Proceedings of the Subcommittee on Population Health
Issue 3 - Evidence, February 6, 2008
OTTAWA, Wednesday, February 6, 2008
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:12 p.m. to examine and report upon 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 (Chair) in the chair.
[English]
The Chair: Honourable senators, we are delighted today to hear from Pegeen Walsh, Director of Chronic Disease Prevention from the Ontario Ministry of Health Promotion; Dr. Andrew Pipe, Medical Director of the Minto Prevention and Rehabilitation Centre at the University of Ottawa Heart Institute; and Laura Pisko-Bezruchko, Senior Director of Planning from the local Local Health Integration Network, or LHIN, in Toronto.
Pegeen Walsh, Director, Chronic Disease Prevention, Ontario Ministry of Health Promotion: Thank you, Mr. Chairman. I am delighted to be here. I was thinking about history today as I was walking up to Parliament Hill, and I was thinking back to being a 23-year-old walking through the halls of the Senate for a job interview as a parliamentary intern. I remember looking at all the portraits of those who have gone before. It was helpful to think about history, because Canada has been a leader in health promotion. Health promotion offers us a lot of helpful strategies to address health disparities. We have that opportunity to be leaders again.
You have been hearing about lot of innovation across the country, and here in Ontario, some being supported by government and led by government, and many exciting community initiatives. I know you have had a chance to look at some remarks that I will offer today, and I will highlight some of those points that I have shared with you already.
As mentioned, I am with the Ontario Ministry of Health Promotion. I want to talk about some of the innovative things we are supporting, as well as things happening elsewhere in the Ontario government, and offer some recommendations.
Two and a half years ago, Premier McGuinty realized that health is more than health care. I was interested to see, Mr. Chairman, that you were involved in producing the Kirby report. As we saw from that report, your committee did extensive research on the health care system and recognized, in the last chapter of that report, that many other factors affect health. Our premier realized that if we do not start thinking about the aging population and the increasing number of chronic diseases and find more innovative ways to address health, we will see the 42 per cent of Ontario's budget already spent on health care increase, consuming more and more provincial resources.
Our current initiative was created two and a half years ago using concepts coming out of the Ottawa Charter and the Bangkok Charter: population health concepts, health promotion strategies, and the ability to be that champion of health promotion and to create a culture of health and well-being. There was recognition that to achieve that goal, we would need to work in partnership, not only across the provincial government or with other levels of government but with various other sectors as well. We are about 140 people with a $400-million budget, focussing on areas like healthy eating, active living, tobacco control, chronic disease prevention and management, mental health and injury. We also provide support to the public health system in Ontario. I will talk about that in a few minutes. That is a critical partnership for addressing health disparities.
In my remarks, I highlight some different initiatives that are happening in Ontario. Two years ago, we launched a healthy eating, active living plan, recognizing how critical it is that people have information about how to eat and make healthy choices. We created something called EatRight Ontario. EatRight Ontario is a free information service. By phone or online, Ontario's citizens are able to have access to registered dieticians so they can get firsthand knowledge of how to address their eating issues. This is especially important because Ontario has one of the lowest number, per capita, of registered dieticians in the country. Especially for those living in remote or rural areas, having that access is critical.
You might also have heard about our northern fruit and vegetable pilot project. We know there are children in parts of Northern Ontario who are not eating enough fruits and vegetables for proper growth and development. It is important for kids to be able to taste and experience fruits and vegetables so that they can make those items part of their daily diet. Working with the Ontario fruit and vegetable growers, public health and school boards, we launched an initiative a year and a half ago and are now reaching up to 12,000 children in northern Ontario in elementary school, who are getting three servings a day of fruits and vegetables, mainly Ontario grown. They are not only receiving those fruits and vegetables but are having a chance to learn about the importance of fruits and vegetables in their diet; their parents are also being exposed to that educational material, and it is being incorporated into the curriculum.
We have also been looking at ways to remove barriers to physical activity. We know it can be difficult if children do not have access to recreational facilities, equipment or support. Through our Communities in Action Fund, we have supported over a million children through different kinds of initiatives, and you can see a list of the groups we are working with. We are especially excited by work that Parks and Recreation Ontario are doing as they look across the province to see what policies need to be in place to remove barriers to physical activity.
In the area of tobacco control, we are not only working on the programming front but on policies as well. For example, last spring we were able to remove the retail sales tax so that we could make tobacco cessation aids more affordable. We are also working with community health centres and Aboriginal health access centres because they have terrific connections into communities that have a lot of barriers accessing services, and they are not only providing free access to those cessation aids but also providing counselling as well. I am sure you will hear from my colleague about some of the work that has been taking place in the hospital setting around tobacco control.
I mentioned our role vis-à-vis public health. Our ministry provides 50 per cent of the funding that goes to the public health system for those programs that are in the health promotion domain. Recently, we have been working with the 36 public health units across Ontario to update the standards that guide their work. When you have a chance to see those, and the new standards are available on line, you will see that woven throughout is a recognition of the critical role of the determinants of health. Unless we start tackling those other factors such as income, employment, healthy child development and working with a range of sectors in those other determinants, we will not see the kind of improvement in health status that is needed. Some 7,000 professionals in the public health system are poised and ready, and for a long time have been making significant progress on reducing health disparity.
In Ontario, we have a unique system of health promotion resource centres that provide support to those working in the health promotion domain. They provide resources, information about effective practices, training and consultation services. For many of those who are new to health promotion, they are able to provide on-line courses around the concept of population health and understanding the determinants of health and how to find effective strategies for putting those concepts into practice.
I have described some of the work of our new Ministry of Health promotion, but as I mentioned at the beginning, it is critical that we work in partnership with others because we know so many of those other factors affect health. I want to touch on some of the initiatives that are happening elsewhere in the Ontario government, whether in the area of education, children and youth, Ministry of Health or work that is under way around poverty and equity.
For the last decade, our colleagues in the Ministry of Children and Youth have been supporting something called Best Start and Healthy Babies, Healthy Children. This is a universal program that is screening all new moms to ensure that they get the supports they need to promote the healthy growth and development of their children.
As a result of the coming into force of the Health Systems Integration Act, the Ministry of Health will now be devising a 10-year plan for health. In this plan, it will set out goals, outcomes and strategies. This is critical because once the ministry starts defining those goals and looking at health outcomes, one cannot help but start peeling those layers off the onion, looking at root causes and realizing that more investment in health care will not necessarily improve health status.
The fascinating thing about the development of this plan is that, during consultations, as they travelled across Ontario and heard from thousands of groups and individuals, the overwhelming response was that there needs to be more emphasis on keeping people healthy, preventing disease and focusing on health promotion strategies. This response came also from those who had no history or involvement in health promotion.
The province, in recognizing this goal, has also been doubling the number of community health centres, which take a more holistic and integrated approach to health, working at the community level with a range of health professionals. The government has made a commitment to a $150 million chronic disease prevention and management strategy. Work is under way to look at implementing that commitment.
In the last year, the Ministry of Health has created an Equity Unit. The purpose of that unit is to look at the strategies needed to reduce barriers to health and human services, and work with ministries across the provincial government.
You may also have heard about the creation of a new agency called the Ontario Health Protection and Promotion Agency. This unit will provide us with a locus of expertise, not only to look at issues of infectious disease but, more important, on how to keep people healthy, and how to have that scientific expertise and knowledge about health promotion and strategies for reducing health disparities.
The Ministry of Education has been working very closely with us around a foundation for building healthy schools. For the first time, we have created a table bringing together those in the education sector with those in the health sector to look at ways to start using the school setting as a means for promoting health. As well, the government is committed to improving graduation rates, supporting at-risk communities and a number of other initiatives outlined in my remarks.
Committee members may have been reading in the paper recently that a new cabinet committee has commenced looking at issues of poverty. This committee is tasked with setting targets and indicators. It is early days for that committee, but they will be looking at the role of different ministries across the provincial government and what more needs to be done to reduce poverty and provide opportunities for Ontarians. As part of that, there is also a commitment to a dental program for low-income Ontarians.
Honourable senators, that gives you a picture of our ministry and some of the things that are happening within the Ontario government. I would like to take a few minutes to offer some recommendations for consideration by your committee.
While health is primarily a provincial jurisdiction, the federal government has many levers at its disposal. It can support new policies; it can provide funding; it can support evaluation and research and generate new knowledge of what is working. Most important, it can create collaborative mechanisms. Often such mechanisms are overlooked in terms of collaboration because they do not necessarily provide a program or initiative where people can stand back and say ``Look at what we have created.'' However, by creating those mechanisms that bring people together, it can build on synergies and exchange knowledge.
Looking at my colleague, Dr. Pipe, I am thinking about the work that has taken place in tobacco control. The infrastructure that was thus created allowing for local, regional and provincial planning has permitted significant progress to be achieved. It would be helpful to not only build on the federal-provincial-territorial mechanisms that exist but also to look at what kind of collaborative mechanism across the federal government can bring departments together for joint planning and best use of resources.
Ontario has been calling for the national government to invest in an infrastructure program because we need those facilities to increase access to recreational programming. We also would like to see a revival of the Pan-Canadian Healthy Living Strategy, something the federal government started several years ago that really used population health concepts and reducing health disparities as its foundation. Unfortunately, we seem to have moved to more disease- specific strategies and value more an integrated approach to tackling chronic disease prevention.
