Proceedings of the Subcommittee on Population Health
Issue 1 - Evidence, February 26, 2009
OTTAWA, Thursday, February 26, 2009
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:45 a.m. to examine and report on the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chair) in the chair.
[English]
The Chair: Honourable senators, we are delighted to have these two outstanding people here to talk to us about an all-of-government approach to population health.
Before our witnesses start, I am sure they are wondering what this study all about, although Mel Cappe has been involved at two levels: one at a round table and one at the session in Toronto when I asked for the business plan.
The reason for this initiative on population health is simple: We cannot afford the poor health we have in Canada. We rank about fifteenth to twentieth in the world in health status and well-being, and about fifteenth to twentieth in the world in productivity. However, we are one of the richest countries in the world, with one of the best-educated populations, and we should not have either of these situations occurring.
Fifty per cent of heart disease, stroke, major vascular disease, cancer and type 2 diabetes are totally preventable. They come from people exposing themselves to unhealthy environments. We must convince every level of government to join hands, come together and produce healthy communities. We must integrate these healthy communities into all levels of governance through the cities, towns, provinces and federal government, to convince people that they are responsible for their own health, and to convince all levels of government to show the way for people to develop healthy lifestyles.
Otherwise, our health care delivery system simply cannot cope. It cannot cope now and wait until the rubber hits the road with all the type 2 diabetes that is coming down the road.
With those remarks, Jim Mitchell will go first.
Jim Mitchell, Founding Partner, The Sussex Circle: Thank you for inviting me here this morning. The most important point in my brief statement to you this morning is to identify the areas where I have relevant expertise to offer the committee and also the areas where I am not an expert. I do not want to appear before you under false pretences.
As some of you may know, I spent over nine years of my career in the Machinery of Government Secretariat in the Privy Council Office. Since then, I have spent a good deal of time working as a consultant here in Ottawa on issues of government organization, among other things.
I therefore believe that I am reasonably well prepared to answer your questions on matters of government organization, the roles of cabinet committees and committees of deputy ministers, government decision making, generally, and the relationships among departments and agencies. On those sorts of things, please feel free to ask me any questions, and I will give you my best answer.
I wish to make clear that the one area where I am not an expert is population health per se. I do not wish senators to think that I am here as an expert in population health. I am not an expert in how jurisdictions, other than the federal government, have organized themselves to deal with population health, although in preparation for this session, I have read up on what they are doing to be as well informed as possible about that subject. However, I do not want to appear to be an expert on those matters.
I am not an expert on federal-provincial relations, although I have my own views on what works and what does not work, in terms of managing issues with the provinces.
To be clear, I do not want to present myself as someone who can tell or inform you about what other jurisdictions have done in the areas in which you are interested, or what works and does not work in population health per se. I am not a medical doctor; I am a former official. Many other people can give you that expert advice.
Having said that, I want to make three broad points before I take your questions.
First, population health in all the dimensions in which the committee is examining the issue is clearly a matter of great importance to the government and to the people of Canada. The idea of taking a whole-of-government approach to this important set of issues makes good sense, not least because so many different jurisdictions and institutional actors are in play. The question with which you have been occupied, namely, the most appropriate mechanisms or tools through which to pursue this whole-of-government approach, is a good question.
Second, as members of the committee are aware, population health is but one of many lenses through which a government can look at the decisions that come before it. No matter how important this lens of population health is, I believe that any government — and any Prime Minister — must be careful not to try to refocus government decision- making around this one set of issues. To do so would impose too great a strain on the larger processes of government.
Third, I wish to inform the committee that with respect to the Machinery of Government, I am philosophically a conservative. By that, I mean "conservative,'' not "Conservative.'' It means I believe strongly in the importance of the Prime Minister's authority to determine how his or her administration is organized to do its business; how it will make decisions; and how it will relate to other jurisdictions.
While it is entirely appropriate for the Senate or the house to express its views on anything and, certainly, on the utility of this or that mechanism, it is up to the Prime Minister to determine how things will be done inside the government.
Therefore, I would be cautious about any effort to impose on the Prime Minister of the day a particular mechanism or a specific machinery solution to the whole-of-government issues with which you are now concerned.
The key issue for Parliament, whether for the Senate or the House of Commons, is to identify the issues with which government should deal and the directions in which government ought to go. How these things are to be pursued in terms of the inner workings of government is, in my view, a matter for the Prime Minister of the day.
Those are the things I wanted to say in my opening statement, and I am happy to take questions at the appropriate time.
The Chair: We will now have a statement from Mr. Cappe. He currently is President of the Institute for Research on Public Policy, as stated on the agenda. Again, he has years and years of experience at virtually every level in the Government of Canada and in the bureaucracy of government, including Clerk of the Privy Council.
We value what you have to say about how we can wire the various components of this great Canadian mosaic together.
