to offer this committee because she was the premier of our smallest province for a number of years and can be quite a pragmatist when it comes to implementation, compared to the Premier of Ontario.
Senator Callbeck: I can tell you that implementation is difficult. We tried introducing policies according to the determinants of health. Some were successful and some were not. We opened a clinic in Sherwood, which is a part of Charlottetown. That is still a going concern. It is very well used and was a great experiment. However, I think that it takes a long while to change people's opinions. Most people look at the health system in terms of the more doctors you have and the more hospital beds. That is the way they determine the health system. In order to do these other things, you need dollars, and that takes away from the number of hospital beds and doctors.
Dr. Heymann, you mentioned two initiatives. One was in relation to looking at other countries, and the other was that you are looking at case studies of national and provincial policies, national and local programs. How long have you been doing that and what exactly are you studying?
Dr. Heymann: We are in the earliest stages of a new initiative, which I will tell you about in a second, and one that has been going on for a while. The part that is looking at working conditions has been going on for quite a while. We looked at labour because we think it is a central route out of property. A few people marry out of poverty, but not many. People tend to marry in their same income level. Even fewer get lottery tickets and are able to get out, but the most common way to get out of poverty is through better jobs and work. We have spent a lot of time studying that.
We have been evaluating national policies for several years, looking at 177 countries on the public sector side. On the private sector side, for about three years now we have looked at companies around the world that are improving the conditions of their lowest skilled workers while succeeding economically. We are doing that for two reasons. One, we think the solution will be private sector as well as public sector, but two, we think it is important for making the case. Labour conditions must be improved, including legislation that says you need to raise wages to make sure people can have paid family leave or sick days. We have to convince business leaders that they can afford to do this and still succeed. We have undertaken this initiative both because of what it teaches us about the private sector but also because of how it helps make the case for public sector change.
That piece is ongoing, but in September of this year we started a new study. It is a five-year program that will give us the results on work and education within two years. We are reviewing the most successful cases of improving labour conditions. Our focus this year will be on the working poor. Next year the focus will be on educational inequalities, the goal being to improve educational outcomes.
Senator Callbeck: Are you looking at cases in every province?
Dr. Heymann: I wish I could tell you we had enough financial resources to look in every province. It is a fellowship program as well, and we have so many people applying and eager to work with us that with more resources we could readily look at every province. Right now we try to systematically look at which provinces seem to be making the best progress and which ones have particularly unique or interesting programs.
We are also conducting these studies globally because we think it is crucial for understanding competitiveness. We have done them in every region in the world, but I would welcome input about particularly interesting policies and programs that should be evaluated in different provinces. If we were to get more resources, we could certainly expand the number of approaches.
[Translation]
Senator Pépin: I have read carefully your briefs. You underline the fact that education, employment and housing are important factors. In looking at all these various factors, I notice that education is provincial jurisdiction, but that social determinants involve different levels of government, various departments. The same remark applies to taxation levels.
How could the federal and provincial governments work together to develop a policy? What government structures are necessary to deal with social determinants? Could you make some suggestions to us?
Both levels of government must be able to work together, but how do you see such an approach? You can answer in English if you want.
[English]
Dr. Frank: That is a great question. I know you had Monique Bégin here. I think you should ask her to come back and talk to you about what the educational equivalent would be for the Canada Health Act. The Canada Health Act is a work of genius because it uses federal dollars to leverage certain standards and it basically costs the provinces very heavily not to maintain the standards that we all know.
The electorate has shown repeatedly that no politician had better touch it. You could do the same with education. You would want to do it with both basic and adult education. Transfer payments are probably not what they once were. I assume they are much smaller now, but if they are still there you have a lever. It is not that you are telling people what to do. It is that if the provinces want full payments, they have to come up to international standards. There are certain standards. For example, there must be policies in place to encourage high school completion and to provide certain skills for those that are not academic. There must be low access barriers or no barriers to returning to school, particularly for skilled trades that are in demand. I mean, it is a federation, is it not?
Senator Pépin: Yes.
Dr. Heymann: Without a doubt, you have put your finger on one of the most crucial areas, which is that these are all social policies. Social policies are carried by provinces as well as the federal government.
I want to mention a couple roles in addition to transfers. There are a variety of ways to do transfers. You are more expert than I am in terms of specifics, but beyond the current health care system, a series of other social transfers exist that are sometimes targeted social transfers. They are not targeted by the population they hit in the way I was talking about before, but targeted in terms of programs. That is an important mechanism. However, there is another mechanism that we should not forget, which is the federal government's role in terms of monitoring, evaluating and highlighting what is going on in the different provinces. It is in the national interest that all provinces come up to a certain standard for the whole population. It is not likely that the provinces who are doing less well are going to highlight this themselves. That is true in any country. However, there is a potential federal role in monitoring what is happening and making information public about the relative successes and gaps in different provinces.
