Proceedings of the Subcommittee on Population Health
Issue 2 - Evidence, December 12, 2007
OTTAWA, Wednesday, December 12, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:17 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 Lucie Pépin (Deputy Chair) in the chair.
The Deputy Chair: Honourable senators, we have the pleasure today of welcoming Dr.James Frankish, Professor and Program Director from the University of British Columbia; and Mr.Lex Bass, Director of Population Health from the B.C. Interior Health Authority.
Unfortunately, the minister could not appear, but he sent us a letter, which is in your kit. He apologizes that he could not make it. I will ask our two guests to make their presentations.
Lex Baas, Director of Population Health, B.C. Interior Health Authority: I will keep my comments brief, knowing that the key is the questions that come afterwards.
Thank you for this invitation. We are quite thrilled that there is so much activity and interest around population health and examining social determinants. For the senators to be interested in this whole field is very encouraging.
The Deputy Chair: For everyone's information, SenatorKeon may attend later. Unfortunately, he is in another committee, and that is why he is late.
Mr. Baas: I would like to briefly put into context the role of the B.C. Interior Health Authority as it relates to population health so that there is an understanding of the work we are engaged in at the ground level. Then I will provide a few highlights of some of the work in which we are engaged.
Interior Health is one of five regions. There is an error in this regard in your documentation. There are five regional health authorities in British Columbia. It covers a great span of southern British Columbia, from the Alberta border right to the Fraser Valley, and includes Kelowna and Kamloops. It is a huge geographic area of 216 square kilometres, large urban centres such as Kelowna, very fast growing, and also many small communities, including 53 First Nations communities, varying in size from very small to medium small.
There is a total budget of $1.4 billion. The area has a population of 715,000 people, which is expected to grow by 9 per cent over the next 10 years, with the number of individuals 65 years and older increasing by 39 per cent.
Kelowna is a desirable to live and retire. It has a warm climate with not much snow in the winter and is mostly flat.
The population health team within the B.C. Interior Health Authority was formed in 2002, not long after the health authorities were regionalized in British Columbia. There were presentations earlier from Prince Edward Island with similar experiences. Mr. Frankish mentioned there were 52 regional health authorities before; now there are five. In some cases, we are still adapting to that reality.
The population health team was formed in 2002, and we were charged with looking at population health and showing what we could do. Immediately, we looked at the pieces we could work at, and you will recognize— I know you have already spoken with Ron Labonte— some of these words here in terms of «educated» and «catalyst.»
We realized that the first thing we needed to do was spread awareness and build organizational and community capacity for shifting to a population health approach. People did not know what population health was, and the understanding of social determinants is limited. Therefore, we started doing population health workshops with as much of the staff as we could within Interior Health Authority. We had a full-time person in a practice-support role. The idea was to go around within the health authority to engage people and to dialogue about the meaning of population health, social determinants and an «upstream» approach so we could move that work forward.
We sought to create opportunities to build readiness and support new ways of thinking about health, so it was not just health care. It was not just helping people that were already in need of health care, but to start that whole shift in moving upstream.
This included an analysis of the determinants of health and using population health approaches. We brought together non-traditional partners, such as people involved in facilities management, in acute sectors, in protection and licensing, as well as nutritionists and others. It is everyone's issue.
There is a diagram on page 1 your handout, which says «Access to affordable food» in the middle of the page with a bubble circle around it. The point here is that we try to put the issue in the middle and say who should be involved in those dialogues. There are roles for health authorities, for various parts within health the authority, for the community and for various other sectors. There are 18,000 employees within the health authority covering that vast region. That work is ongoing and needs to move forward.
Last year, our Senior Medical Health Officer's report, Beyond Health Services and Lifestyles, took a social- determinants approach to reporting on health of the population of the region. It did the classic things about reporting on health but then also applied the analysis of social determinants and inequities. For example, why is there such a disparity? It provided some analysis of that question. I do not know whether you have seen the report. I sent it to the clerk, and it certainly will be made available to you if you have not seen it.
That report generated a great deal of dialogue within the health authority and also beyond. Suddenly, there is a gradient and there are inequities. Those kinds of words started coming into the vocabulary and forced us to look at how to deal with these issues. By applying a universal application to solve a particular issue, we could increase the disparities because we are not focused on specific target groups. Those kinds of debates came into play.
We cannot do any of this work without partnership and collaboration. Our goal is to engage with all the people and the groups that need to play around a particular issue. To do that within the health authority, there are challenges. We have looked at ways to bring people together. Most recently, we invited people from all sectors of public health and beyond to come together for a two-day meeting with the focus of how to apply a population health lens to the work you are engaged in within your departments. There was huge interest.
Partnership and collaboration extends to communities. We have done a lot of work with municipal councils and regional districts.
I would like to highlight two pieces from the provincial government that have helped us move in this direction. The first is ActNow, and I hope there will be questions about that later. The minister would have spoken to that program if he had been here today. ActNow is a provincial initiative that forces all ministries to play an active role in health promotion. Modeling the program at the provincial level across all ministries within the health sector lends credence to our work in communities. We have used the lifestyle focus of ActNow as a wedge with that publicity to start to dig into more of the social determinants and the upstream approaches.
The other initiative I would like to mention from the provincial government in B.C. that has a huge impact on the health authority is the model core program review. It is a renewal of public health where 21 or so model core programs were identified. An evidence paper is developed for each of those programs in consultation with all of the health authorities. There is analysis of the evidence papers and then model core programs are developed. Those programs are approved by all the health authorities, so there is a dialogue. After that, each health authority does a gap analysis — the work in which they are engaged compared to the model core program — and then they have to post on the public website their improvement plans, with goals.
The critical piece in all this is that for all of the model core programs, which cover everything within public health and beyond, a population and inequity lens is applied. Rather than looking only at the issues, what does it mean to apply an inequity lens? Why are certain groups having access and doing well and others are not? We start to do that analysis. I think this is an exciting piece; it is huge. There are many resources and challenges.