Mel Cappe, President, Institute for Research on Public Policy: It is a great pleasure to be here. As an official, I have always found it preferable to appear before the House of Commons because you can watch them argue from side to side. It was always more difficult to appear before the Senate where they dealt with more substance. As a citizen, it is much better to appear before the Senate and talk to substance.
This question is an important one for the future of the country. My last line will be, and my first line should be, to encourage the committee to take the question seriously and take on the challenge. It is crucial.
Chair, you started by saying that we cannot afford the poor health that we have. One way to capture the importance of that notion is to talk about the economic consequences of bad population health. We have not thought that part of it through yet. We talk about absenteeism and other elements, but those economic consequences are worth focusing on.
A couple of years ago, my predecessor, Hugh Segal, now Senator Segal, had started a process at the Institute for Research on Public Policy to look at what we called the "Canadian priorities agenda.'' It was a view that governments did not have a strategic agenda. We said: What are the strategic issues facing the country? We published a book about that subject, entitled, A Canadian Priorities Agenda: Policy Choices to Improve Economic and Social Well-Being. Fundamentally, all roads lead to population health. Whether it is economic issues, income security issues or environmental issues, they all come back to population health.
Second, in the paper I saw, you raise the notion of whether, in a unitary state such as the United Kingdom, where I was Canadian High Commissioner for four years, it is easier to deal with population health. The answer is absolutely. The challenge of dealing with population health in a federal state is that much greater than it is in a unitary state. It does not mean it is done better in a unitary state, but it is easier to deal with. That is both our strength and our weakness.
Next, nothing in government is done unless it has an acronym. We do not have population health as an acronym yet, but we have WOG, the whole-of-government approach. It is reassuring that WOG is taking on some meaning, and we are dealing with a whole-of-government approach in Afghanistan. Perhaps your challenge in dealing with a whole- of-government approach to population health is a good thing.
[Translation]
Another question raised in your document deals with how to evaluate progress. I would advise you to be cautious if you go along that route.
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You have to be careful of what you measure. My experience in the United Kingdom on this issue of health is that the U.K. tried to measure a lot of things. They ranked the hospitals in a league table, as they called it, from the best hospitals to the worst. They ranked them on 32 measures, one of which was the return of breast cancer and another was patient satisfaction with meals. The hospital administrators recognized that one of those measures was easy to deal with and the other one was hard to deal with. They dealt with the easy one, and patients in the U.K. loved their meals, but it does not mean that they had better health or, for that matter, even better health care. I would be cautious about what you measure.
In 1994-95, I was Deputy Minister of the Environment and chaired a task force of deputy ministers on horizontality. That is not about how we work in the prone position but how we work collaboratively. Collectively, we had 450 years of public service experience around the table and discovered the blindingly obvious: To make people work together, we have to align their objectives, reward good behaviour, punish bad behaviour and promote collective decision-making. A report was published by the task force but I do not commend it to senators because it is self-evident.
In background, the organic gram of government does not matter. Rather, it matters how people work together. They can shift the boxes around and change responsibilities but, at the end of the day, as Mr. Mitchell said, it is the prime minister's prerogative. The prime minister has only a few instruments to manage with, one being the organization of government. What counts is how the prime minister tasks ministers, and how they task their officials, to work together.
The committee has some choices to address and I will list seven of them. First, you can politicize or depoliticize this issue. I am of the view that you can accomplish a great deal by stealth, and depoliticizing this issue is a way to proceed. Population health is not a partisan question. I am sure all parties are committed to it and, therefore, do not make it a political football.
Second, you can make this issue high profile or an issue that takes place under the radar. I have become a great advocate of staying under the radar. Again, you can do a lot by stealth. I remember that at Human Resources Development Canada, HRDC, we collocated our offices with the Alberta government. When it was made a political issue, it was difficult to accomplish and when it was not a political issue, officials got on with it and worked collaboratively with the province.
Third, you have a choice of centralizing or decentralizing the issue. I think that centralization is the proper way to approach this issue, although it requires political and bureaucratic leadership. Therefore, I lean towards centralization.
Fourth, you have a choice between soft instruments and hard instruments. Again, I would shy away from the hard instruments and focus on the soft leadership approach that will promote officials working collaboratively.
Fifth, you have a choice between institutionalizing population health or deinstitutionalizing population health. I think deinstitutionalizing is more important. Making it the responsibility of everyone runs the risk of it being no one's responsibility. At the end of the day, everyone must take responsibility for advancing the interest of population health. Having a department of population health allows the people at Environment Canada to say, that it is not my job. I do not think that is desirable.
Sixth, you have a choice of dealing with these issues from the top down and or from the bottom up. You raised that question with the document. Someone once said to me that the real choice is whether you go top-up or bottom-down. I think you go from the top. Whether you go up or down, you must start at the top. I fully agree with what Mr. Mitchell suggested: The prime minister must own this issue and the prime minister must charge ministers with making progress on it.
Seventh, you raised the question of a step-by-step approach or dramatic change. I would love to think we understand how to bring about dramatic change but I am confident we do not know. I would be in favour of slow progress, which is progress, nevertheless. We build on the shoulders of giants. If your report leads to significant but modest change in government, it will be a good thing. Then, your successors will continue in this vain and make more progress yet again.