As I mentioned at the beginning of my remarks, we had the minister of Health Canada in 1974, Marc Lalonde, who provided a report on new perspectives of health. That report laid out many of the answers to the questions on which this committee is now deliberating.
Then we had Canada at the forefront, working with the World Health Organization in 1986, bringing health promoters from around the world together to create the Ottawa Charter, which has been confirmed in subsequent meetings as providing that road map for the way ahead.
As set out in the Health Council of Canada's report in 2005, a group of experts in health care spent extensive time looking at how we can strengthen the health care system and concluded that the major barrier to strengthening health care had to do with reducing health disparities. Their message was to raise awareness and understanding about how critical those other factors that affect health are to improving health.
We do have examples of other governments. For example, recently in England we saw an almost $1 billion commitment made to tackling obesity. We know that, so often, those who have low incomes and low education have the highest rates of many chronic diseases.
We do have the road maps; we have many of the strategies; we have the public's growing interest and recognition of how critical it is to focus on keeping people healthy. As I mentioned, there is much innovation. I highlighted some of the things that are happening in Ontario and you will have a chance to hear of things happening elsewhere in the province.
I congratulate your committee for taking on this issue and using it as an opportunity to bring it to the public's attention and offer concrete ways in which we can work as governments, as communities across the country to reduce health disparities.
The Chair: Thank you very much. That was an excellent presentation. For those of you around the table who are not familiar with Ontario, the Local Health Integration Networks, or LHINs, are the local organizations. They are not exactly regionalized as yet, but I think we will get there. They are a giant step forward in Ontario in an attempt to get services on the ground in the province.
Ms. Pisko-Bezruchko, perhaps you will tell us about the LHINs and then what you, specifically, are doing. Also, If you and Dr. Pipe could each keep your remarks to 10 or 12 minutes, each senator will have about 10 minutes to cross- examine you afterwards.
Laura Pisko-Bezruchko, Senior Director, Planning, Toronto Central Local Health Integration Network: I am the first senior director of planning, integration and community engagement for the Toronto Central Local Health Integration Network, commonly known as LHINs. When I started two years ago, I walked into an empty office. I had no distribution list of stakeholders, nothing. When we called people to say that we are the LHIN, we would get, typically, the response: ``LHIN who?'' We are still in a state of newness, if I could put it that way, in Ontario. Generally, the public does not understand what a LHIN is, or what it is about.
I will tell you a little about what the LHIN is. I will talk from an operational perspective in terms of what we are about at a very local level with respect to population health and planning, and funding a health care system. Thank you very much for inviting me to participate in this panel to talk about our work on population health.
I will make three main points: First, I will talk to you about the reality of a high density and diverse urban community and how we have built an understanding of the broader social determinants of health into our planning and priority setting. Second, I will talk to you about how we have undertaken community engagement to guide and ground our core businesses of planning, integration and funding local health services. Third, I will explain how we have come to see addressing health disparities as a defining priority for our LHIN, and how principles of diversity and equity are central to our work.
What is an LHIN? In particular, the Toronto Central LHIN is one of 14 Ontario Crown agencies established in 2006 under the Local Health System Integration Act. If you looked at a map, you would see that the Toronto Central LHIN hardly appears; we are commonly known as the ``Postage stamp LHIN,'' as contrasted to the northwest LHIN, for example, which is the size of France. There is a huge amount of variation among the LHINs. Our mandate is to improve the health of local residents through better access to high-quality, coordinated health services and to manage the local health system effectively.
Although we are a made-in-Ontario regionalized model, we do have similar functions to other regional health authorities in other provinces. In the Toronto Central LHIN, we manage $4 billion worth of health services, but that does not include physician services, public health emergency services, such as ambulances and laboratories, among others.
The Greater Toronto Area has been divided into five LHINs. We are the only one that is totally within the city of Toronto and we fund 196 different agencies, many of which operate different programs and are located on multiple sites. We have adopted a population health lens in our community engagement and planning. We have one of the largest populations, about 1.2 million people, and we have the highest concentration of health service providers of any Ontario LHIN.
As the only wholly urban LHIN, the Toronto Central LHIN must respond to a unique set of socioeconomic circumstances, needs and complex factors such as demographic, cultural and linguistic diversity, sexual orientation and inner city disadvantage. Conditions such as income inequality, homelessness and addictions must be considered when we plan and evaluate health services in Ontario. A snapshot of our population shows that we have wide income disparity, some of the lowest income households and neighbourhoods in Ontario and Canada, and some of the highest income and highest education neighbourhoods.
We are the first home for recent immigrants and refugees, and our residents come from over 200 countries of origin and speak over 160 languages and dialects, adding to the complexity of the work we undertake. In socio-economic terms, we have high rates of lone-parent families, low income population, people with low English language fluency, people with HIV/AIDS, and seniors living alone. We have a high concentration of people who are homeless, including people who are mental health consumer survivors and people with serious substance abuse problems.
We have a daily inflow of commuters. Approximately half a million people come into the Toronto Central LHIN, many of them preferring to use Toronto Central LHIN health services. We have stark disparities with respect to health outcomes and access to health services. For example, the percentage of people reporting health as poor or fair was three times greater in the lowest income groups compared to the highest in our LHIN.
We have the fastest growing and highest incidence and prevalence rates for diabetes in Ontario. We have diabetes rates that are higher in neighbourhood areas with a higher proportion of recent immigrants and people with limited English language fluency.
Within our neighbourhoods, recent immigrants are less likely to have a regular family doctor than the rest of Ontarians. They are likely to report more unmet health needs and are two and half times more likely to report difficulty accessing health care, and they use fewer preventive services.
Despite significant effort and resources on the part of the Toronto Central LHIN to increase access to hip replacement, we know that significant unmet needs exist. For example, despite poor health and higher number of visits to physicians for arthritis in lower income neighbourhoods, Toronto Central LHIN residents in such neighbourhoods were 60 per cent less likely to have a hip replacement than people in highest income neighbourhoods. That is one example of the many kinds of disparities within our LHIN.
Acting on and understanding social determinants of health is a core planning principle for us, and I will outline how that has evolved. We have built in health equity from the beginning of our two and a half years of existence. As the LHINs were first being established by the Ontario government, working groups of service providers, community agencies, researchers and other stakeholders were set up in each LHIN area to identify initial priorities for integration. The need to address underlying social determinants of health and health disparities were central priorities identified by these groups in the Toronto Central LHIN report. We have validated and built on this report. We knew that extensive community consultation and engagement was an essential building block for effective and responsive health planning and that the process must be iterative.
Since 2006, we have engaged in a dialogue with those who live, work and use services in our LHIN. Nearly 7,000 people and over 200 health service organizations have been consulted in this short period of time.
I will not go through all the messages we have here, but some of the messages are consistent with what was outlined by Ms. Walsh. We need to pay attention to the social determinants of health. We need to improve access to services for seniors in particular, those with mental health and addictions and those with special needs who are often overlooked, such as our transient Aboriginal population and homeless population. We need to include health promotion and education in our planning. When we talked to people, they told us not to focus only on disease and sickness but also on wellness and health promotion.
Our first strategic plan arose out of our consultations as well as a review of previous planning studies and research. Our first plan, called the Integrated Health Service Plan, identifies an action plan for key clinical areas such as the ones I have outlined, as well as rehabilitation services, administrative health and long-term care provincial priorities, such as the wait-time strategy.
As well, it defines key enabling priorities for system transformation, such as e-health, back-office integration and health human resources, addressing health disparities through improved access and navigation, quality of service. More efficient and effective coordination of services is fundamental to all these clinical areas. For example, our priority on seniors focuses on increasing available supports for marginalized seniors who need assistance to navigate their way through the health system. I am sure we all have our stories about how hard it is to get the services we need for our loved ones.
Recognition of the social determinants of health is a core planning principle, and I have provided a current case study on how we are incorporating these principles and practices. In the interests of time, I will leave that with you.
We have ensured diverse, broad community and stakeholder involvement to move our Integrated Health Service Plan priorities to implementation stage. We have established action-oriented, multisectoral advisory councils for each of the priority areas as well as forums and mechanisms to involve local residents in the implementation process. When we first started, health service providers told us that we should not and could not do that, but we did, and we have proved them wrong.
We have begun work to develop a solid policy framework for addressing health disparities. Our board has established a task force of board staff and community members, and we have seconded an experienced expert to help develop our road map for health equity. We are looking at the best of what is working well locally, across the country and abroad. We are building on the capacity of our large number of health service providers and strong academic and research community in Toronto. While we do not have a complete road map yet, we expect it will include components, for example, the identification of priority challenges, such as systemic barriers in the form of policies and regulatory issues, limited access to primary care, language barriers, the issues that many disadvantaged populations face and the problems that have the most potential for being fixed easily or having the most positive impact on disadvantaged communities.
One challenge is that we do not always have reliable, timely data, for example, on health needs and services used by ethnocultural groups and new immigrants. We are attempting creative ways to match up data sources, and to relate databases to one another so that we can uncover diverse health needs and preferences.
Given our limited resources, we cannot address all of our issues immediately. We need to plan carefully for how, over time, strategic investment and intervention will have the most impact. To date, we have been reaching for the low- hanging fruit, as we call it — the initiatives and things that have already been started in our community that we can expand from a pilot stage or demonstration project to something that is more systemic across our whole local health system.