At the last Canadian Public Health Association meeting in Vancouver, the B.C. Interior Health Authority worked with the Capital Health region in Alberta to host a pre-workshop conference on how to operationalize population health within a regional health authority. This workshop was at 9 a.m. on a Sunday morning, which is not prime time. Forty absolutely enthusiastic people came from health authorities all across the country and wanted to engage with us in how to do this and to learn about the barriers.
There are many of barriers. The classic one, of course, is the tension between the acute side of the equation and the need to provide health care, and then to do the health promotion where the outcomes are not immediately apparent. It is hard to make a causal link between the work in which we are engaged and the results. Those are part of the evaluation challenges around this work.
I wish to also highlight the Community Action for Health initiative that we did within the B.C. Interior Health Authority, where we had an opportunity to support some of the ActNow targets with one-time funding of close to $1 million. We had to spend it within one fiscal year. I think it was Monique Bégin who said that Canada is the land of pilot projects. This was, in fact, one of those projects with term funding. In applying that funding, we allowed the communities to make the decisions. The only provisos we made were that the communities had to address the ActNow targets and the interventions had to create policy or environmental shifts. By insisting on policy or environmental shifts within those applications, communities had to think about what that means, which started this whole level of dialogue. There was initially a lot of resistance, but in the end there was huge support for it.
I wish to speak about the advocacy role. We agree with the submission made by Vancouver Coastal Health that the goal of advocacy is to gain support for the involvement of government and non-government agencies in the actions that improve the overall health of populations and strengthen the understanding of governments and populations about the broad determinants of health. We need to advocate and to speak up. Of course, there is sensitivity around that role, being part of a provincial health authority funded by the province, so we need to do it in a way that is engaging and that will move pieces forward.
The latest reports from FirstCall B.C. indicate that B.C., for the last four years, has the highest child poverty rate in all of Canada, yet it is one of the richest provinces. How do we deal with that dilemma? What is our role as a health authority and how do we advocate?
At the bottom of the handout there is a snakes and ladders game that you might recognize from when you were children. We had a conference a couple years ago. Dr.Michael Hayes, from Simon Fraser, used this analogy in terms of looking at determinants of health and applying population health pieces. He explained that we are all born with a certain number of snakes and ladders on our board that change through the course of our lives. We can get more snakes and more ladders. By analyzing it in that way, it takes the control out of the individual. It is an analogy that you will see again in the Community Action for Health tabloid that is available for circulation here as well.
James Frankish, Professor and Program Director, University of British Columbia: Senators, it is great honour and pleasure to be invited to speak with you today. I told my neighbour's son, who is 6 years old and crazy for hockey, that I was coming to Ottawa to see Keon and the senators. He wants me to bring him home a sweater. He is going to be deeply disappointed.
I will briefly introduce myself in context, as did Mr. Baas. I will echo many of the comments that Mr.Baas made today and that others have made in previous submissions. I had the pleasure of reading the presentations to the committee that were on the Web, which was very helpful. What I say will not be entirely new, but I will emphasize some points that have not come up in the dialogue and discussion so far.
I work at the University of British Columbia in the Centre for Population Health Promotion. I am the director of a CIHR-funded research training program that focuses on community-based research. I think it is relevant for this committee to know that I am a board member of an organization called Lookout, which is the largest homeless shelter provider in Vancouver. That is how I spend my days.
My research at the moment focuses largely on two areas. One is the area of health literacy and literacy in health, so I am a big fan of Senator Fairbairn. We are interested in the role of literacy as it relates to health and as a determinant of health.
I also focus on vulnerable populations and marginalized groups, and particularly on issues of homelessness and health. As you all know, we still have significant challenges with homelessness in Canada. I have not seen many homeless people on the streets in Ottawa, but perhaps it is too cold.
I provided you with a two-page handout. I will refer to some of the points on the first page, but a number of them are consistent with what Mr.Baas and others have said about inequities.
The one point that I think we need to factor in as we move forward on population health is the difference between inequalities and inequities, that there will always be fundamental inequalities between and among Canadians. I always tell my students that not everyone can be as smart and good-looking as us. We are more interested in inequities, those things that arise from policies or programs that are unfair, systemic and that need to be changed. Simply improving the health of the population, shifting the curve, may or may not do anything with respect to inequities; in fact, it may make inequities worse.
We know, for example, that when new technologies arise, they often help the haves more than the have-nots. What happens is that the haves have more and the have-nots are still where they were. I have not seen many homeless people with cellphones.
I make a distinction between self-responsibility and self-reliance. Mr.Baas referred to the notion of snakes and ladders. We talk about it in terms of chances, choices and conditions, that there is always an element of free will. People make choices, sometimes bad ones, but people cannot be reliant on resources they do not have.
For me, the fundamental role in my work— and I think part of the role of government— is to help people to identify and to be more reliant on the indigenous resources that they do have and to help them to get more resources.
At the bottom of the first page, I highlighted three points that come from a model that we have used in our work for a number of years. It is from one of my colleagues, Larry Green. It is called the Precede-Proceed Model. There are somewhere in the order of 1,800 published applications of this model. The model says that if you are to change things in society, if you are going to move toward population health or if you want to change your husband or boyfriend, there are three fundamental steps. The first step is creating a predisposition or a motive. Mr.Baas spoke eloquently to that point with respect to changing knowledge, attitudes, beliefs and values.
One of the fundamental truths of human behaviour is that knowledge is a necessary but not sufficient condition for change. Being a physician, Dr.Keon would recognize that many people know that smoking is bad for them, but people still smoke. We have to create the predisposition.
When people are motivated to think about and act on population health, we need to create an enabling environment— that is the second piece— through the teaching of skills and the training of the next generation of decision makers and leaders, and through providing available and accessible resources. Given the determinants of health, available resources may or may not be accessible for cultural, linguistic or economic reasons. There are many reasons why people do not avail themselves of what seem to be existing programs or resources.