In conclusion, I would say that a cabinet committee would bureaucratize the process, and the bureaucrats would serve the committee rather than make progress on the substance. I am not in favour of that. As Mr. Mitchell suggested, the mandate of the prime minister is the most important instrument that you have.
As a deputy minister, I told my minister that something was not important and the minister reached in his jacket, pulled out the mandate letter from the Prime Minister and said, "Of course it is important; the Prime Minister told me it is important.'' Ministers take those mandate letters seriously, and it is desirable to use that instrument.
Committees of deputy ministers work but only if the clerk and the prime minister care. If the clerk and the prime minister task the committee deputies, they can make a great deal of progress in bringing together the various threads of government.
On the question of your health impact assessments and the spending reviews, I agree with Mr. Mitchell. You cannot say that population health is more important than foreign affairs — in a way, foreign affairs is everyone's responsibility, and more foreign affairs work is being done by the Department of Agriculture than by many other departments; or more important than climate change, another cross-country issue that has population health consequences; or more important than women's issues or human rights issues. All these issues cut across government and require a cost-cutting, whole-of-government approach. I suggest that population health is not different but neglected. You have to find a way of giving it attention without making it the number one issue.
Who leads is crucial. If the Privy Council Office does not bring departments together, it will not happen. Again, the prime minister or the clerk of the Privy Council Office must mandate that a meeting called by the Privy Council Office will be attended. A meeting called by the Deputy Minister of the Environment is attended at times and not at other times.
From Citizen Cappe's point of view, — I suggest that you keep your focus and keep it on effectiveness. No one disputes the importance of population health but no one has figured out how to make it real. Keep a focus on evidence- based policy. I am somewhat disconcerted by how many policy announcements are based on ideology and not on evidence from real research.
I would characterize your challenge as pulling on an elastic to move the government. However, if you pull too lard on that elastic, it will break and you will not move the government at all. The challenge for the committee is to pull it hard and far enough that you will move the government, but not so far that you are dismissible.
Thank you for your time. I wish you courage.
The Chair: Before I open the discussion to honourable senators, I have a question for Mr. Cappe.
You attended a session at the Conference Board of Canada when they released the first draft of their report on the economic impact of improved population health or improved health in the workplace. They were kind enough to respond to my request and draft that document to provide us with some data. While you are here, I want you to comment on the record. Can you remember anything from it?
Mr. Cappe: I frankly do not and I would rather not comment.
Again, the document is an attempt to measure the impact. I know that the former Senator Kirby's study on mental health also tried to capture some of the economic consequences of poor mental health. None of the estimates are hard. However, I would be cautious about dismissing the estimates because the Conference Board of Canada's study does not present the estimates to the third decimal point. No one would dispute the direction or the significance. The study gives you an indication of how important the issue is. In that sense, I support using it as an instrument to show people that the issue is important.
Senator Eggleton: Something I have in common with the two of you is that I served at the Treasury Board. When I arrived at the Treasury Board in 1993 as minister, Mr. Cappe was there as assistant deputy minister. One of our first conversations was about horizontal links. That is what I want to focus on now.
Population health involves several departments if it is to work. We operate in a system known for its silos and stovepipes. There is ministerial accountability, as opposed to horizontal links. Although efforts have been made over time, the discussion is ongoing. I am sure there have been some successes. I am not aware of any major success in terms of horizontal links on an ongoing basis, but this issue requires horizontal links.
I think you need a top-down commitment to start. You need the Prime Minister to say, this issue has a high priority. Otherwise, I do not know how you will overcome those silos and create those horizontal links. You do not necessarily need a minister of population health. A cabinet committee of ministers would help to do that. It could be put into the mandate letters. I have had several of those letters so I know how important they are. You seem to agree that would be a route to go.
At the same time, you need bottom-up input in terms of delivery. Remember that a lot of these policy areas are deliverable at the provincial or local levels. Maybe we need some mechanism there as well. A top-down commitment and bottom-up input into the delivery system would be a combination that would work.
If we do not have a cabinet committee to bring the horizontal links, how do we keep the focus, or the feet to the fire to accomplish this goal?
Mr. Cappe: I make a distinction between a "cabinet committee'' and a "ministerial meeting.''
The communiqué from the Prime Minister's meeting with the President earlier this week was helpful in tasking people. People followed up on doing more work on the relationship. A ministerial meeting that may have only a short period would force people to be accountable and prepare material. It would also lead to tasking of more work on the subject.
I do not know enough about the current structure of cabinet committees, having been out of government for 2.5 years now. However, we had standing cabinet committees on economic union and social union in the time when I was clerk. We also had something called the ministerial meeting on security and intelligence. It was not the ministerial committee, which tended to de-bureaucratize the issue a bit. It was a regularized, annual meeting that met from time to time, as necessary. There were also ad hoc committees or meetings where the Prime Minister would say: This is an issue that is of import. Let us bring all the ministers together who are active on this file.''