We have the social transfer mechanism, the direct program mechanism, the monitoring mechanism, and then we have pilot programs. Funding is required so that successful examples can then be imitated in other provinces under provincial jurisdiction.
[Translation]
Senator Pépin: I have another question in a completely different area. Dr. Frank talked about care for pregnant women and postnatal care. I must admit that I am surprized. I did not know that there was an impact for pregnant women or for women after birth if they were living at a certain poverty level, but I did not think that this was true from the moment women got pregnant.
[English]
Dr. Frank: There are a few different issues here. One thing that will probably not make a difference is more access to medical care in pregnancy. Good studies have shown in Canada that we achieve good enough levels of medical care in the sense of doing what medical care can do. There is the traditional one-on-one care, doctor-mom, pregnant mom medical care with no midwife and not much time for counselling, sitting down to talk and get people ready to breastfeed and parent. It is all about bio-medical risk factor detection and management. It is important, and we probably do that, but moms from a disadvantaged background may have subclinical or clinical depression and other problems. Treatment takes a lot more than some doctor spending 10 minutes of time every month for six or eight visits. This is all about a big approach.
I think you would want to look at ``la maternelle'' in France. I have not seen the actual documents and perhaps they are not widely available, but I am told ``la maternelle'' was started in France to improve perinatal outcomes. I am also told that it is one of the few really clear demonstrations in the world, even in countries at an advanced stage of socio- economic development, of a concerted effort to provide a wide range of supports for pregnant women universally. Universality can shift birth outcomes. We are not serious about it here in Canada. We would have better outcomes if we were serious about it.
Dr. Lynch: I would only add that it is not just mothers affecting their children but grandmothers as well. There is evidence across multiple generations of deprivation that grandmothers affect their grandchildren via maternal transmissions. You can imagine situations where the grandmother is smoking while her daughter is pregnant. That affects the growth and development of the mother and that affects her ability to carry her own child. Those links have been demonstrated many times, so the situation is even more complicated.
Senator Pépin: I have question regarding breastfeeding. I do agree when you say that we should have a law that says women should be able to breastfeed and have a break.
[Translation]
It has decreased. Now less women are breastfeeding. This means that we must pass a law to this effect, and I quite agree with this. However, how long would they be breastfeeding? What are we to do if they must return to work?
[English]
Dr. Heymann: The notion behind having a basic right to breastfeed while you are working is that people can do it once they go back to work. In terms of duration, you will see a lot of different recommendations, but nine months, 12 months of breastfeeding will still show marked benefits to kids less than six months of age.
These are benefits are outlined in ongoing studies. There are literally scores of studies on this subject. Every time a study is repeated, the benefits are still there in the context of advanced affluent economies and health care. There are protective effects in terms of decreasing deaths from diarrhea and illnesses such as pneumonia. There are some very good, recent randomized studies. They did not randomize breastfeeding, which of course they could not do, but they randomized conditions that supported breastfeeding leading to significant improvements in cognitive outcomes and measurable differences in IQ scores. We know that the benefits of breastfeeding remain strong. The research evidence is also very good that women can breastfeed while they are working, the question being whether their working conditions allow them to do so. That is why that piece of the law is so important. Also, they can breastfeed prior to returning to work if they are able to have paid maternity leave or paid parental leave. It is essential to fix Employment Insurance to make sure that everyone really has those benefits.
[Translation]
Senator Pépin: At the present time, the majority of women who are breastfeeding are on maternity leave because we do not have a labour law to this effect, unless employers who are very compassionate allow them to do so. In Montreal, there are a few daycare centres in workplaces. There are not many of them, but we do have a few. I quite agree that we should introduce such a legislation. It would allow disadvantaged women who need to return to work quickly to breastfeed their kids, which they cannot do presently.
[English]
Senator Fairbairn: In listening to you and the questions and answers about how we could get things going, I have a few thoughts.
For some time now, almost 10 years, there has been a painful effort, but a good one, between the federal and provincial governments to establish a federal-provincial job training agreement, workplace training agreement. It now exists. Presumably it came about with people behind the scenes taking a look at the changes in our society. Jobs very quickly had turned into something different. In order to lift up all of those who were already in the work force, let alone those who were coming into it without particular skills, the federal government and the provinces negotiated this agreement, and it works. The other side of the coin is that there is a vacuum of sorts in that the people who need to learn and who have low literacy levels are staggering through life in a very different world than the one they started out in because of technology.
There was a large, high-level national meeting in Toronto a few years ago that focused on this topic. There were many discussions and group meetings. Literacy advocates tried to explain what it all meant, but a lot of people did not either accept it or want to accept it or understand it at all. The shocker at the end of the day was that every group was asked to put forward their top three ideas with respect to workplace training. Number one was to establish a pan- Canadian literacy program similar to what has been done with labour market training.
That concept has been worked on again and again, but it keeps falling off the table. It does not matter who is in power; it has not happened. There is a big chunk missing there.