We have been identifying solutions through work with health care providers and others, and we know this will work only through partnerships and collaboration. We have begun to work with health service providers so that equity is built into their service delivery and organization. For example, our board has requested that all 18 of the hospitals that we fund in our LHIN, which accounts for $3.2 billion of our $4-billion budget, develop and submit concrete plans to address health equity. We expect that the plans will demonstrate innovation and address disparities. For example, a hospital may decide that building partnerships with community-based agencies for outreach and follow-up to specific populations or neighbourhoods is necessary.
Our board has made health equity a priority. Accordingly, our roadmap will begin to identify clear objectives and performance metrics against which we can measure our progress. For example, a success indicator could be increasing access to defined services in a disadvantaged neighbourhood area or setting targets to reduce differences in utilization of particular services such as the hip replacements that I mentioned earlier.
We have begun work with health service providers to build concrete expectations into our funding and accountability relationships with them, using the levers that we have to advance health equity. The LHINs have significant powers to ensure accountability of health service providers under the LHIN founding legislation. We have powers to make integration decisions that are in the best interests of the public. We can build equity expectations and indicators into the service accountability agreements with our health service providers.
For example, we could require each hospital to demonstrate that its service utilization patterns reflect the diversity of its patient population. Some expectations may need to be very specific; for example, demonstration by downtown hospitals that they provide appropriate and adequate services to homeless people. Many other things could be thought of.
As you may appreciate, the LHIN must make informed but often difficult decisions for effective allocation of scarce resources. We know that we must first identify the barriers that disadvantaged populations face. To do this we are building diversity and equity lenses into our decision-making and funding allocation processes and tools. We will consider targeting new investment in programs and services where they will have the most impact on reducing health disparities; for example, concentrating new services in disadvantaged neighbourhoods, investing more in community- based services such as multi-disciplinary care teams that have been shown to be effective in supporting disadvantaged populations; funding community-based health service providers to deliver culturally-appropriate chronic disease prevention, management and wellness programs to ethnocultural communities that may face language and cultural barriers.
We know we have health disparities on many fronts. While this may be daunting — and some days it does feel very daunting — we have, since the beginning of our mandate, recognized the tremendous assets and strengths to be built on in our community, even within the most disadvantaged communities. We are unique among Ontario LHINs in that we have a rich concentration of health research and knowledge in our major academic institutions in 18 hospitals. Another asset is the depth and diversity of community-based service providers. Thus, a key part of our strategy is to build on and support existing networks of health service providers and experts, support leading practice innovative programs that address health disparities or the unique needs of disadvantaged populations, support innovative demonstration projects to build evidence, support community-based or other research to identify promising practices, and build evaluation into our health equity initiatives.
We know that reducing access barriers and increasing coordination of health services to support those experiencing health disparities will never eliminate those disparities. The roots of health disparities lie outside of the traditional health care system. As you know, the LHIN cannot build affordable housing, increase literacy or reduce poverty. However, we can draw two conclusions: LHINs are now an integral and important part of the Ontario health system with a mandate to make system changes to improve the health status of the population we serve, in part by improving access to the health care they need and making strategic decisions about integration of the system components. Second, our LHIN must work to take the broader social determinants of health into account in creative ways.
We are looking to develop or join appropriate local cross-sectoral collaboration and planning forums and tables with the municipalities, schools, academic institutions, social services, immigrant settlements and other sectors beyond health. We are supporting innovation among our health service providers for coordinated cross-sectoral service delivery.
For example, within our LHIN, new community health centres are creating partnerships for co-located child care, employment support, family services and others. We are looking to provide coordinated, one-stop access to the almost 200 health service providers in our LHIN and expanding that to include referrals to social services. We are developing an electronic inventory of programs and services for consumers and providers that will be searchable by neighbourhood area, and in the future we will be available in multiple languages.
Finally, we are enabling relationships with grassroots groups that have not traditionally been funded within the traditional health system. The Toronto Central LHIN is at the beginning of our system transformation journey, a journey that we hope will ultimately mean a healthier population using a more accessible, equitable and coordinated system of health services.
Thank you again for inviting me to present before you. It has been a great honour and privilege to be here today, and I look forward to your questions.
Dr. Andrew Pipe, Medical Director, Prevention and Rehabilitation Centre, University of Ottawa Heart Institute: Thank you for the compliment of the invitation to be here today. I will try to be brief and move us to a slightly different level. It is embarrassing, or somewhat depressing, for me to realize that I am approaching my thirty-fifth year of medical practice. Throughout much of those 35 years I have been very involved in approaches that have been designed or intended to prevent disease or to promote health.
I well remember the ringing declarations of the Ottawa Charter, the Victoria declaration and the Lalonde report. I am getting a little frustrated because we have been very good in Canada at producing ``roadmaps.'' This is a country, as one of your colleagues once said, ``of pilot projects.'' In my new role at the University of Ottawa Heart Institute, I am determined to attempt to move beyond the rhetoric and try to realistically apply evidence-based, best-practice programs to address some very real disparities in our area and to use population-health and best-practice approaches in an attempt to transform the health status of the residents of our region.
Twenty years ago, I sat as the vice-chair of a ministerial advisory committee on health promotion and disease prevention for the province of Ontario. I followed that by sitting on the premier's councils on health in the province of Ontario. Therefore, I am personally familiar with the abundant literature that describes how we might do things better. Ladies and gentlemen, I want to start doing some of those things. I want to share with you today some of the experience in our region of the province and of Canada which demonstrates vividly some of the health disparities present in our population and which also provides an example of how we might utilize various segments of our system in an integrated manner in order to begin to address them. I will then conclude with the identification of some of the roadblocks that seem to impede our moving forward in this way.
I will first draw your attention to a map of the Champlain district. It is a unique LHIN in Ontario because it is co- terminus with three public health units. It is unique as well because this, after all, is the very heart and soul of the province. You find communities such as Pembroke nestled within the corner of this LHIN. It is a microcosm of Canada. Twenty per cent of the population is francophone. We have Aboriginal communities; we have a large urban centre in Ottawa-Carleton; we have remote communities; and we have service-based smaller urban areas. If we can make things happen in the Champlain region, we can provide a model that might be replicable for the rest of our province or other areas in the country.
On the chart entitled ``Risk Factor Profile,'' you will see in the four columns with circles a marked expression of the disparities that exist. The bottom row provides an outline of figures for the city of Ottawa. I draw your attention to the city of Ottawa and its cardiovascular disease mortality rate — the furthest left column. That rate is 186.5 per 100,000 persons. If you move east, west or south 20 minutes from the city of Ottawa, you are in communities that have rates of mortality 50 or 60 per cent higher than that of Ottawa. Similarly, the risk factors identified in the remaining three columns with circled data show that exactly the same disproportionality exists between and among the regions of our LHIN, the risk factors and, therefore, not surprisingly, ultimately the morbidity and mortality of our citizens.
Recognizing these inequities, my colleagues at the University of Ottawa Heart Institute, long-schooled in the obligation and professional responsibility to serve the total community, decided that we would try to address, to the best of our ability, these disparities, given our role as a tertiary care organization, and use our credibility to catalyze the creation of the Champlain Cardiovascular Disease Prevention Network which might, in an integrated, cooperative, collaborative manner, using public health units, community health centres, voluntary health organizations, the education sector, the tourism and recreation sector and others as well as the health sector, begin to address these disparities and in so doing enhance the cardiovascular health of our communities.
En passant, it is very important to point out that if you address cardiovascular disease risk factors, you address virtually all chronic disease risk factors. As I am sure you are aware, we are facing a tsunami of chronic disease. In the next five to 10 years, public policy experts will be grappling with the challenge of how we possibly provide the chronic disease services that our population will require, just projecting the trends that we know are evident today. That is all the more reason we start to not only think outside the box but, if you will forgive me, build better boxes in terms of the way we begin to approach these kinds of problems.
We also identified for ourselves some targets. We would hope that we might be able to reduce premature deaths from cardiovascular and other forms of chronic disease — although this is just cardiovascular disease, heart disease, stroke and diabetes in this particular data set — by between 5,000 and 10,000 premature deaths by the year 2015. That is a pretty ambitious target, but there are things one can do simply by doing ordinary things extraordinarily well that might allow and permit you to approach the targets. You will have seen that we have identified specific targets for risk factors. I realize that I am using very much a medical model series of data, but in order to address that medical model series of data, it will be necessary to use a variety of social interventions, not the least of which will be to address some of the social inequities in our community.
The pyramid that appears on one of these charts indicates that we are hoping to be acting and active at each of these three levels. We want to act with the broad expanse of the general population so as to reduce the likelihood of risk factors ever developing, and that is where the greatest return on our investment will come. We want to act with those people in whom risk factors have become evident so they do not ultimately fall victim to the diseases that those risk factors would otherwise portend. We want to have state-of-the-art secondary prevention processes in place so we are doing what we know to be best practice in terms of the management of those who fall ill as a consequence of our inability to intervene earlier with these other kinds of interventions.
In the moments that remain, let me give you a few examples of the way we are proposing to do this. We want, for example, in our region, in an integrated fashion, to operate at the level of the primary care practitioner, at the level of the hospital, at the level of the school system and community, and involve and engage all of the communications apparatus available in our region. I have picked out two examples that I think are intriguing and which apply a population health approach.