Therefore, I think we have a lot to do in working with the public and Canadian society. We need to create that predisposition, change knowledge, beliefs and attitudes to create a supportive, enabling environment for movement toward population health. We can do this through skills, availability and accessibility of resources.
People tend not to do something for which there is no payoff. That is equally important. If we try something and there is no reward, we tend to move on to something else. The health care system is dominated by professions that, I believe, have some measure of conflict of interest around population health because their jobs, training, raison d'être is on the acute side, which is sorely needed and very important for the health of people.
However, the question is: What would be the reward or payoff for Canadians to engage in greater population health? We would have a healthier, happier society and, perhaps, reduce morbidity and mortality rates. That is the message we would like to see sent.
One cautionary note I would make regarding homelessness and supportive housing is on the money-saving side. I think the evidence is still out as to whether or not population health would save money. That is a highly debatable question. It depends on how you count the beans and who does the counting. I am not sure that is the only way, or the best way, to sell it to Canadians.
Those are my opening comments on the first page of my presentation. For the second page, I thought I would bring some messages from my work and colleagues. My first message builds on what was said by Mr. Baas: It speaks to the idea of changing knowledge, attitudes, beliefs and values. I raise some ideas for a continuing shift. I think we have to build the evidence base. I think the Canadian Institutes of Health Research and the Social Sciences and Humanities Research Council and others need to fund population health research, but we need to engage Canadians in a fundamental conversation about what determines our health. There is a harsh reality there. I have listed some ideas. We are doing things in this regard, and I would suggest to you that you would find a welcome audience in terms of this conversation.
I will point to three recent examples. First, some research was recently done in Saskatoon. They did a large population survey and asked people about their willingness to shift funds from health care to population health. I think people realize it is not just a zero-sum game; it is not bedpans or waiting lists versus something else. They found a high level of support for engaging in conversation about shifting resources.
Second, we had a poll in Vancouver not long ago where the mayor asked people about their number one expected outcome of the 2010 Olympics. I have a grant to evaluate the impact of the Olympics on the inner city. To my surprise, the number one outcome expected by Vancouverites was reducing homelessness. I do not know how people can see the Olympics reducing homelessness in 17 days.
Last, we finished a study recently where we looked at all of the newspaper articles on homelessness in British Columbia for the last 30 years. We analyzed them using something called discourse analysis. We found that Canadians, unlike the American media, tend to attribute homelessness to societal causes rather than individual causes. They do not attribute it to weakness or immorality. They see a strong role for individual self-reliance and responsibility, but they also see a concern about the erosion of the so-called Canadian social safety net.
The second message builds on what has been talked about by Mr. Baas. It builds on the notion of linked-up government, an idea from the U.K. They had an initiative launched strategically and very wisely. It was done not by the Minister of Health but by the Chancellor of the Exchequer in which all departments and ministries were asked to speak to health inequities. There is a great opportunity to build on the things that Mr. Baas referred to in an effort to link various ministries within government, and I will provide you with some examples.
I note that the ActNow program is a fantastic initiative for breaking new ground, but it is largely still at the lifestyle- behavioural level. When I go to meetings with Health Canada or the Public Health Agency of Canada, I do not see people from HRSDC or the homelessness branch. When I go to the homelessness meetings, I never see the health people. It is as if there are, as we say in Canada, two solitudes; perhaps 200 solitudes. There is a need for that kind of linkage.
We have, in the past, reviewed national health goals all over the world. We tried to establish British Columbia health goals, and we did get them. I have done work with Sweden and other countries on national health goals. Sweden has robust goals of that sort. For whatever reason, we in Canada have an aversion to this concept. Perhaps it is related to the whole provincial-federal dialectic. There are probably a whole host of factors. I believe there is a need for measurable targets: targeted resources and resource targets. At the moment we do not have them. The danger is that, as my friend and mentor would say, with a lack of targets, you can call anything you hit the «goal,» which is not necessarily good.
I would commend to this committee the notion of creating at least some case study-oriented targets to play out the population health agenda. I advise you to have measurable targets that would speak to this government's interest in evidence-based decision making and accountability. I think that is what Canadians want.
I would also echo what Mr. Baas said: I think that the targets and however you evaluate them need to fit with communities. There must be both a top-down and bottom-up blending of things.
The last message I would leave you with is around the overlooked opportunity to link population health with economic and social productivity. In Canada, one of the largest groups of unemployed people is Aboriginal youth, specifically young Aboriginal males. It is a huge issue.
There is an opportunity to train the next generation of decision makers, physicians, nurses and others, but also to engage ministries like HRSDC and others to work with marginalized youth to engage them in population health initiatives that would advance and improve the quality of communities. For example, in B.C. we have a project that we are doing with street youth. We are creating something called independent living accounts. Money put into a bank account is matched by the private sector or government and can be used for education, work or housing.
I think there is a huge opportunity there to think not only of funds from the health sector, because the health sector is sorely overburdened already, but also to link it to ideas of literacy, economic and social opportunity, and other kinds of opportunities. We can then make inroads with respect to population health in Canadian.
Those are my messages and my comments.
Senator Wilbert J. Keon (Chair) in the chair.
The Chair: Thank you very much indeed, Mr. Frankish.
Mr. Baas, I am sincerely sorry that I could not be here to hear you. I will catch up with you on the telephone further to what transpires here today. We have an urgent health problem in Canada now that I had to speak to in the Senate chamber this afternoon, and there was nothing else I could do.
I want to thank the deputy chair, Senator Pépin, for carrying on under very short notice and making the most of your visit.
I will bring you up to date on the hockey news. I indeed have a number. I am No. 3 of the Ottawa Senators, which is the third sweater autographed by the whole team and given out. It is in a big frame in my country home. I understand there is still not a No. 4. When I retired from the Heart Institute, they made me an honorary Ottawa Senator. I told many people that when I was appointed to the Senate, I thought I was making a comeback. That is why I accepted so quickly.