I remember, Senator Eggleton, the first cabinet committee after the 1993 election was one you chaired on infrastructure.
That committee was not an institutionalized one, but it was a way of bringing together ministers. I caution against creating a structure where you have a secretariat with a hierarchy of committees where people feed the beast rather than getting on with the job.
I agree with you that you need ministerial attention, but there are different ways of accomplishing it.
Mr. Mitchell: I wish to add a couple of thoughts, but I agree with what Mr. Cappe has said.
First, the critical factor is that the Prime Minister makes this issue a government priority and tells Canadians that it is a government priority.
Second, the federal government must be prepared to put some money behind it. As you said, senator, most of this delivery is the responsibility of other jurisdictions. Therefore, the worst thing we can do is to make it a national priority and say that it is up to the provinces and the municipalities to do their thing. As we all know, they do not like that. Make the issue a government priority and put money behind it.
As Mr. Cappe said, drive it in the sense that you want results delivered by the concerned ministers and their departments, bearing in mind that the issue is a long-term one. As the chair mentioned in his opening remarks, we all know this will take 30 years to bring us from a ranking of fifteenth in health status and well-being to a ranking of fifth. The issue is a long-term, complex, multi-jurisdictional problem.
The only place I disagree slightly with my senior colleague here is that a ministerial meeting is a great way to tackle an immediate problem where you want top level attention from the ministry and you want results; that is, you want something done. We want top level attention from ministers, but we need to sustain that attention over a long period of time. I think that whatever mechanisms are used to bring ministers together, the key thing is making Canadians see that the problem is a important one for the whole country and that the government will be behind this problem for a long time. Then, the federal government must be prepared to resource its commitment to be a credible partner with the provinces.
Senator Eggleton: Those thoughts are helpful.
Let me ask one more question on the step-in or incremental approach versus "here is the big picture'' or the vision.
Mr. Cappe, you suggested the step-in approach. However, does there need to be a big vision there where people understand the overall goal? You can implement it by some incremental step-in approach, but do you not need both?
Mr. Cappe: I agree totally with that approach. Senator Eggleton, you are absolutely right.
You need the statement — the vision. In a way, it is revolutionary because we have never seen it before. Everyone tugs on their forelock when they talk about population health, but we have never seen a real statement that says, here is what this is and here is why it is important: that overarching statement. It is the implementation that I am talking about. You want to notch your belt with a few successes and then build on them. That is when the public sees that government is doing something positive.
Mr. Mitchell: I have one other thing to add.
We need to make Canadians understand that this issue is a big problem. For example, as the chair pointed out, type 2 diabetes is a looming threat to Canadians. Population health is like two other problems I think you have all witnessed over the last 20 years. One is making Canadians realize that debt and deficit were a big problem. It took a long time. Mr. Cappe and I were both in the central agencies in the early 1980s and 1990s. It took a long time for government to make Canadians realize we could not continue running $40-billion deficits. Finally, around 1995, when the government of the day acted strongly, the public environment was conditioned to action. I thought that strong action was important.
Take climate change as the second issue. It takes a long time for Canadians to realize that, yes, this problem is big. When government has made them accustomed to that problem, then, when governments act, as the federal government and provinces are about to do, Canadians say: Okay, I guess we will do that, then, because it really is a big problem.
This issue of raising awareness, sensitizing the people to the fact that this issue is a major one for Canada in all the dimensions you have talked about in this committee, is important. Then the Prime Minister is out there personally identifying this issue as a government priority and putting money behind it. Then the actual mechanics of making progress is a lot easier.
Mr. Cappe: One problem is that we see the cost of acting but we do not see the cost of not acting. Conditioning must be done to explain to the public that not addressing this problem, whether in social housing, income security or any of these elements, will make things worse down the road. The public says: Do I want my tax dollars going to that problem now? The answer is: Yes, otherwise, we will pay a bigger price.
Senator Eggleton: In other words, you want a business case developed.
Mr. Cappe: Yes.
The Chair: Before moving to the other senators, I want to take you down to another level with the comments that both of you have already made.
In our research and travels and in our preliminary reports, we unearthed some fairly ideal models of communities of good health, well-being and productivity. They were not necessarily in Canada, although some are, in particular, in our native communities. We were impressed in Cuba, for example, considering the expenditure.
In our report, we will present a few designs of communities of good health, well-being and productivity that can be applied to downtown Toronto, to rural communities, to the frozen North, to Aboriginal communities, et cetera. You have both alluded to the fact that the Prime Minister must take charge of this issue but it also must "get to the ground'' and there must be some successes.
How do we get the Prime Minister to the ground?
Mr. Mitchell: How do you move from the prime ministerial level downwards to results on the ground?
The Chair: That is another way of putting it. How do we get the Prime Minister to the ground?