The first uses the population of all of those admitted to hospital. In Canada, if you are born in a hospital, within half an hour of being born, someone has to drop antibiotics in your eye to address neonatal conjuctivitis and someone has to collect urine from you in order for us to check for phenylketonuria. If you have foetal ketonuria. In many hospitals in Canada, you do not leave that hospital as a newborn unless accompanied by a nurse who makes sure that, as you go to the parking lot, you go home in an approved child seat properly installed in a car. Who would argue about those interventions? However, what if you go into most Canadian hospitals and ask how many patients admitted to your hospital last year were smokers? There is an embarrassed silence. Tobacco addiction is Canada's leading cause of preventable disease, disability and death, but our hospital sector until very recently has allowed this issue to fly below the radar.
At the University of Ottawa Heart Institute, we have developed what is now being referred to nationally and internationally as the Ottawa model, a process in which we identify every single patient admitted to a hospital as a smoker or a non-smoker and offer sensitive, non-judgemental and appropriate assistance to them as they deal with nicotine withdrawal while in hospital in an effort to significantly enhance the likelihood of their stopping smoking thereafter. The savings to our health system, if we could reduce smoking by even a small percentage in our population over the next decade, is incredible. The most powerful way to reach this population, if you do the numbers, is to multiply the number of smokers admitted to Canadian hospitals by the number of hospitals and apply this particular stratagem; the impact would be profound. We can do some very innovative things in the hospital setting to address this major public health issue.
Let me draw your attention to the issue headed dietary salt intake, which is another example of an approach that we would encourage you to examine from a truly population health perspective. Your average ``free-grazing'' human being, were he a hunter-gatherer a few centuries ago, would require only 1,500 milligrams of salt a day. Our bodies are constructed to operate on that intake. The typical salt intake of Canadians is more than two and a half times that today. If we could just reduce salt intake, we could significantly reduce, on a population level, the blood pressure of Canadians, which would allow us to reduce by a factor of 12 to 14 per cent all of the strokes in Canada. We would reduce the number of premature heart disease deaths and, overall, dramatically have an impact on the health of the population. Ironically, the population is in some ways powerless to influence its salt intake. Why? Even if you take the salt shaker off the table, most of the salt we get comes in the processed or refined foods introduced by the food industry. A population health approach that said we will introduce public policy, as has been introduced in the United Kingdom, Sweden and elsewhere, that mandates the reduction of sodium in our processed foods would very easily accomplish a profound and significant reduction in premature morbidity and mortality. Food policies of the past have often dramatically influenced the health of the community, an example of which were the public policies introduced in Europe in the 1930s, of which frankly I am a beneficiary. As a result of the growth deprivation and resulting intellectual deprivation that was commonplace in Europe in the 1930s, European governments introduced policies that subsidized the availability of milk and high-fat foods and orange juice. As a child in England, I got fed a lukewarm, rancid bottle of milk every day at recess, which may account for the fact that I am six feet tall. Those public policies dramatically addressed the unfortunate situation that had existed in Europe.
A great biologist and philosopher once said that every society has a pattern of disease unique to it. Any force or factor that changes the social or physical environment will necessarily produce a change in the nature of the diseases that society addresses. Ladies and gentlemen, 40 per cent of Canada's children already have one major modifiable cardiovascular disease risk factor. They are obese and inactive. That is precisely as a consequence of the fact that we now have what has been described as an obesigenic environment. It will take population health approaches reflected in sensitive but strategic public policies if we are to redress those environmental circumstances and forestall that oncoming tsunami of chronic disease.
In the Champlain region, we are beginning to look at the ways in which we can, in our particular part of the province, affect these kinds of changes. We are looking at the ways we can work with urban governments and urban planners. We are trying to transform primary care practice and integrate in a coordinated manner the way in which we manage chronic disease. It has been said that it takes a health professional to diagnose a disease, but it takes a system to manage it. To this point, our systems have been fragmented; that must change.
This is a brief snapshot of what we are about in our region and what we aspire to. What is precluding our being successful? It is that the reallocation of resources has not kept up with the rhetoric. We have had three decades of rhetoric about the need for the prevention of disease and the promotion of health, but the funding mechanisms have not yet reconfigured themselves to facilitate the development of these kinds of integrated, state-of-the-art, evidenced- based, best practice models. Anything, ladies and gentlemen, that you can do using your good offices to influence public policy thinkers in this respect would be very welcome and I would argue is long overdue.
I thank you so much for taking the time to indulge me in this way this afternoon and I would be happy to respond to any of your questions, comments or criticisms.
The Chair: I understand Dr. Pipe has to leave at 5:30, so honourable senators, those of you who want to have at him, go right ahead, because I have never been able to handle him. I have tried for about 30 years.
I want to thank all of you, and it is wonderful to see the way the universe is unfolding in Ontario, I must tell you. That is not to suggest that everyone is happy with the LHINs and the way they are designed, but I must admit I think Ontario has, right now, one of the best ministers of health it has ever had. His heart is in the right place.
Senator Eggleton: I will pass that on to him.
The Chair: It is a fact, because he is moving in the right direction.
I have been surprised that the witnesses coming before us have never really referred to the point that Romanow made in his report, and that is that 50 per cent of disease arises from social determinants; 25 per cent of disease is dealt with through the health care delivery systems, yet we spend $140 billion flat right there. We spend virtually nothing on the 50 per cent that is related to the determinants of health.
Dr. Pipe, you raised the point of how we can get there. I will ask all three of you, but let me prime it a little bit. It is too bad we could not have had someone with the public health agency with you today. We have had them here but we could not have them today. It would have been interesting to have someone from the Public Health Agency of Canada with you, Ms. Walsh, Ms. Pisko-Bezruchko and Dr. Pipe, as we go from the top to the ground in the system.
I want to ask all of you because Ms. Pisko-Bezruchko mentioned repeatedly the community health centres. I think our report will be advocating more community health centres in a very strong way. At that level, they can integrate with the other centres, and so forth, and with the other determinants of health.
I do want to ask all three of you to comment on how we, as a committee, can finally impress the powers that be in Canada, including our citizenry, that we are not investing in the right place and that we have to change our thinking. We are about fifteenth in the world in health status and our health disparities are truly awful.
Ms. Pisko-Bezruchko's LHIN is tremendously interesting because there are terrible health disparities right there. We are blessed to have among us the former mayor of Toronto, who will be questioning you in a few minutes. I am not saying it is his fault.
Let me focus this: How can we get a system on the ground that can integrate the agencies, can deal with the homeless, with poverty, with food banks, with education and the other eight or 10 forces that are the determinants of health? Can we do this through the health sector alone with the community health centres? I do not think so. How do we get the community health centres built with the social services and plugged into the schools and that kind of thing?
Ms. Walsh: I was thinking about the Champlain LHIN because you have brought together public health and many other organizations with the health care sector. Public health has a long tradition in Ontario of using a determinants- of-health lens and reaching out and looking at the workplace, looking at the education sector, working with homeless and what have you. It is this kind of infrastructure, a collaborative mechanism, that allows people to come together and supports that planning.
The other challenge is then the resources that will be invested in those other aspects as you mentioned, because if you look at the amount of funding going into health care, versus strategies that are trying to prevent disease and promote health, in Canada it has been approximately 2 per cent to 3 per cent. That is a huge imbalance.
The other thing I want to mention is that I think in Ontario many communities also see the school as an important hub for reaching out to the community and providing a range of services. This is something we are seeing in Ontario, with the Ministry of Education, is how to build different initiatives through the school at the community hub as well.
Ms. Pisko-Bezruchko: From my two years in the LHIN, one of the observations I would have is that we need a mixture of approaches: we need a top-down kind of approach and we a need a bottom-up approach, and we also need something in the middle as well. We have paid a lot of attention to the top-down and we have paid a lot of attention to the more powerful voices in our society, and it is time to really let the grassroots have a say. That is part of the mandate of the LHINs.
We are premised on community engagement, working with the public, ensuring that their voices and their needs are heard and that they have a role in decision-making about the system that they want. They are clearly articulating in our LHIN that it is not just a health system they want, it is a health and social services system, it is healthy neighbourhoods, healthy communities. It is a very broad picture that Ontarians bring to the table. They do not think in terms of the traditional health care system when they start talking about their health. They talk about their families. The majority of them are the caregivers in our society. For seniors, 80 per cent of the caregivers are family and friends. They are not paid workers. They bring that bigger picture to the table and we need to keep listening to them and try to build their ideas into the system.
Ms. Walsh mentioned earlier that the Ministry of Health in Ontario is coming up with a 10-year plan. It is important that we have a longer-term vision for where we want to go. We hear over and over again that we have been talking about this, and I think Dr. Pipe has said this as well; we have talked about it and talked about it, but we need something that crosses political agendas, crosses terms, if I can put it that way, that are longer. We need something that will really excite people and make them want to mobilize and come together.
One of the things that we are doing in our LHIN now is working on an aging-at-home strategy, which the government has announced; the Minister of Health announced a $700-million strategy. Part of that strategy is very exciting. It is building on grassroots organizations and the volunteerism that exists within our communities now, starting to look at what they are doing and building new ways of caring for people, supporting in this case seniors in the community.
We need to bring to bear the partnerships and the collaborations that I think all three of us have talked about, not only at a government level or not only in the traditional health care system or social services system, but all the other people. It will take multiple levels of government. I am not sure how you get there but I think, in Ontario anyway, we recognize that the federal government has to work in partnership with the provincial government.
One of the things I see as really important for helping us get an integrated system is electronic technology, information systems, to help people navigate through what is a really complicated system; not just health services but also the social services.
I am sorry I took so long to say that, but I feel passionate about it. The time is right for action. There are many pieces positioned well and we can really make some progress.