Senator Fairbairn: You started a trend there.
The Chair: The other good news is that I have a grandson aged seven and his hockey team gave him No. 14, which is Dave Keon's number from Toronto.
I have no more hockey news.
Senator Pépin: Thank you both for being here today. Your expertise will really help us.
You spoke about the B.C. Population Health Network. Could tell us a bit more about its role?
Mr. Baas: The B.C. Population Health Network has been in existence for about two years, maybe a bit more. It brings together leaders in population health from all of the health authorities. There is also representation from the B.C.Provincial Health Services Authority, which is considered the sixth health authority for the entire province. Trevor Hancock represents the province and usually chairs that committee.
The goal of the committee is to network. There is real communication about what we do across the province in the different health authorities, so it is a forum for airing issues and focusing on emerging themes within the health authorities and how we can best address them provincially. The meetings are held officially four times a year. In terms of reference, the network is moving slowly to actually taking action and creating forums for advocacy work.
Senator Pépin: Could you also tell us whether your finance department is involved in ActNow B.C.? Does this initiative examine low social economic status as a health determinant impacting on poor diet and low levels of physical activity?
Mr. Baas: Are you asking about the finance department within our health authority?
Senator Pépin: I asked if your finance department is involved in ActNow B.C.
Mr. Baas: ActNow B.C. is a provincial cross-ministerial initiative targeted at healthy eating, physical activity and smoking reduction. The premier in B.C. has set goals for making B.C. the healthiest jurisdiction, by 2010, to hold the Olympics. All of the regional health authorities in B.C. are engaged in working toward ActNow targets.
Some resources already exist, but the bottom line for us is that it is a balance between how we are already funded and how we can rearrange or redirect those funds to address those targets.
Mr. Frankish: I think you were asking a slightly different question. My sense is that you were trying to get at whether there is an analysis happening or consideration of the links between lifestyle, exercise and nutrition, and more socio-economic factors. Was that your question?
Senator Pépin: Yes.
Mr. Frankish: I do not know of an explicit allocation of resources to look at the performance of ActNow across different socio-economic strata, for example, or if there are different levels of participation by children from different socio-economic backgrounds.
Dr.Clyde Hertzman in B.C., who many of you would know, is a very good friend and colleague of mine. He is a world leader in early child development and developed a tool called the Early Development Index. He has mapped all of the schools in British Columbia in terms of children's readiness for school— emotional, cognitive and social. He has mapped it across different levels of socio-economic status. This tool holds the promise that it could be linked to programs like ActNow, but I do not think the health regions have the data sets. You could try to do some analysis with Statistics Canada data and postal codes.
Your question is very perceptive, and those are some things we could do.
Mr. Baas: A further challenge in that vein is that when we look at certain regions and populations, many of our communities are so small that it is hard to apply the particular analysis. We would have to look at Stats Canada data, for example, on a large enough scale to have two communities side by side. On the larger scale it looks like we are in the middle, but there could be huge disparities between those communities. That is a challenge as well.
Senator Munson: In your opening statement, you talked about the child poverty rate in British Columbia as being one of the highest in the country, but B.C. is probably one of the richest provinces in the country, next to Alberta. In the last couple of years, your committee has been dealing with population health. Has it been able to address the notion of bringing people together in a concrete way to alleviate some of the pressing issues of child poverty?
Mr. Baas: That is a great example because there is no way that a health authority, on its own, can address child poverty. Child poverty requires action at all levels of government in terms of strong policy. Mr. Frankish talked about policies that set particular targets. There are examples of other jurisdictions, such as the U.K., where child poverty rates have been reduced significantly.
What we are starting to do in applying population health approaches and an inequity lens when we target particular programs is ask what we can do to help alleviate the pressures of poverty. Addressing poverty right now is all about education, awareness and engaging in dialogue to move poverty from an individual perspective to one that is broader. It is all about looking at the appropriate role within our health authority. It is something that is very clear on our agenda.
We are working on becoming more involved in community capacity building and engagement around housing issues. We hit right up front: What is the issue? The issue is poverty, so it comes up time and again. In some ways, it is a sensitive area for us in that it is embedded within the health authority as well.
Senator Munson: In your opening statement, you talked about your population health support team and that you had early successes with programs concerning tobacco use and the prevalence of seniors falling. How did you do that?
Mr. Baas: A specific number of communities were involved in the falls project;actually, we targeted seniors facilities initially. We wanted to go into those facilities and do very basic analysis and support training. In doing so, we raised the awareness that falls could be prevented. As you know, falls are a huge piece for seniors.
Analysis and support were carried out at a number of pilot sites. Within a very short time, in the order of one or two years, we were able to reduce the rate of falls by something like 20 per cent— not the number of falls but the rate. The actual rate dropped significantly based on those interventions. Subsequently, that information has gone into the development of a region-wide health authority falls strategy, which is still in the process of being implemented.
On the tobacco reduction side, we conducted a campaign called «Kids need breathing space.'' It was a social marketing campaign to target families and places where children are potentially confronted by tobacco smoke. We raised that awareness. In evaluating the success of the campaign, there was a significant reduction in tobacco use around children.
That being said, the whole attribution piece is difficult, because at the same time there is a huge push provincially — and I think across Canada — in terms of reducing where people smoke and having smoke-free premises. There is societal momentum to get away from smoking.
Senator Munson: Professor Frankish, I was startled — as you were, I think — when you talked about the survey you did on housing and said that everyone thinks the Olympics willalleviate the problem of homelessness.