Mr. Mitchell: First, let us assume that the Prime Minister and his government agree it is as major an issue as this committee has identified it to be. Second, I would look for willing partners who are prepared to work with the federal government, using federal resources as appropriate, to undertake pilot projects and demonstrate some successes.
For example, lots of innovation takes place in the health care system in Canada in different provinces. In Quebec, for example, les centres locaux de services communautaires, CLSCs work well. That model has not been appropriately adopted elsewhere.
If the Government of Canada is prepared to work with jurisdictions, for example with the Northwest Territories or Nunavut on small Aboriginal communities, or work with a given province that is interested in running pilots where they bring lots of the different players together, the feds can step in there as support. They can encourage, support and partner without seeming like they are coming in as too much of a driver on the ground.
If you had some successes like that and a continued attention to the issue, then the newspapers would write about the issue and Canadians would recognize it. You build the momentum for change that way. I would say, make it an issue and then create pilots that work and show results.
Mr. Cappe: I agree. Several honourable senators have been politicians in your past lives. Not a lot of immediate, positive reaction or reinforcement comes from taking these step-by-step approaches to improving population health. Where is the political feedback?
It is like the investments that the government twice-removed made in science. The university presidents all quietly came to Ottawa to encourage this investment but it was like one hand clapping. What was the return for huge investments in science?
You need to find a way of having the political reinforcement and encouragement. I think that Mr. Mitchell is onto something because the way political reinforcement happens is for the local non-governmental organizations and local community groups to insist on this project being done, then profusely applauding when it leads to a lot of success.
The only example I can point to in the case of the investments in science was when severe acute respiratory syndrome, SARS, hit in Toronto. The University of British Columbia took out a full page ad saying, This scientist that we brought back to Canada as a Canada research chair helped sequence the genome that was responsible for us figuring out how to deal with this problem. That was the only example I have. However, if you spend $10 billion and receive a newspaper ad out of it, that is not a lot of political encouragement.
It was the right thing to do and I do not mean to be partisan about this subject. I think this government has done a lot of those right things as well; they have extended some of those investments in science. However, no one has taken out newspaper ads applauding the government for that action. Instead, when they do not increase the money that they are already spending, they see newspaper articles against it.
I think there is a way to find political payoff for this issue but I have not figured out how. Mr. Mitchell may be on to something; namely, that political payoff must come from those local communities.
The Chair: I picked up this horrible flu up north announcing infrastructure money — and it must be one-third, one- third, one-third. In this case, it worked well.
I want you both to tell us how to address this subject in the report because it can be a huge barrier for a little community that wants to organize itself into a healthy community of well-being, productivity, improved education, improved nutrition for their kids, improved maternal health and parenting and so on, but they do not have the resources to match the money from the province. They do not have the resources to go after the province to match it.
How do we address this problem to go around the universal rules?
Mr. Cappe: I am less sympathetic to the argument that the local communities cannot afford it. First, matching is not an affordability question; it is not because we want the local communities to lever the federal money, or the federal money to lever the local money. Rather, it is to say, put your point where your mouth is: If this issue is a priority to you, then we think the local community should identify it as a local priority. It is not a federal priority; it is a local priority. If the local community puts up money, the federal government will do so and the province will also.
Second, the money is all fungible. Money goes into these investments — and they are investments. We should come back to this point because that is another problem. They are treated as expenditures but they are investments.
Nevertheless, these investments are a manifestation of not only priority, but of putting up the local money. The federal money can then lever it, which frees up other money in the local community. I understand the point, and I know that the municipalities do not have the tax bases on which to raise the funds in order to match, but investment demonstrates their commitment as opposed to a commitment determined in Ottawa, and they still have the flexibility of shifting money around.
Mr. Mitchell: Again, this difference is rare for me, because usually Mr. Cappe and I sing from exactly the same song sheet. It seems to me that doing more on population health at the local level may often call for more money. It may often call for money that local communities may not have. Provinces may or may not have the funds. If more needs to be done, then more may cost more. The question is: How do we pay for those investments? As Mr. Cappe said, those are investments. I completely agree.
What the communities bring to the table are local people, local capacity and local problems that need to be addressed. Communities bring local ideas. They bring a commitment to obtaining results. The provinces bring jurisdiction, capacity, and some money. The federal government brings a larger policy perspective, research perspective, an understanding of what is happening in the rest of the world, and money.
If you are the federal government and you want something to happen, then you have an informed point of view, which the government obtains through items such as this Senate committee report; you have research to back up your opinions, as Mr. Cappe said; you have relationships with those in other jurisdictions; and then you bring money to the table. That shows that you care.
What you cannot do is expect Baker Lake to bring money, and you cannot expect a lot of small towns in B.C. or Saskatchewan to bring money, or towns in Quebec or in Gatineau, where I am. They do not have money; they have issues, ideas and capacity.
Mr. Cappe: To show that, indeed, Mr. Mitchell and I do agree, I totally agree with what he said. The one third/one third/one third is not a magic formula. In fact, I have no idea where the number came from. I think it came from the first infrastructure program, but it is not the right formula.