Dr. Pipe: We have a major challenge in terms of public education. While I think we are all agreed on the wisdom of the kind of approach that we have been supporting; I am not sure that the public is necessarily there yet. I think that notwithstanding our experience in some sectors, the public still equates health with access to health care facilities and health care professionals. I am not sure that when I go back to my hometown of Avonmore, Ontario, which is near Cornwall, that the kind of conversations that I am likely to have with people on the street will necessarily reflect an appreciation or understanding of the social determinants of health. We have a huge challenge to put this into perspective. A huge agency like the Public Health Agency of Canada can be very helpful in trying to stimulate the kind of discourse that will be necessary.
Ms. Pisko-Bezruchko has already mentioned that we need to stimulate longer term horizons in terms of political thinking. We must try to encourage our politicians, whom I admire. The task they do is unbelievable and the thanks they get are minimal, but we have to encourage them to take more than a short-term electoral cycle perspective. We need to try, if possible, to de-emphasize the back door approach to health policy through making partisan issues out of things that relate to access-to-care issues. I do not mean in the broad sense, but they immediately score some political points on these kinds of questions.
There must be an elevation of public consciousness. That will also be assisted by the changing demographics. As more of my generation become involved in caring for our parents, we will, all of a sudden, understand the importance and necessity of the integrated services, which our European colleagues have taken for granted for decades.
Finally, there are the information systems. I am embarrassed when I go outside this country and look at the information systems to which my colleagues in other health systems have access. We have gerbil-powered information systems in many of our institutions in Canada. If we are to manage chronic diseases, we need the ability to address and assess an array of factors that will simply not be possible unless we have information management tools like a universal electronic medical record at our disposal.
Senator Eggleton: Thank you very much for your presentations. I will try to get a few quick questions in here.
Ms. Walsh, you have outlined in your presentation what the Ontario government is doing in areas that relate to the social determinants of health. You have talked about the health care system, as is always part of it, but also the education system, tobacco control and the cabinet committee that is dealing with poverty reduction headed by Minister Matthews. These things seem typical to what government does. It does it in a silo context; vertical, up and down. How do you bring about coordination of all these? How do you bring about a coordinated set of priorities and strategy to deal with all these social determinants of health in some comprehensive context, as opposed to the traditional silo method?
Ms. Walsh: I am thinking about the interministrial committee we had on healthy living. When the Ontario Ministry of Health Promotion was created two years ago, part of the mandate of our minister was to create an interministerial committee that allowed our minister to look across the provincial government and see what other ministries were doing. It was a chance to create that inventory and to address how to better coordinate it. Coming out of that, we created various initiatives such as the healthy schools framework and the fruits and vegetable initiative that I talked about earlier. We are looking with the new minister at a new mandate. That is, what kind of system can we support that will bring together the cross-government planning? I am not as familiar with the poverty committee because it is just getting under way, but my sense is that is how the government is looking at it, namely as a vehicle to use that lens across various investments and initiatives to see how those different activities can provide opportunities for Ontarians and lift them out of poverty.
Senator Eggleton: You are saying there is some coordination. What about at levels below the ministerial level or the central Government of Ontario level, the LHIN, for example, or other entities. Is there a message going from the government to them, from the premier to them, saying that we want you to take into consideration all of these social determinants of health; that is, a population health approach? Are they being encouraged to do that?
Ms. Walsh: I am not in the Ministry of Health but they have created a new equity office. That office has started to look at what kind of plans can be put in place that looks at the health and social side. That equity office has brought together officials from across Ontario who must start using that lens. Again, it is early days. I can provide you with a contact name and information for the kind of work that is happening. That is a very exciting development because it is working at an official's level.
Senator Eggleton: Let me move over to Ms. Pisko-Bezruchko. I think I have some understanding of the LHINs, but I am not sure if it is correct. Who makes up the LHIN? Who comes to the meetings?
Ms. Pisko-Bezruchko: To our board meetings?
Senator Eggleton: Yes.
Ms. Pisko-Bezruchko: Our board meetings are comprised of appointed individuals from within the community. They are appointed through order-in-council by the provincial government.
Senator Eggleton: They are not necessarily representing the stakeholders such as the hospitals?
Ms. Pisko-Bezruchko: No; they do not. They represent the community itself. Currently, our board has three vacancies. They are recruiting with an interest to reflect the diversity of our community.
Senator Eggleton: My impression of the LHIN is that it has been primarily focused on health care professionals or the institutions, the hospitals, et cetera, looking for money and that entire sort of stuff. You have a lot of big hospitals in the central LHIN, but you mentioned homelessness about three times. What do you do specifically, or what do you see as being done specifically on homelessness? Is it something that is a topic of discussion frequently at the LHIN meetings as opposed to talking about hospitals all the time?
Ms. Pisko-Bezruchko: Absolutely. Our board has created a special task force, a committee of the board that consists of board staff, as well as experts from within the community. They have appointed a special adviser from a community-based research organization in Toronto to develop a plan for the LHIN. We will be focusing on health disparities as a very important aspect of the work that we do. The board is very clear that, while accountability for the $4 billion that we have as part of the health care system is very important, we must work to address the health outcomes or health status of the population that we serve. We know that we have very disadvantaged populations within the Toronto central LHIN. We also know that they disproportionately use health care services because of the adverse conditions in which they live, for example, or sometimes because of their genetic make-up or other issues due to their own personal circumstances. We are trying to focus on those who most need better access to health care systems so that we can start reducing the pressure on the acute care sector, for example. The acute care sector is the most expensive part of the traditional health care system, as contrasted to community-based services. If we build up the capacity of the community-based sector, it will relieve or depressurize the acute care sector.
Senator Eggleton: That really sounds good. I am really impressed with that. Are the other LHINs doing the same thing — not necessarily homelessness, but whatever else in that LHIN might be a social issue?
Ms. Pisko-Bezruchko: Each LHIN is different in terms of the geography and the population it has, so there are different focuses. I hear more and more from my colleagues that a population health lens and perspective is important in their work.
Senator Eggleton: Thank you. Dr. Pipe, this developing crisis on chronic disease certainly gets a lot of attention these days in the media. What do we get the federal government to do about it? We have had some smoking control programs for a while, but for obesity and inactivity, what do you think the federal government can do to advance the cause there?
Dr. Pipe: We still labour under the misconception that so many of these issues are the result of individual misbehaviour. I think we rather naively assume that individuals are more in control of their behaviour than, in fact, is the case. For instance, we can have all the health promotion messages we want about eating fruits and vegetables, but if you are a single parent with limited income and the cheapest source of calories is at a convenience store in your neighbourhood because your neighbourhood is such that a large grocery chain will not locate there, you do not have the ability or opportunity to purchase healthy food. You know where I am going with that particular argument.
It comes back to things like the public policy instruments available to us. Just as we can influence the salt content of food, we can also change the perverse economic incentives that exist to make high-calorie fructose corn syrup, one of the cheapest ingredients that our food manufacturers can use. Sweden, for instance, has changed its tax structure so that it stimulates or subsidizes the purchase of healthy fruits and vegetables by raising the taxes on unhealthy high-fat high-sodium foods with no change in government revenues but a remarkable change in the eating patterns of the population. There is a brilliant, simple, straightforward way to begin to address the obesity epidemic.
The way we design our communities is the way we ultimately design ourselves. You only have to travel 15 minutes in either direction from here and you will see the malignant spread of suburbs that you can only navigate with a mall assault vehicle, with no sidewalks, and which fail the ``popsicle test.'' The popsicle test of urban planning is that you should be able to design a community in which a child, on a bicycle or on foot, can go to a neighbourhood store and buy a popsicle and get home before it melts. Those are the neighbourhoods in which purposeful, incidental, daily physical activity is possible.
The way we structure our cities, the way we subsidize or do not subsidize certain foodstuffs, are very powerful ways to influence the development of obesity. There are a variety of public policy instruments that allow us to get at that in those kinds of ways.
Senator Eggleton: Thank you for those answers.
Ms. Walsh: On that last question, I spoke about the pan-Canadian healthy living strategy. Federal-provincial- territorial governments worked together for several years to come up with a plan. The plan embedded the equity lens and looking at disparities and evidence. We would like to see a stronger commitment and investment to that kind of approach.
Senator Fairbairn: It is overwhelming to listen to you today with all of your backgrounds. You talked to us in a way that I personally have found easy to understand. So much of all of this subject, and in your own presentations, is not rocket science; it is common sense. You are the people who do it so well.
When we listen to you, we can see the health problem. You can hear it, you can see it, and you can turn a coin and see what got it there. You have talked about smoking; you have talked about lack of activity; you have talked about obesity. You have even talked about difficulty with learning, which is something that has been very close to my heart for a long time.
I think we all feel frustration here. The frustration is that this is not rocket science and why can we not get on with some of these programs, instead of elevating people's futures to such a level that you are leaving them behind by doing that, whether it is health, learning or whatever. Governments seem to be doing this. I am not sure that anybody around this table can give me an answer, either, as to why we, in public life, are unable to vigorously suggest the kinds of activities that could be put into the lives of the people who are having the most difficulty.
Ms. Walsh talks about the report of the Health Council of Canada and the disparity between groups in Canadian society, a gap that must be reported and highlighted, and you say this is a difficult message to get across in the current environment where the public is preoccupied with funding for health care, but it needs to be done.