Mr. Frankish: It was actually a mayor's poll. The mayor asked people in Vancouver to identify the top issues facing Vancouverites in the next couple of years. They were also asked parallel question: What was their number one expectation of the Olympics? On both questions, issues of poverty, addiction and housing scored the highest — both specifically to the Olympics and more generally in terms of what people thought were the big issues for the city. Issues like crime, civil liberties and other things were on the list, but they were further down.
Senator Munson: If a city, a province and a federal government can get together and host such a thing as the Olympic Games, is there the same attitude in British Columbia or in Vancouver toward easing the problem of homelessness? I know infrastructure is important; I know the highway is important and that they build new buildings. However, is there the same desire inside the belly to say, "Okay, we have a very serious issue because of our homelessness problem''?
Mr. Frankish: I believe the desire is there on both sides. On one side, it is just from being human and seeing the pain and suffering of these women who were murdered by Mr.Picton. I was walking down the street the other day and said to my friend that I just realized that I live in probably the best neighbourhood in maybe the best city in quite likely the best country in the world. I have been fortunate enough to be born in a time in history when I did not have to go to war. If you put me next to the billions of people who live on Earth and have lived during my lifetime, I am pretty blessed. However, when I walk around the corner from where I live, I see four young people sleeping in minus five degree temperatures on the sidewalk in front of McDonalds because it is open and they can go in and use the washroom; so something is wrong.
I met recently with some people from HRSDC and others. My view on the Olympics is that it creates a window of opportunity. I think you are absolutely right. We have to be realistic; we cannot expect the Olympics to solve the social ills of the country or the world. It is a 17-day travelling circus in which they charge you a lot for using the brand.
However, we are proposing that the Olympics could be catalytic in terms of creating the wedge that was referred to earlier. I met with a deputy minister from HRSDC and we talked about using the Olympics for a community revitalization approach in the Downtown East-side. For example, there is an abandoned school in the Downtown East-side. The province collects $1 billion a year in property transfer tax. I have approached the government with the notion of taking 1 per cent of the provincial property tax transferfor three years around the Olympics to create a population health implementation centre. I have had very positive responses from two provincial ministers.
Part of the challenge for the health authorities is that we all know the words to the song, but no one has the money to play the music. I think we have to be really creative. I proposed that we use the Olympics as a catalyst to fund a centre that would provide services, link up with communities and engage in social enterprise such as job training with street youth. That is the way it will happen, I think.
Senator Munson: It should be a catalyst for the country.
Mr. Frankish: It could be.
I would point out to senators that at least three Australian states have extremely well developed health promotion foundations that are funded by dedicated tobacco or alcohol taxes, similar to the taxes that were proposed around the mental health commission. The Western Australian Health Promotion Foundation, for example, does amazing population health and health promotion things. The tax generates $30 million a year, I believe, and they fund community projects, students, research— a whole host of different activities.
Population health is not going to pay for itself. That is part of the challenge; how can we be creative in finding resources? Taking them from the acute sector is not a good first choice.
Senator Munson: In your strategy, you talked about conducting a pan-ministerial review of health disparities, led by the Treasury Board and the Senate. The other part that intrigued me was establishing binding national health equity targets. In lay person's language, what are binding national health equity targets?
Mr. Frankish: As soon as I put that in my presentation and thought to myself, as a closet federalist, about making anything from the federal government binding across provinces, I recognized the political sensitivities and complexities of it.
Senator Munson: I like it.
Mr. Frankish: My sense is that until population health and health promotion becomes a line item in someone's budget, they will always be cut, always be pushed to the side and always be the first thing that goes. The health authorities want to do more, but they know at the end of the day they will get fired or discharged if they screw around with the acute care system and hospitals more than if they do not do anything about population health.
Right now in Canada, a politician would not become unelected for failing to deal with homelessness. He or she would be more likely become unelected for changing the price of beer. I think there has to be some measure of accountability. Governments always talk about accountability and evidence-based decision making, but I find, with due respect, that many people in public life have an understandable schizophrenic attitude toward accountability. They love to talk about it, but they are loath to establish binding targets, particularly if they go beyond.
Another challenge to which Mr.Bass alluded is that so much of population health is way beyond any one electoral cycle. It is a long-term project. It is like changing seat belt behaviour, smoking behaviour or drinking and driving behaviour. It is a generational thing. It is too important to leave to government. It is too important to leave to any one party. It transcends the electoral cycle. Governments are understandably thinking about this election; they are not thinking about the guy 10 years down the road. We have to somehow rise above that.
Senator Callbeck: You have five health regions, and I am wondering about the structure or the framework. Who do they report to? Obviously the Minister of Health is on top. Do you have a committee of other departments, ministers from other departments? Do you have an agency or an authority? What is the structure?
Mr. Baas: I will respond with the proviso that the minister might respond differently or more accurately.
There are five geographic regional health authorities, each with a board and a CEO. Those health authorities have an agreement with the province to deliver all of the services that they are required to deliver. My understanding — and Mr.Frankish may know more about this — is that each health authority, while there is certainly dialogue, is individually, as a unit, responsible to the minister.
Mr. Frankish: To my knowledge, B.C. has never had a provincial level. I know that Saskatchewan had the Saskatchewan health council, and some other provinces have had similar type things. I know that the MHOs of all the boards get together and that the CEOs and executive teams talk, but I do not think there is a formal cross-region, mid- level between them and the government, per se. I could be wrong, but I have never heard of it.
Senator Callbeck: In other words, the regions are directly responsible to the minister. No committee of other departments is trying to get them involved in population health.
Mr. Baas: There is certainly a lot of collaboration. For example, if I look at the work of the B.C. Population Health Network and the B.C. Ministry of Health on issues such as smoking, all health care facilities within the province need to go smoke free by March 31, 2008, I believe. There is a huge amount of collaboration between all the health authorities directly involved in implementing that policy. Within our health authority, there is huge discussion about how this policy will actually be rolled out and how to make it happen. There is regular discussion between the people from the health authorities who are leading that implementation. Those discussions happen very much at a practical level around all kinds of issues, including population health.