If one thinks about who has responsibility for these kinds of investments, you might well put it as 10 per cent from the local community, 75 per cent from the province and 15 per cent from the federal government. However, that is not where the initiative will come from. What we are talking about is that the province is in a better place to fund these investments and to be responsible, but you want the ideas to come from the local community and you want the money to come from the leaders on the file, which may well be the federal government. Do not take the one third/one third/ one third formula as magic.
Mr. Mitchell: I completely agree with that point.
The Chair: Honourable senators, I am sorry for pursuing this matter, but I want to reach an end point here, because this opportunity is unique.
Senator Callbeck: Thank you for appearing this morning. I want to talk about the bottom-up approach. I truly believe that approach to be effective: You must have the top-down approach but also the bottom-up approach. If the public is not with you, the program will not last long. If the public are sold on the idea that population health is important, then the politicians will listen. When there is an election, the program will continue after the election if the public thinks the government should have it.
You spoke about the debt and the deficit, and it is true that it took a long time for Canadians to realize its importance. What lessons have you learned that we can use in informing Canadians that population health is important?
Mr. Cappe: That is a good question. One lesson, as Mr. Mitchell suggested, is that it takes a long time and you have to keep at it with a consistent message. I remember once asking Don Mazankowski whether he resented the fact that Paul Martin received the credit for breaking the back of the debt, because it was Michael Wilson and Don Mazankowski who started the sensitization process of the debt and that it was unsustainable. Mr. Mazankowski's answer, by the way, was: no, because we talked about it, but we did not do it.
This is another part of the question. I mentioned a step-by-step approach, not a dramatic, revolutionary approach. However, sometimes when you face a crisis, you can take dramatic measures that you would not otherwise take. I think there was a build-up over time where the public learned that the debt was a serious issue. The time horizon and the continuity of the discussion are important. Although I am a big fan of the step-by-step approach, sometimes you have to be opportunistic as well. When New Zealand hit the wall on their debt, there was a lesson for Canada, and that lesson echoed here in a way that made people stand up and take notice.
In terms of population health, it was interesting that the chair referred to some First Nations communities where there are successes. All we ever hear about are the First Nations communities where there are failures. Sometimes you have to point to the successes and build on those.
In a way, these issues are not new. They are certainly not bureaucratic. I think political actors are in a better position to figure these issues out. You do need to take the long-run view. If you can point to some of the costs of not taking action, that information will convince the public that population health is important.
Mr. Mitchell: In the background material prepared by your staff, they talk about the importance of champions. I think visible champions are important. I can think of two issues in recent years on which senators have been visible champions. One example is Senator Kirby on the issue of mental health. He pushed that issue, not only in the Senate but also publicly. He identified with the issue of mental health, made it a big deal, and then, through a lot of skilful work on all sides of Parliament, big things happened.
Another example is Senator Kenny on issues of national security. He has put those issues on the public agenda. I am sure not everyone agrees exactly with what he says, but he has been tremendously successful in sensitizing the public to those issues.
With regard to the issue of population health, if you want Canadians to think about this issue, you need visible champions, ideally political figures like yourselves, or members of Parliament, or a minister or prime minister: someone who is prepared to make this issue a big deal over years.
André Picard writes on health issues in The Globe and Mail. He should be totally sensitized to this issue. A series of articles could be written. Studies could be conducted in Aboriginal communities or places where type 2 diabetes is erupting badly, so that you have a concerted campaign, with visible champions, to make this a big issue for Canadians. That is how you obtain results.
Mr. Cappe: A group of people out there needs to be mobilized, and that group is non-governmental organizations, NGOs. They have credibility. With all due respect to honourable senators, you have seen this government; the public does not distinguish one side from the other. The credibility of NGOs is important.
I think of early childhood development, the National Child Benefit and so forth. The roles of Martha Friendly, Senator Landon Pearson and Fraser Mustard were crucial in sensitizing the public to those issues. You have to push for that sensitization as well.
Senator Callbeck: Moving from the bottom up is so important. It can be sold to the government, but unless the public really buys into it, the next government may change it. To work long term, as we need to, we need the public to buy in.
The Chair: Thank you, Senator Callbeck.
I am sure you both know the former premier of Prince Edward Island. She has some experience.
Mr. Cappe: Absolutely; that is why we bowed our heads when we talked about provinces.
Senator Callbeck: I have been through some of this experience.
Senator Eaton: Mr. Cappe, further to what Senator Callbeck said, you said, stay under the radar. Looking back at the deficit and looking at the notion of bottom-up, I wonder whether that policy is the right one. Perhaps population health should become a general discussion between the federal minister of health and the health ministers of each province.
I like to think that schools and private industry have parts to play. We could educate industries on managing employee health in order that lost productivity would go from six days to two days. In schools, we see more and more children who are vastly overweight. We could convince the parents and the schools to have an hour of gym class in the morning, and to cut out pop. I am not an expert in this subject, but perhaps we could start in small ways.