Why is it that we, who sit on Parliament Hill, cannot seem to pull together as an institution, including a government, an opposition, the whole thing? Why is it so difficult to get this message through to people who are in a position to change it, yet it does not easily happen? I must say this particular committee, over the past few years, has probably done one heck of a lot in getting off Parliament Hill and going out into the country and getting messages out.
What do you see as your biggest barriers to getting to what is so vividly obvious? What is it that stops when you come to governments and programs and things like that? They may sound great on paper, but are not a reality for people who are having the difficulties and who need help.
Ms. Walsh: Most people think: What does this have to do with me and how does it affect me? I was thinking about healthy child development and how 15 years ago there was very little investment at the provincial and federal levels around healthy child development. You might remember champions like Fraser Mustard.
Senator Fairbairn: Absolutely; God bless the man.
Ms. Walsh: He began translating into messages that were easily understandable. Most important, he reached out to the non-traditional sector, business leaders. How does this affect the economy? How does this affect Canada's prosperity? We have to find a way to take these terms that are jargon and that present a barrier. What does health promotion mean? It is not intuitive. What is population health? We have a barrier around our language. We need to find a way to reach out to sectors that traditionally have not thought or cared about these things and see how that will affect the global competition for talent; how does that affect the communities that you live in? Maybe we can find a way to get champions who can easily convey those messages. When the Romanow report came out, there was a very tiny paragraph dealing with these kinds of issues. Recently, Roy Romanow came to speak at a conference we had at our ministry and I asked him where that chapter was that tried to explain to Canadians: ``Okay, I have gone on to explain the health care system, but at the crux of it let us look at the root causes as to why people are getting sick and who is being affected.'' He mused about this unwritten chapter. It would be timely if you were to write that chapter. It is the same thing with the Kirby report. There was a reference to this being a very complex issue but not really offering an answer. This is the chance to provide that unwritten chapter and then to have many champions to go into non- traditional areas.
Fraser Mustard opened many doors for those others who were champions for programs to support child development who could not get access or attention, because he was able to make that business case.
In Ontario, for example, through Sheela Basrur's leadership, she approached her colleagues in the Ministry of Labour and said ``Let us create a table that brings union and business representatives together to start talking about building healthy work places.'' A number of business leaders recognized that this affected their bottom line, if we can keep the workforce healthy. Yet we still do not see most workplaces having comprehensive workplace health. One of the things I have been thinking about is how to reach out beyond the traditional sectors that care about health and social issues to the business sector, to translate into how this will affect Canada's prosperity.
Senator Fairbairn: We are in a society now where learning is absolutely critical. However, for some reason government and other parts of society have been letting go on the whole issue of literacy, at whatever level, that helps people get through the days.
You mentioned Fraser Mustard, bless his heart. He was at the University of Lethbridge three weeks ago talking about this subject, and how you started the minute the child was born and got on with it. From then on, it is hoped that you could have a whole generation of human beings who were able to climb up that ladder and understand the kinds of things that you are talking about. That has been slipping rather badly in the last few years, too.
What can we do in a simple way — with our friends in Parliament, in government, in all the parties — to put things in a very vivid way, so that they will not say ``Well, you do not need to worry about that''? What is the biggest thing we have to worry about, other than children?
Ms. Pisko-Bezruchko: I am not sure why everyone is looking at me, but I think I alluded to E-health and the need for a common platform for an enabler to help us learn more about the population that we have in Canada; to connect the dots for people to help them access the system and get the care they need when they need it. Right now, there are many people who do not know where to turn for help.
We need to reach out into neighbourhoods to engage people on the street — the neighbours, the friends, the family — to help them understand and reach out and support their friends and neighbours. Again, it is getting back to the grassroots kind of perspective.
Just as a microcosm kind of example, when we started our community engagement in the Toronto Central LHIN, because it was so big we divided the area up into relatively homogenous, socio-economic neighbourhoods. We gathered a lot of information about those neighbourhoods and we took a little one-page fact sheet to people. We said ``Here is what the neighbourhood looks like; here are your health behaviours and here is what you look like in terms of your education,'' and so on. People said, ``Wow, we did not know that about ourselves; can you give us more of this kind of thing?''
Part of the method is engaging people in the discussion and making it real to them. To make it real to them, you cannot give them data and information at a Canadian level. It has to be in their neighbourhood, and it has to involve their grocery store, their pharmacy, their banker — all those non-traditional people that we were talking about today — to start having a very different kind of conversation about what health care is or what health means to people in Ontario and in Canada.
Dr. Pipe: I think there is a real challenge in enhancing public understanding of these factors. There is a slide that I often show, which looks at the reduction in mortality from tuberculosis over 135 years; it went from here down to here. The interesting thing was that it was about here before we even realized what caused tuberculosis; and it was here before we found out any way to intervene to treat or prevent tuberculosis. It makes very powerfully the connection between social environment and health, because it was changes in the urban environment — civil engineering, access to food, an overall level of economic well-being — that contributed to the reduction in that disease. You could superimpose all of the diseases of the late 19th and early 20th century on the graph.
Similarly, when people hear the story of Dr. John Snow, who eliminated the cholera epidemic in London by dismantling the pump that was spewing out infected water, they immediately understand the connection between the environment and a particular health problem. They need to make the same kind of connection to some of the other issues which now influence and affect our social and physical environment.
I am a Fraser Mustard disciple, like most of us around this room, I suspect. I think he would say if you want to have the greatest return on investment, have healthy mothers and healthy young children. You will then have a safe and healthy society. The degree to which you address the inequities between the richest and the poorest in your societies is the degree to which you will produce the healthiest, safest, and arguably the most civil society. Those are difficult messages to sell to people of various political persuasions, so there is a challenge for us there.
Senator Fairbairn: There is a challenge for us, too. Each one of us has an opportunity, wherever we live in Canada, to learn a lot of things through what we do — just as we are learning today. It is a question almost of things becoming so scientific. You can see it with all of the numbers that you hear right across Canada almost every day — that we are having a problem because we do not have a workforce that is able to take advantage of the new way of learning. That fascinating science has brought us a new way of learning, but without individuals being able to get there.
It seems to me that we must understand that better. In terms of telling people what they should do, we should be trying to tell people that things have changed; things are different. However, learning how to live their lives, how to step forward and learn how to read and eat properly and do all these other things — those are still very basic. Sometimes we get well beyond basics.
Maybe that is something that we have to learn. Are there any thoughts on that?
The Chair: We looked at the maternal health program in Cuba. Senator Cook will be next, and I do not know if she will be commenting on it or not, but it is astounding what they did there with very little.
Senator Cook: It is overwhelming for me to understand what is in front of me, simply from a numbers point of view. I come from the Province of Newfoundland and Labrador. You put more people through your system in one day than my total population. When I attempt to understand how you do what you do — forgive me, I do not mean to be flippant — I will need to sleep on it. To look for the ideal that Dr. Keon is looking at and taking us along on this journey, there are a lot of barriers or rocks along the way.
Dr. Pipe, you talked about everything except the food industry. How do you legislate common sense? When I was a child, I got a bag of chips; I think they were 25 cents or something. Now there are all kinds of varieties in the supermarket; and it is not the little bag now, they are big bags. They are laced with salt and they are wonderful.
How far can you go in a democracy to legislate against the food industry? Where do you begin?
Looking at it from a child's point of view, during my schooldays, I went home to lunch. Children get on buses now and they drive all day long. What do you put into a sandwich other than processed food? We are what we eat? How do we manage that?
Dr. Pipe: Thank you for your questions. It certainly is not easy, but the great triumph of the public health movement of the 20th century was the fact that it legislated standards for the food and water industries. Those standards related to quality and purity. Now our standards must, perforce, address issues such as quantity — how much salt you put in the food, for instance. You can use all of the standard political instruments and levers to influence food industry practice. It is done in other jurisdictions. I am sure we are equally as deft politicians as our Swedish colleagues. Why can we not do what people do in other places? You give incentives that favour the production of healthier foods. We are seeing this emerge in the ultimate free market community of the United States. People in places such as New York City want to regulate the density of fast food franchises.
I understand the challenges of developing public policy that affects big industry. I bear a number of scars from the tobacco wars. However, one can do ordinary things extraordinarily well by beginning to address these issues. In so doing, you influence the consumption patterns of children and mothers, and you make healthier food more accessible and more affordable.
You mentioned children walking to school. We have very unusual policies in Canada with regard to the degree that we put kids in yellow containers with wheels on each corner and move them around. Ninety-one per cent of Canadian children have bicycles; only 5 per cent of them ride them to school.
I was in Fredericton a few weeks ago, at a conference about childhood obesity. Someone said that a directive had come home from a school principal asking that children not go to schools on bicycles because the bicycles were being left in the areas where vans pulled up to drop children off. There is something very wrong with that picture.
Humans are brilliant and logical, but they are also remarkably stupid and illogical at times. Edmund Burke once said, ``The challenge is to do today what men and women of intelligence and good will would wish 10 or 15 years hence had been done.'' We are already at levels of obesity in Ontario that were anticipated to occur by the year 2015. We cannot afford to wait any longer for some of these imaginative public policy interventions. I have seen the crisis and it is here.
Senator Pépin: With regard to food in schools, Quebec has passed a law that no fast food restaurant can be installed in schools and no French fries or other such food can be available in schools. I agree with what you said about bicycles, but I do not know whether I would put children in Montreal on a bicycle to go to school.
Perhaps schools could send home suggestions for lunches that parents can prepare to send to school. Is there a network in the schools for such a plan?