Population health really is an approach. In terms of our population health unit — and not all health authorities have specific population health units — we have been charged with bringing a population health outlook and approach to the rest of the health authority. The initial dialogues we did within the health authority, those practice support pieces, focused on how to actually engage in dialogues around social determinants and looking upstream. We discussed what all those things mean in terms of our role within the health authority. For example, if we are not actually treating someone, we are asking, "What are the causes of the causes?'' If we begin to ask those questions throughout all departments of the health authority, we can start making more of an impact.
If we take the community nutritionists and the tobacco reduction coordinators out of the B.C. Interior Health Authority, we are left with something like seven people. Seven people across a massive 216 square kilometres and 700,000 people is not a lot. We cannot actually go ahead and do it. We can only do it by being catalysts and bringing with us that level of dialogue, and it is starting to work. It is everyone's responsibility.
Senator Callbeck: What about the federal government's role? What role did they play in moving to a population health approach in your province, if any? If they did not play any role, what role should they have played or should they be playing?
Mr. Frankish: Not knowing all of the initiatives that have happened, I am sure that somewhere there is a deputy or a minister who will listen to what I have to tell them and say, «Yes, but we did this and that and it was related to population health.»
I do not know the answer. I cannot speak to examples where prima facie the province and the federal governments explicitly entered into something involving population health specifically.
Mr. Baas: There is a population health department within the Public Health Agency of Canada, so that part is there in terms of information, developing resources, hosting events and so on. We are certainly aware of the extent to which that actually translates into direct dialogue between federal and provincial counterparts. We look at the research that has been done and have those kinds of discussions. For me, the critical piece is what happens at the federal policy level across specific population health issues. If you take child poverty or homelessness, what is the provincial role, the federal role and the municipal role, and how are policies enacted that get to the point where changes actually take place?
Mr. Frankish: Two examples come to mind. One is the Canadian Institutes of Health Research. I happened, fortunately, to be in Ottawa as a member of one the grant review committees giving away your tax dollars to researchers. There has been a profound shift in health research funding from the days of the old Medical Research Council. It has changed dramatically. It has expanded and the focus has shifted to include things like population health. The federal government has played a huge leadership role in that shift.
The other initiative I would point to, which is also a Crown-type corporation in that it reports to Parliament, is the Canadian Institute for Health Information. They gather information needed to plan and enter into informed decision making about the health and quality of life of Canadians. Increasingly, they are collecting population health data. They have an initiative that funds a grant to do with the Olympics called the Canadian Population Health Initiative.
At the level of specific and actual program delivery, over the last 10 or 20 years the federal government has gotten out of the business of program delivery. When I first started doing these kinds of things, Health Canada was very much involved in prenatal nutrition programs and early childhood development programs. These programs are still there, largely with First Nations, but they have decreased dramatically. You would have to ask the ministers in each province for more detail.
This begs the question of which activities around population health are best made at which level of the system. Some things are done well federally, some things need to be done more at the community level, and some in the middle, for the provinces. We are still in the business of sorting that out, and this committee is a great step toward articulating what the potential federal role can and should be.
Senator Callbeck: You talked about community action for health as being a one-year project. You said that at the beginning there was tremendous resistance but that it turned around and there was great support. How did you do that in a year?
Mr. Baas: The resistance came in two places. We insisted on two things. One was that some of the money would go to hiring community developers, community engagement personnel. Through the interior health region, the money was funnelled through seven host community agencies. The host community agencies did the hiring for a part-time community developer, and there was resistance to that. Why not give the money right to the people who are applying for it?
The second area of resistance was that in terms of supporting the ActNow targets we insisted that the projects which were brought forward had to address either environmental or policy shifts. There was resistance because there was no sense of what that meant.
What is an example of a policy shift in a small community? We held many meetings throughout the region to talk about this topic. There was an incredibly short timeline to get this $1 million out the door. Once the community developers started to engage with the host agencies, people began to come forward with ideas. The community developers worked with the people who had applied and looked at it from a policy perspective. As the projects started to come in, we identified that having someone focused on community engagement and community development benefited other projects in the community, even though they were not part of the target piece.
I have copies here of a tabloid that articulates the 73 projects that were funded. It gives short descriptions and some more in-depth pieces. It was a matter of people becoming more familiar with the process and understanding that we were looking at the long term. The effects of funding for one year can be extended if we do something that addresses the environment or policy. That was recognized and it went beyond.
Senator Cochrane: I have a question about something that is not mentioned in your notes. Tell me about the centre that has been in place for quite a few years where people get clean needless. Is it working? Do you know anything about that?
Mr. Frankish: You are talking about Insite, the safe injection site in Vancouver.
Senator Cochrane: It is in the Downtown East-side, is it not?
Mr. Frankish: I can speak to that issue because I have been involved in it, and perhaps Mr.Bass will want to add something.
Insite, a safe injection site, has had, as some people in the community would say, a stay of execution from the government for a period of time. It is not without controversy. The philosophy is that people are making what many others consider to be poor choices. They are engaging in risky and unhealthy behaviour using intravenous drugs, which are highly addictive and cause much collateral damage ranging from infection to overdose.
People in Holland, Germany and other places around the world came up with the notion of harm reduction, which is that if we cannot get rid of the problem right away, let us try to reduce the harm generated by the problem. They have been quite successful in Germany.
Part of the challenge with Insite is how to define success. If you define success in terms of fewer people starting to do drugs or choosing not to do drugs, it is probably not successful. A team of researchers from Vancouver led by Evan Wood and other people, my colleagues, have done the best research in the world. There is no need for any more research. Their research has been published in the New England Journal of Medicine and other very good journals.
Insite works in reducing overdose deaths and the sharing of needles, which we know is highly related to hepatitis C and HIV transmission. The challenge is that it is not resourced, funded or designed to move people where we all want to move them, which is into treatment, to a better quality of life and to social re-engagement.