Will the political payoff not come from lower health costs for which health ministers can take credit as a result of programs they had instituted?
Are you convinced that we should stay under the radar and not make this issue a national talking point? It is awful to see children with diabetes at the age of 10, and having strokes and heart attacks. I do not understand your point of keeping it under the radar.
Mr. Cappe: I probably am giving mixed messages, because I agree that the issue needs a profile, that the public must demand this change, and that politicians must take this issue seriously in a sustained fashion. I tend to agree with your direction.
My point was whether progress can be made on the ground by politicizing or depoliticizing. By raising the profile, you make winners and losers, and I am trying to find a way to make everyone a winner.
Senator Eaton: How do you make a loser if you raise the profile?
Mr. Cappe: When the federal government announces this initiative and embarrasses the provinces because they have not taken action, the provincial minister becomes steamed, or vice versa. If we take the collaborative approach that this initiative is in the interests of everyone, and is not partisan, federal or provincial, everyone will be aligned.
The National Child Benefit is an interesting example of where the federal government and the provinces came together and instituted a new program, and everyone received credit for taking the right action. A lot of money went to the people who needed it. If it was dealt with in a way that someone had to be given credit, it would have been a failure.
You are right that the costs avoided as a result of investments in population health are politically valuable, but they are valuable to the successors of the people who take action now. The long-term nature of the issue makes winners and losers as well.
Senator Eaton: I do not understand, being new on the committee. We talk about costs, and there are costs to everything, but I think population health would be a matter of education and information. I cannot force someone to quit smoking, but I may be able to educate them about the reasons to quit smoking. The anti-smoking campaign worked, and it was largely an information campaign.
We talk about costs, but maybe we should think more about information, education and support.
Mr. Cappe: Information is crucial in this matter, but even information costs a lot. When I was the deputy minister of the environment, in the 1995 budget we cut state-of- the-environment reporting. The program was only an information one, but it was an important information program. We had to make tough decisions, and we stopped the program. Information costs money.
Senator Eaton: Yes, but the anti-smoking campaign has reaped huge benefits, has it not?
Mr. Cappe: I agree with you. It is worth the cost.
Mr. Mitchell: I am in clear support of Mr. Cappe. Anti-smoking is an example of a federal program. The federal government provided the programming and paid the costs. It has been successful in the long term, and it does not involve, for example, asking the provinces to contribute potentially embarrassing statistics on 14 determinants of health.
One problem with making things too high profile, and having too much evidence and data on the table is that the provinces become embarrassed. They are reluctant to be embarrassed and they do not like providing information about what they are doing or not doing in ways that lead them to negative comparisons with other provinces.
In many of these determinants of health, some provinces have poor numbers, others have less poor numbers, but no one has great numbers. The provinces own much of the issue and do not like to be shown up by the federal government. The key is for the federal government to work with the provinces in a way that puts the focus on the issue and not on who is doing a poor job.
Senator Eaton: I cannot agree more. I see this approach more as a positive thing than as showing anyone up. I do not see it that way at all. I see it more as helping people.
Senator Cook: Thank you for coming here and for challenging my brain this morning.
We talk about public health, which is the health of the public. People do not know where to go, and we cannot show them. We have not talked about the cost of food. You can talk all you like about good health and good outcomes, but if a person cannot afford to buy the proper food, which is often the case, where do we go?
In the 1990s and a bit before that, my province of Newfoundland and Labrador was hit by a massive social problem, the collapse of the groundfish fishery. Wisdom prevailed in the government of the day, and they developed an IT program called Community Accounts. Have you heard of it?
Mr. Cappe: No.
Senator Cook: This committee went to study the Community Accounts program. It was a comprehensive profile of the community including its resources, the age of people and what was available there. It is online at www.communityaccounts.ca, and it is free, which is important. It is a Department of Finance program, and it is funded by the government. The government uses it as a blueprint not only for the determinants of health but how they apply. The stories are legion. I know the fellow well that ran the program. The government prepared the program and targeted a community. They said to the community, We want to come and make this presentation to the Chamber of Commerce. With apprehension, they made the presentation. They said to each other on the way out, We will be told, what does that crowd in St. John's know about what goes on here? They made their presentation, and it was well received. The people who heard it said: We did not know we were like that; there are some things there that we can do for ourselves that will not cost us any money. Therefore, an awareness was developed. That tool is free. It is used by whoever wants to use it.
I know it is a simplistic solution to a complex problem, but can that approach be a catalyst whereby we present that kind of a vision and create the awareness within the community at the local level?
The prime minister of the day will say, what are you talking about? I believe we must create awareness along the continuum. It is simple. That blueprint is there, and I ask you learned gentlemen to look at it. It has been used in Australia. They have taken it to Turkey. It is a success story. It is free, thanks to the generosity of my province, which reaped benefits because they looked at who they were, what they could do for themselves, and everyone bought into it.