Dr. Pipe: I understand, and to a great extent I agree. However, we have some very real challenges. We focus upon the schools as if that is the key to influencing child behaviour. In the Champlain region, we are focusing on school-aged children, because so much of their time is spent outside the school.
Here are some unique challenges: We have the data on the incidence of obesity and inactivity in children in the Champlain region because we did our homework, and it is consistent with national levels. We have completed, but not yet released, a survey of parents in the Champlain region that asked them to tell us about their children. Not surprisingly, all the parents surveyed in the Champlain region told us that their children are not obese; that they are all vibrantly physically active. There is a remarkable disconnect between what the data tells us and what parents understand and appreciate about their own children.
There are significant educational challenges here, and some of the vehicles you have identified could be helpful in addressing them. For every complex array of problems, there is probably an array of solutions, none of which individually would suffice.
[Translation]
Senator Pépin: The implementation of health policies of course requires not only the involvement of the various governments but also of governmental organizations, of the private sector or perhaps of universities. Earlier, someone briefly mentioned the role of the federal government, so I am wondering what role the federal government may or may not have played to support or hinder the transition to a focused approach to population health in your province?
Were municipalities involved as well? Was there a resistance, shall we say, to supporting your program? Were other areas, like the private sector or universities, involved at all? If not, what else can be done to get their support?
I mention schools, universities and the various parts of the private sector, but was our federal role a good one? Should we have acted differently? Did it work at municipal level as well? What must we do to make it work?
[English]
Dr. Pipe: One of our expert panels is actually called our policy panel, and we are about to embark upon an exhaustive scrutiny of municipal and other policies that either promote or preclude the acquisition of good health, whether that is in urban planning, transportation, recreation, or other areas. In Ontario, the public health units are aligned with municipalities and are an arm of municipal government. Therefore, in our organization, all the public health units in our region are involved, so there is that engagement with municipal authorities. We will be working with housing authorities, et cetera. There is a willingness on the part of individuals within the municipal government to become involved.
Ms. Walsh: I spoke earlier about collaborative mechanisms. As an example, the federal government has supported the coming together of provinces to talk about school health. It is a minimal investment, but we are hoping it will continue because it is critical to have those kinds of networks. For example, in Ontario we are developing nutritional guidelines. We have coordinators across the country whom we can call and ask what they are doing.
These kinds of mechanisms can be very helpful. It is unhelpful when we read in a press release about something the federal government might be doing with a community. We talked earlier of thinking of health as a system and all the parts of it as opposed to fragmentation. For the federal government to work effectively with provincial governments, there needs to be respect for the fact that we are trying to create a system in the province and we must have dialogue about how federal funding programs or federal policies can support the work of the province.
We are now looking at poverty reduction strategies and it would be terrific, along with many other partners, to have the federal government work with us so that it feels like a partnership with joint planning and to have the mechanisms that facilitate that kind of conversation.
Senator Cook: You spoke about bikes being in the way of vans at the schools. I would think that the vans are dropping off children coming from daycare centres, because not many children go to school in vans.
Is there some way to influence public policy?
In larger cities than mine, mom, dad or someone drops the children off very early in the morning, and they are at the daycare or whatever you choose to call them. Then they are driven to school and spend the day there, and then they come back to the after-school program. Then they get picked up by the parents after work. We need to look at where our children live and who is taking care of them. It is not only the school; there are two ends to it.
Can you see a way in which we could influence public policy with the early childhood development centres or daycares, or whatever? That is where they eat for the most part, except on weekends.
Dr. Pipe: I think you put your finger on what is an issue for a subset of Canadian children, and admittedly there are some challenges. Ms. Walsh earlier talked about making schools the hub of community services and activities. Until recently, it was the case that schools closed their doors at 3:30 and did not open them until 9:00 in the morning, and actually put padlocks on the gates around the schoolyard so that what was an open space in the gymnasia and other facilities in the schools were essentially isolated from the community for the rest of the day.
One can do some imaginative things in terms of making sure the school becomes a hub of community program, particularly that which emphasizes physical activity, from 6:00 in the morning until 10:00 at night.
It is still the case that there are large numbers of kids who are not going to daycare, who are transported either by parents or in buses who could walk or ride to school.
One of the other challenges we face is that kids do not go out and play any more. Some of us probably terrorized our neighbourhoods on bicycles and threw hockey pucks through windows and all that sort of stuff. Your question alludes to the fact that children today often go home and are told to stay inside until the parent gets home. When that kitchen door closes, another door opens, and it is usually a refrigerator. Then kids sit mute in front of a television screen or a cathode ray tube screen, eating calories rather than being outside playing. There is a misperception that somehow our communities are unsafe for kids to play, and that is a big challenge.
There is a whole array of social forces and factors that have emerged that we must try to address. I do not think any of us have the answer to all of them, but we can be far more imaginative than in the past in getting at the challenges.
Senator Cook: It is about managing change; is it not?
Dr. Pipe: It is.
The Chair: Senator Callbeck is the former premier of Prince Edward Island, so she knows a lot about all the systems. She has had them all at her fingertips.
Senator Callbeck: We have had some experience.
You were talking about the federal and provincial governments. As we know, health is a provincial priority. Ms. Walsh, you talked about health promotion in Ontario and specific things that you have done. Then your first recommendation was that the federal government can build on these initiatives, first, by funding and, second, creating policies. What policies are you thinking about there?
Ms. Walsh: There are things in the federal domain, for example food labelling. Look at the range of levers the federal government does have around policy and have the discussion with provincial governments. As we say, here is what we are doing under diabetes and our crime disease prevention strategy. Here is what we can do in our domain, and here is what we would appreciate that you can do in yours.
In Ontario our former Chief Medical Officer of Health, Sheela Basrur, came out with a report called Healthy Weights, Healthy Lives. It really sounded the alarm about obesity. In that report, she specified things that the federal and local governments, the private sector, food industry, restaurants, et cetera, could do. This is the kind of thing where you look at strategies to figure out what lies in which government's and which sector's domain. The call to action is about getting all sectors engaged so it is not just about one group or another.
Senator Callbeck: Dr. Pipe, you talked about our need for more public education. Do you see the federal government playing a big role here?
Dr. Pipe: I want to be clear that when I talk about more public education, it is probably not the kind of education in the form of exhortation, telling people to get out and do more of this or that. We need the kind of education that raises the consciousness about the issues and the factors which actually shape the health of communities as opposed to, ``Just do it!'' or those kinds of exhortations.
Nonetheless, the federal government can be very helpful in the way it uses its abilities to mount demonstration projects, to conduct pilot projects in a number of different provinces, assessing the effectiveness and validity of those approaches in different populations in different settings. It can make strategic use of the federal resources which it provides to provinces in terms of putting conditions upon certain forms of federal funding.
For instance, if you are funding certain forms of urban infrastructure, a certain percentage should be given over to ensuring that active personal transportation is facilitated or encouraged by the way in which you design or build a particular community. There are all of those kinds of approaches, which is where the federal government can play a very intriguing role.
Again, to bring it back to something more personal, perhaps, our hospital-based smoking cessation program is now part and parcel of every single hospital in this part of Ontario. Thanks to Health Canada, it is now being replicated in the B.C. Vancouver Coastal Health Authority and the New Brunswick River Valley Health Authority with the expectation that it will become, at some point, probably a national standard. The federal government is playing a powerful role there in transporting best practice, if you will, into various provincial jurisdictions.
Senator Callbeck: Ms. Pisko-Bezruchko, do you have any data on that?
Ms. Pisko-Bezruchko: It is difficult for me to comment, given that I am an entity of a provincial government. The thing that concerns the LHINs with federal involvement is the whole information highway and how we are better able to connect people to services, health providers to health providers, to get people the information they need. That is farther away from the discussion right now.
Senator Callbeck: You have only been set up since 2006?
Ms. Pisko-Bezruchko: Yes.
Senator Callbeck: In a very short period of time, you have accomplished a great deal. You mentioned having broad community support. How did you develop that?
Ms. Pisko-Bezruchko: There has been a series of things that the provincial government initiated in terms of local conversations and discussions about priorities. We tried not to reinvent the wheel, so we brought to the table things we already knew. We have been trying to go to networks and groups of people who have already come together around a common cause, and reaching out to them instead of making them come to us.
What is a LHIN? People do not know what an LHIN is, and quite frankly, I do not think they should care what an LHIN is. They should care whether they know about the services available to them and how to access them when they need them. We are not involved in creating new infrastructure but in going out to where those groups of people naturally convene and to hear from them.
Senator Callbeck: Are your boards all appointed?
Ms. Pisko-Bezruchko: That is right.
Senator Callbeck: Is there talk that there will be elected boards down the road, or is that not up for discussion?
Ms. Pisko-Bezruchko: To your point, we are still new. There has not been assessment or evaluation yet of LHINs and our effectiveness because we are so early in our mandate.
Ms. Walsh: I want to come back to your question because I wanted to give it more reflection. I thought about the number of income support programs that exist at the federal level. Obviously, if you are thinking of health disparities, income plays a critical role.