The next thing that will be considered in Canada in relation to this problem is what has been done in the U.S., which is assertive community treatment— giving people a choice of going either to treatment or to jail because they are not making good choices. As Canadians, we are loath to intrude on the social liberties of individuals, which is nice. However, from everything I have read, being dispassionate and objective about the issue, Insite works in relation to everything that it was charged to do. It is a success. The research is very consistent. The program was not designed to end drug use; it was not designed to reduce the number of people starting to use drugs, but it is working for the things it was designed to accomplish.
Mr. Baas: I would add that if we are looking at this issue from a population health perspective, then we are looking at the whole continuum as well. How do we create a society that is healthy and vibrant, where people feel engaged so that the number of people who end up on the streets or homeless or using drugs is very small? It can be a whole lot smaller than it is now so that the harm reduction piece falls away from that point, somewhere in the middle. There is harm reduction, but then you can carry the continuum right to tertiary care or incarceration. It is one of those pieces. That project has a narrow focus, but it is so high profile that you can find tons of information about it.
Mr. Frankish: That speaks to another huge issue in which the committee might be interested — the notion of continuity of care. There are a number of places in our system, in particular around issues related to population health, where we have very poor continuity of care. For example, when people in prison are released, they usually have huge problems, but there is very little care for them. I was talking to a surgeon in Vancouver the other day. We are starting a new project. People going to Vancouver hospitals for major surgery are discharged back to the street or to a homeless shelter, which is absurd. When someone goes into Insite, there is no continuity and no next steps of followup.
Senator Cochrane: This subcommittee is interested in examining the effectiveness of various interventions to reduce the health disparities or inequalities among various sectors of the population, whether Aboriginal, youth, seniors or others. That is our purpose.
Based on the B.C. experience, what are the fundamental building blocks or strategies to improve health for all and to reduce health disparities?
Mr. Baas: That is a good question and a big one. There are a number of ways to answer it. From a provincial perspective, the fundamental building block would be a realization that inequities exist and that they can be addressed; and a commitment at all levels to actually do something about that. Starting there, we see that initiatives are being undertaken, such as ActNow, with an individual focus to provide great leverage within the health authorities and use it as a wedge to address the more fundamental determinants that lie underneath. I would also mention the review of public health programming within all of B.C. to apply equity population and equity lenses to all of the work that public health is engaged in.
The typical budget for a public health department for a health authority in B.C. is about 3.5 per cent, or perhaps less. The specific budget amount that is allocated to population health would probably be less than 1 per cent because public health includes all of the aspects, such as immunization and so on. That is not unusual. It is pretty standard across Canada. As part of that dialogue, people have been advocating for 6 per cent rather than 3 per cent.
Mr. Frankish: In no particular order, the first of my three building blocks is early childhood development and the kinds of things that Dr.Hertzman and Dr.Mustard talk about. It is much more challenging to repair the damage than it is to intervene early on.
The second is literacy, and the third is educating and employing as many women as possible — in particular Aboriginal women — in productive well-paying jobs.
The fourth, which is so fundamental to everything else, is adequate, affordable and supportive housing for people with mental illness and addictions — for all Canadians. The UN rapporteur was in Canada not too long ago and visited some First Nations communities. He said they were worse than communities in Third World countries.
To recap, my four fundamental building blocks are early childhood development, literacy, women's health and housing, and, in particular, supportive housing for people with mental health problems and addictions.
Mr. Baas: With respect to early childhood development, health authorities are now expected to use information from the instrument that Dr.Clyde Hertzman developed. I am not sure about the exact wording, but it is in the letter of agreement between the health authorities and the province. More than health authorities are involved because early childhood development also entails education and other support. Acknowledgement is important.
Senator Cochrane: Are there particular interventions that you believe to be most effective in reducing these disparities?
Mr. Baas: My starting point would be the great amount of work that should be done on policy at all levels of government. From a health authority perspective, we are effective to the extent that we can engage communities and get them to come to the table with resources, such as personnel. In that way the community engagement process is active. For example, it is a matter of helping communities develop a food security group or bring awareness to falls issues or motor vehicle crashes. It is a matter of working with the Northern Health Authority and the Vancouver Island Health Authority to determine a way to address this issue from a health authority perspective and who else needs to be involved in those pieces. The key is to engage. We have seen that to be effective on the community action health project. It is fundamental, but not in the absence of solid policy.
Mr. Frankish: There is a famous story about a bank robber. Someone asked him why he robbed, and he said, "Because that is where the money is.'' I would suggest that you look to countries like Sweden and the U.K. where they have made great changes. Even the United States has made some great changes with respect to homelessness. Beg, borrow and steal the best ideas of what works in other jurisdictions. Some of it we know and a lot of it we are still working on. It is clear that you need government direction at a policy and a political level — and they are not the same, as you know — meshed with a bottom-up community approach. One without the other is not adequate.
Senator Cochrane: Are there any particular barriers that you see?
Mr. Baas: From a health authority perspective, the most obvious barrier is the tension between health care and the huge demands on cutting wait lists, as well as looking at health promotion and the population health piece. For the latter, the results are not immediate; they are long term.
That said, we feel solid support within our health authority and are grateful for that. At the same time, we recognize the huge pressure it is under.
A large amount of work is needed in terms of community engagement and awareness. The population health lens needs to extend far beyond the health authority. The other piece is how we actually engage with communities.
There was a conference in Kelowna a few months ago that we helped promote. It was called Cities Fit or Children. We got the municipalities, the regional districts, health authorities and business people to come together. It looked at how we can actually make our cities fit for childrenin terms of transportation, housing, et cetera.
Senator Cochrane: Is that still going on?
Mr. Baas: That was a single conference. There will be pieces that follow out of that. The conference also had involvement from the Union of British Columbia Municipalities. There were many players at the table. Those kinds of forums are critical.