In committee hearings on literacy we asked several times about what happened to the notion of a pan-Canadian accord. Somewhere along the line it seems to have ground to a standstill. If proposals concerning learning and training were to come together, we could probably do a lot of good.
The concept is on the table, but it has not come together. I am not quite sure how to make that happen. In listening to all three of you today, my hope is that we can circulate your ideas widely because there is a very good reality check here for an agreement that would put learning and training together. We would find that every province in our country would have a much better future ahead of it. It also touches on the main concern of this committee, which for a long time now has been health. In the end, surely a pan-Canadian approach is a large component of whether or not we have a healthy Canada. If you have any ideas about how to get these suggestions in front of the people we have not been able to reach, please tell us.
Senator Cochrane: First, someone mentioned that we have to develop the brain to reach its potential. I just wanted to say that this is the crux of the problem. We do not know how to train the brain to do all the things that it can do.
Second, I do not know why, Dr. Heymann, but I have not heard very much lately about breastfeeding. I have not even seen mothers breastfeed. Eight or nine years ago, I used to see mothers at restaurants take their children aside and breastfeed them, even at the table, but I do not see that any more. Have we stopped advertising all the positives things that breastfeeding does? I was impressed with your comment that breastfeeding has an impact on cognitive development. Could you elaborate? Perhaps we should be putting out more brochures to publicize this fact. Maybe I am old, but I am not seeing enough of this.
Dr. Heymann: I think there are a couple parts to this issue. One is that do people understand the impacts. There are periods when there is an erosion in understanding the importance of breastfeeding, particularly in high-income countries. The assumption is that breastfeeding does not matter as much and that it can be perfectly replaced with formula. To the extent to which those assumptions and misconceptions are part what is going on, then, yes, getting that information out there helps, and every generation needs hear it.
At the same time, social and structural barriers are increasing, which really has to do with the rise in Canada, as in every country we have studied, of mothers in the workforce who have children from the age of zero to one year old. The increase of mothers in the workforce does not in any way need to impede breastfeeding, but, unless we bring our policies up to date, it will.
That is why we have to make sure that people who want to stay home can afford to do so while breastfeeding and nurturing an infant in those early months when it is hardest to put together affordable, quality early care. We must ensure that those who want to or need to return to work have that right. There has been a dramatic transformation over the past 25 years in terms of the rise of number of women who are making the decision to work and breastfeed simultaneously in those early years. The laws in Canada and elsewhere have not fully caught up with this reality and we very much need them to do that.
Senator Cochrane: What about cognitive development?
Dr. Heymann: I think the evidence on cognitive development is getting better with every study. Early studies suggested that cognitive development mattered with breastfeeding, but they were not what we would call gold standard studies. Instead of having random samples, they asked women if they had breastfed or not and then looked at their adult children many years later. While those early studies suggested for a long time that breastfeeding mattered to cognitive development, people did not know if different women were breastfeeding or not breastfeeding, and so we did not consider them gold standard. Maybe there was a selection bias or a logic problem with the studies.
Now, however, we really do have the gold standard studies. These include, for example, a recent study in which the researchers went to hospitals. In one set of hospitals, they did a series of interventions to promote women breastfeeding and in the other hospital they did nothing. They followed the kids, and IQ scores were higher among children from the hospitals where there was an intervention to promote breastfeeding.
Dr. Lynch: That research was done by a Canadian, actually, so we should be proud of that. It was done in Belarus by our colleague Dr. Michael Kramer.
I wanted to add that we do these comparisons with other countries not because we are Sweden; there is no way we can be Sweden. They have a different culture, history and context. We cannot necessarily transplant what happens in Sweden. We have to be selective about what we do, but these can be inspiring stories. Ninety per cent of women in Sweden participate in the labour force, and if you look at breastfeeding rates, they are better than ours. That is because of the structural supports that exist. It can be done.
Dr. Heymann: Individual countries can be inspiring. When we look around the world and see that over 100 countries guarantee breastfeeding breaks, we know that it is not about one political system, one historical system or one economic or social system. A full range of countries have found a way to do it, so it is something we can do for sure.
Senator Pépin: It would be very good because we would have child care in the workplace everywhere.
The Chairman: The discussion this afternoon has been fascinating. I want to tell our witnesses just how truly grateful we are that they have given us their time.
There is another line of questioning that I would love to pursue with all three of our witnesses, perhaps through a teleconference with the committee about a year from now, I suspect, or maybe a little later. I see some divergence between the three of you when it comes to how to do some of these things. Dr. Heymann is saying that the flat programs really count, such as better jobs, education and early childhood care. Sometimes that suggestion is a little hard to sell. I notice also that if we have the will to do it, we can eliminate early childhood deprivations such as poverty; we should be able to put together programs for children that give them a fair shake.
When we get to the recommendations stage of our report, we will be in touch with you again. Thank you very much indeed.
The committee adjourned.