I thought about our Healthy Eating Active Living conference, and one of our experts pointed out how more than 15 years ago the federal government was concerned about the health and well-being of seniors. As result, there were significant changes around income support, and we have seen a significant improvement in seniors' health. I am in the position of representing government, but I would like to speak as an individual who has been involved in health promotion for a long time. Something we have not talked about here is volumes. I talked before about champions and leadership. You have that opportunity around providing leadership by what you talk about and by what you value. I keep thinking about when I was pregnant and getting off the subway at Dundas Square. I was about seven months pregnant and there was another young woman, pregnant too, and she was begging. In my mind, I am thinking about my mother telling me about folic acid and asking me whether I am sleeping and eating properly — everything and everyone supporting me. Here was this woman begging and I thought, ``My daughter is already further ahead.'' This is a fundamental value that we grapple with in Canada because we think we are all starting at the same place, and we are not. When we talk about areas for greater investment and commitment, we are struggling with values. As you look at disparities, that is something to address.
Whether it is community or provincial government where we put our investments, politicians are looking at what is valued in the community. Earlier, we talked about infrastructure. Perhaps those recreational facilities are a luxury compared to saying that healthy eating and living will improve our children's ability to participate in the community and to get higher marks in school, and so on. We are not making those links. In your report, perhaps you can increase attention to this and to links to other values that we have in terms of prosperity, well-being and quality of life.
The Chair: I will have to intervene here because we only have a few minutes.
Ms. Pisko-Bezruchko: In response to your question, I understand the federal government does provide money to help eradicate homelessness right now in Canada. There is some question about whether that money will continue. In our LHIN, in particular, it is a matter of grave concern that many of the programs that have been very successful were established with that money. There is a real worry that if that funding ends, those programs will end as well.
Senator Brown: Dr. Pipe and your colleagues, I think you have brought us a big elephant here today, but I think you also brought the solution. If you re-examine your own graph, the answers are there, as well as in the comments that you have made.
I was playing with your graph. I started out with social engineering and I pointed down to basic societal change. I then went to the three arrows that say ``reduce blood pressure, reduce salt intake and increase physical activity.'' Then I went to three more that go to ``eat less, eat better, and exercise more.'' I think all three of them are individual choices, which is exactly what you said.
I know we have used tax changes in the past to influence behaviour. I do not think we can change our neighbourhoods overnight; we have built an awful lot of them in this country. However, we can focus on behavioural change. I believe we did that with the big monster of smoking. We have not killed that monster yet, but we certainly crippled it over the last generation.
When I was young, virtually everyone smoked. Through a whole generation of negative advertising — and I think TV works well there, but we also used negative labelling on the package itself — we were successful. Over the long term, that is required for re-engineering society. A big chunk of this $140 billion we are spending on health care needs to be spent on positive advertising for exercise and more negative advertising for salt content in foods and for overeating. That might be a problem. As soon as you hit it, you will start focusing on people's body shape. That might get a lot of push-back there in terms of human rights or that kind of thing. As you said, you bore the scars of the smoking war. You might get some more scars when we start emphasizing overeating or obesity.
It really comes down to an attitude change in those three areas. Even when people do not have big recreational complexes, and so on, they can still exercise. There are programs available. The RCAF used to have a great exercise booklet that did not require any physical stuff at all. I used to use it years ago. I now use a $500 recumbent bike, but I do not use it like I did with the personal exercises.
Dr. Pipe: If I could make an observation, while these are individual behaviours, I thought I was clear in saying that individual behaviours are less susceptible to individual choice than we would like to think. We live in an obesigenic environment. For instance, it is clear that today's kids in Canada actually participate in sport to a far greater degree than has ever been the case, except that for the rest of the week they are far less active than has ever been the case. The standard approaches, the exhortations, the campaigns and the slogans may be necessary, but they are far from sufficient. That is one of the lessons we have learned from the tobacco wars: You must have the public policy changes to change the social environment. You denormalize smoking and eliminate the opportunity to use lifestyle advertising.
I certainly agree with you that these are individual behaviours, but we must be able to create a social environment in which it is more likely that those individual behaviours will be expressed. That basically requires environmental change.
Senator Brown: I agree with you. I just believe you need a combination of both the information out there on the negative side and on the positive side about what can occur when you lose weight or when you stop using too much salt, or whatever. You can spend a lot of good money on television, because there are few people who do not watch it, and get some kind of program of advertisements out there. I was thinking of the Simpson family, with a whole new genre of showing people who are healthy and slim because of their habits; those kinds of things, for example, a clip or advertisement, over a long period of time.
Senator Munson: Dr. Pipe, you said I have seen the crisis and it is here. As Dr. Keon alluded to, we were in Cuba. They do a lot with so little with polyclinics. In terms of promotion, preventive medicine or promotion of health care at the street level, do we have to have a pragmatic attitudinal shift in delivering health care? In these polyclinics, for example, you used the example of Sweden raising taxes, but what we saw in one of these clinics in these multifaceted facilities were grandparents, 60 to 70 years of age, being taught through child psychology programs how to deal with grandchildren and early childhood development.
Must we shift our focus with preventive medicine? We automatically think in this country, ``I am sick. I am going to the hospital.'' We never think of the Elgin Street clinic or clinics because if we go there, it is one dimensional and sort of, ``Yes, we will treat this but you have to go over there for that.'' I would like your views on that assessment.
Dr. Pipe: Clearly, the Cuban example of what they have managed to do with limited resources in terms of both literacy and health care is quite remarkable. It is almost in contrast to some of the things that I have been saying. One of the other realities that we currently face in Canada is for those whom the preventive system is too late because they already have a disease.
One of the crises that we have that I see daily is that people do not have access to virtually any form of primary health care. I spend a considerable part of my day trying to find family physicians for people who do not have access to family physicians. They already have established diseases but cannot get access to those kinds of services.
Yes, I think we will have to reconfigure our health system. In Ontario, there are models afoot, family health teams and family health groups that seek to integrate a variety of professional disciplines, not just health care practitioners but other professionals such as counsellors and social service professionals, under one roof. That, clearly, is the direction of tomorrow. I think you have put your finger on it.
Senator Munson: It was mentioned that we have a barrier around language when we say ``population health'' and that sort of thing. I know you do your surveys and get there. In Cuba, because of the system there, nobody is forced to answer, but people love statistics there, and they really get statistics. When there is a problem, they all go somewhere and there will be 12,000 people, and 12,000 people will gladly give their life history so they can look at the issue and try to tackle that issue with new medicine or whatever may be needed. In this country, it must be an issue of human rights. Are you getting the real picture when you do these surveys? You talked about the fact that parents tell you one story but you see something else with the children. Is it difficult to get down to the street level?
Ms. Walsh: A very appropriate federal role is that of supporting research, evaluation and creating new knowledge. The role Statistics Canada has played has been fantastic. I am sure they would say that they could use additional investment. For example, the Canadian Community Health Survey is a fantastic resource, but it is not run every year. For the sample size for Ontario, we have to buy extra sampling to get the information we need. It would be helpful to look at all the different measures, what are those indicators, and does Statistics Canada have enough support to give us the kind of data we need. There are different investments, for example, through the Canadian Institute of Health Research, the Population Health Institute and the National Collaborating Centre. Some institutions out there are doing helpful research. I am sure they would say that they could use so much more support in comparison to other areas that are being supported. That is a helpful federal role, and we value it. It makes more sense to have something like that done nationally. We are consulted in terms of what types of questions will be helpful, and we work together across the country to generate information that will be helpful for all of us.
The Chair: Unfortunately, our time is up. That is a truly important question. It is the Achilles heel of this whole thing.
We will have Glenda Yates before us on February 13. Ms. Yates is the head of the Canadian Institutes of Health Information. One of the things I will be putting to her is: Can you develop the tools so that the various people involved, like Ms. Pisko-Bezruchko and Dr. Pipe and yourself, can do health impact assessments of what you are doing? That will be a challenge down the road. If any one of the three of you can imagine anything about how that might be possible, we would like to know, because we would like to bring that into our report.
Ms. Pisko-Bezruchko: I would support what Ms. Walsh just said. We need to have that survey done more frequently. We need to open up the discussion again about the kind of information we collect about people who use the health care system. Right now, we do not ask people about their racial or ethno-cultural background. We do not ask them about their income. We do not ask them about all the things that impact on their health, yet we know that those things are so important.
In my position in the Toronto Central LHIN, I am forced to find creative ways to extrapolate between different pieces of data from different databases and infer that this population and this neighbourhood has these kinds of health needs and behaviours. That is not the way it should be. We should have the evidence at our fingertips and take away the horror of collecting this type of information. It goes back to understanding what this is all about and realizing that it is broader than just the traditional hospital-based services. It has to do with the whole social environment in which we live.
Dr. Pipe: We also need sentinel populations. The problem with much of the data collected in Canada or provincially is that it is collected on such a broad population basis that it is almost impractical to apply at the local level because it may have no meaning. We need reference data and reference populations. We need not just questions in surveys but also we need, in some instances, physical measures. Much of our data about obesity in Canada is derived from telephone surveys where we ask about height and weight. Guess what? When we go out and measure Canadians, they are actually shorter and their waist circumference is bigger than they reported on the telephone. All our data has been skewed in this respect. We need to put some leather on the streets, to use the epidemiological term, and actually go out and get meaningful physical data and collect it regularly. This is a sampling approach that might ultimately allow the data to be applied at an operational level. Rather than a national 50,000 foot examination, we need to take a closer look at differing Canadian populations. The information collected in many data sets is unhelpful when trying to deliver programs in the Champlain district or the Toronto LHIN.
The Chair: Thank you very much, all three of you. You were absolutely terrific. You gave us a great deal of information.
Honourable senators, we will go in camera for a few minutes to settle some business.
The committee continued in camera.