Mr. Mitchell: That idea is terrific, and that is precisely the kind of tool and mechanism that can be useful for general application across the country, or in any jurisdiction that is prepared to take it up. It is great to hear that it is free. It costs money to use a tool like that effectively in communities, to populate the accounts with the right data about the health of those communities in all the ways you are talking about, and then to paint the picture and have people, whether at the community level or from the province, to go into communities and feed back to people. The idea is terrific. It will cost a bit of money, but that is no reason not to do it. My point is that if you have agreement in the province that you want to do take that approach, then the federal government can put money behind it.
Senator Cook: I reiterate that the tool is free. Who uses it? The public health nurse, the Department of Education and the community leaders use it as part of their ongoing mandate. It helps them perform their jobs. It does not cost anything other than the maintenance of the account. It is legislated into the system. It is in the Department of Finance. It is written there forever. There are benchmarks, and the accountability is in the application of presenting it in the budget.
Mr. Cappe: It is free, but it does cost us. Someone must collect the data and put it on the website. The beauty of information is that when I read it, it does not prevent you from reading it. There is no exclusivity. One problem that Mr. Mitchell referred to is accountability. It used to be that the federal government liked to hold the provinces to account for the way they spent federal money. The provinces said they will not be accountable to the federal government. They will be accountable to their electors. They said, you give us the money, and we will be accountable to our electors for how we spend it.
Then they started to waiver a little, and in many of the health transfers, they backed off from that position. We went to a national system as opposed to a federal system, where the Canadian Institute for Health Information, CIHI, is intended to provide a lot of that information so the public can use it. The information is not community based, which is what you suggest, and exactly the way to go. You are right that that you want a community base. If you can disaggregate what CIHI is doing, you can provide that in a way that does not threaten the local community or the province.
Senator Cook: It is not threatening, because it teaches the community how well they are doing and who they are. If you are nosey, you can go on the Internet and find out how your community is faring this year as compared to last year. The information is free. The tool is an essential for the well-being of people. If you went to the prime minister of the day and said, Here are the benchmarks and the evidence-based information, what prime minister would not support evidence from people at a grassroots level?
Mr. Mitchell: That is a perfect example from my perspective of the kind of tool that governments, both federal and provincial, can use as a key ingredient of a comprehensive, national approach to addressing public health issues. That is community-level benchmarking, supported by good data and accessible technology. It is perfect.
Senator Cook: The first thing they look at is the price of groceries and the cost of delivering them to the consumer. If we believe that we are what we eat, we will never be a good and healthy citizen if an orange is $1.49. Who can afford that?
The Chair: I want to expand on this point. It is truly interesting. This tool will be included in our report. We looked at this tool in detail. They give communities a green, yellow or red dot, depending on their state of well-being. The communities are not intimidated. They want to move from green to yellow to red. Therefore, the communities organized themselves with a sort of committee on the 12 or so determinants of health. They changed the nutrition programs in the schools. They changed some of the public education programs. They improved the public health programs. They improved the employment programs. They improved the housing programs. They move from green to yellow to red.
Senator Cook: If I might close with a story, when I was readying myself to go to my province, I did not understand the tool. I asked a lot of off-the-wall questions. I had a researcher who lives at home — she is English — and she said, Let me print out the information where you come from.
There are 13 zones, and my zone had nine communities. She said, Sit down and look at the resources. I looked at the community I was born in and still very much a part of. I said, you are wrong: The average income in that community should be less than mine. We argued back and forth. She said, Joan, you need to think. Then I realized there is a regional high school. Guess where all the teachers and employed people were living? Was I embarrassed? I think so. However, I was not intimidated by it, and I was not upset. That is how accurate the profiles of the communities are. If, as Senator Callbeck said, you bring the information from the individual up, the structure will take care of itself. That will come. I am less concerned about structure than I am about awareness.
Mr. Mitchell: If I may add one more point following on Senator Cook's point: If you give people that information in the way you have described — useful, accessible information in red, yellow, green, which is very important — you create an instant demand for action by local and provincial authorities to address the problems revealed by that information. Therefore, I strongly recommend that you not use a tool like that unless you are also ready to come in with remedial measures that communities themselves will demand. If you do not have those remedial measures, you create a big problem for yourself.
Senator Cook: That is my point. Where I come from, the public health nurse is a fixture there anyway, in a building and doing her work. She can do the work much more effectively when she knows the strengths and weaknesses of her population, so it is an investment and not a cost.
Mr. Mitchell: We agree entirely with you, senator. It is an investment and not a cost.
The Chair: We are deeply indebted to both of you for coming here this morning. I know you have a 12 o'clock deadline, and it is now 12 o'clock, so we will wrap up this meeting. We have a major round table coming up with all the data gurus. I sent you a copy of this information. They assure us that they can now wire this, especially with the infusion of $500 million. If we can do this for Canadian society, maybe we can move population health up a few notches in the foreseeable future. I thank you for taking time out of your busy agendas. We needed to hear from you at this point in time.
(The committee adjourned.)