How do you change such forums into action and resource it? If there is public support, great, but that is a challenge in terms of dialogue. People ask me why they should put money into helping people stop smoking. The 3.5 per cent budget is all for public health. Truly, we are putting small amounts of money into that program and asking what the cost savings are. Smoking is one of those classic examples.
Senator Cochrane: Regarding your ActNow program, have you evaluated it? Has an assessment been done? Is an assessment approach in your framework? All programs need to be assessed.
Mr. Frankish: They have actually just had some recent calls for bids on contracts to do a major evaluation. I applaud the fact that they are going to do what looks like a pretty substantive evaluation. It is in the early days, but it is clear that they are planning to do a robust evaluation. They have calls for proposals and I know some people who have put in bids.
Senator Cochrane: Do you have anything evaluated yet?
Mr. Frankish: I think there are probably some pieces of things. If you were to talk to Minister Hogg, he could probably give you some of the early information. I know they have a framework and the wheels are in motion.
The Chair: I want to ask a couple of questions that are of tremendous importance to us as we go along.
Mr. Baas, you mentioned that each regional health authority does not have a population health unit. From the five health authorities, how many are there now?
Mr. Baas: There are different structures, so it is hard to say. All of the health authorities have some involvement with population health, and I think that the structure in each one is quite different. Within our health authority, our public health is regional. Our whole public health department is responsible for the entire region and population health is part of that. As a director of population health, I am there with the other directors for prevention services, protection and so on. That structure is not the same in the other health authorities. That is part of the history of how regionalization happens. All of them have a focus, but I could not answer the question as to who has specific population health departments.
The Chair: What is your relation to the public health authority or agency of B.C.?
Mr. Baas: We work very closely with them. John Millar sits in as part of the Population Health Network and is very engaged. There is a very close relationship on anything to do with population health.
The Chair: I have known Dr. Millar for a very long time, and he has appeared before us here.
To whom do you report?
Mr. Baas: I report to the Senior Medical Health Officer of the B.C. Interior Health Authority.
The Chair: Public health.
Mr. Baas: Exactly.
The Chair: What is your relationship with the Canadian Institute for Health Information, CIHI, when it comes to your data collection, especially in relation to the population health initiative?
Mr. Baas: I know that we have an evidence and surveillance person working specifically on population health. Also, within the Interior Health Authority, the evidence and surveillance people have access to data and foster close working relationships.
The Chair: Does your data go up into the data bank in British Columbia, not into the CIHI data bank?
Mr. Baas: I cannot give you that now but I can get back to you.
The Chair: What is your relationship to municipal government? The National Occupational Mortality Surveillance Study, NOMS, controls the 12 or 13 determinants of health. If you want to pull groups around a table, what authority do you have? What relationships do you have? For example, do you have a seat on the municipal government?
Mr. Baas: I forget the official number of communities within our region, but it is a very large number. We do not have seats on municipal governments. In terms of authority, if, as a health authority, we participate in forums or initiate a forum around a particular issue, there is great interest.
The most effective work we do is when we participate around particular issues, such as homelessness in Nelson. Some of our staff are engaged in dialogues. They are saying, «These are all the pieces that need to happen. What is a legitimate role for us? What can we do within the health authority?» The dialogue is at that level.
In terms of authority on the population health side, we do not have any authority to gather people together. We can do that by invitation and engagement. That engagement varies across theregion. It can be easy to do that in communities where we have strong engagement. In some communities, there has been little engagement, and that is part of the disparity piece we are having to address. I would be wrong to say we have a great relationship with all the communities. We do not, and that is a challenge before us.
As a part of public health, we are engaged in looking at schools. There are 16 school districts within the health region. There is a project called healthier schools, healthier children. The health authorities had many people involved with schools: nurses doing needles, nutritionists dealing with food issues, tobacco reduction people, injury prevention people, the licensing people, et cetera. As a result, we started a large engagement project where we asked the school districts how we could best work with them to achieve healthier outcomes for children and what would be an appropriate role for the health authority. That project is turning into a fascinating discussion, and I can see real movement over the next year as school boards actively engage in it. There is a clear focus. We are not coming to them saying, "Here is this project and could you guys to this?''
The Chair: The healthy schools theme is something we will hope to use very often in our report.
Mr. Frankish, I really wanted to get into something with you, but I will have to do it when we wind up. I will do it privately with you.
Senator Munson: Everyone has to be in the room when this issue is discussed, and the private sector has not been talked about at all. Are they in the room when you are doing these feasibility studies about population health and how it works? What strategic role do they play in terms of funding programs within the core of a city?
We have heard testimony here and elsewhere about how it is working better in the United States with corporations. Front-door people are on the street providing funding collectively to work within the municipal, state and federal jurisdictions.
Mr. Frankish: To date, they are not in the room as often or as prominently as they could or should be. Population health will be limited without their involvement. The determinants of health include employment, working conditions and education, all of which are intertwined with the private sector. I cannot see population health succeeding in Canada without their involvement.
The reasons for doing population health are as much about social productivity, social reintegration and quality of life as they are about health in a health care sense. It demands private sector involvement. They have huge expertise and huge resources; that is, potential resources other than taking resources from the illness care system. They have a lot of wisdom to bring to bear on the issue. We need to get them to meetings like this and engage them in the conversation.
At a small business level, people really struggle. The vast majority of businesses in Canada have fewer than eight employees. I used to do workplace health promotion, and it is easy to talk about BCTel or UBC which have thousands of employees. However, when you talk about what role a small business person can play, you hit the nail on the head. They are about 90 per cent of the businesses in Canada, particularly in smaller rural and remote communities. That conversation has to be more active.
Mr. Baas: I would add one last thing. The researchers have looked at the B.C. Healthy Living Alliance initiative in which the provincial government is engaged. I am not sure if there were comments about that $25-million grant.
The Chair: Thank you to both of you. We are enormously grateful.
The committee continued in camera.