Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 22 - Evidence for October 2, 2003

OTTAWA, Thursday, October 2, 2003

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:06 a.m. to study on the infrastructure and governance of the public health system in Canada, as well as on Canada's ability to respond to public health emergencies arising from outbreaks of infectious disease.

Senator Michael Kirby (Chairman) in the Chair.


The Chairman: Honourable senators, this morning, our witnesses are from the Canadian Coalition for Public Health In the 21st Century. We will hear from Dr. Elinor Wilson, the co-chair and Dr. Maureen Law, a member of the coalition, who has also had, as many will remember, positions around Ottawa for some time over the years. Welcome back.

Dr. Elinor Wilson, Co-Chair, Canadian Coalition for Public Health in the 21st Century: Thank you very much for this opportunity to present to the committee. Dr. Law and myself will share our presentation, and then we will both be available to answer questions.

We appreciate the mandate of the committee and its current short-term look at one piece of our public health system — the infectious disease component. However, the coalition believes that the systemic issues that Canada experienced in dealing with the SARS crisis demonstrate overarching challenges we face with the entire public health system. These challenges have given Canada an unprecedented opportunity to look at the entire public health system, and, obviously, improve it for the overarching health of Canadians.

I should like to introduce first the coalition. Last year, the Canadian Institutes of Health Research, CIHR, through the Institute of Population and Public Health, commissioned a paper on the future of public health in Canada. This paper was commissioned prior to all of the extreme health crises that we faced in this country. In May 2003, there was a forum held in conjunction with the Canadian Public Health Association meeting on the future of public health in Canada. This think-tank brought together disparate groups and individuals with expertise to debate the issues relating to public health in Canada. The coalition was formed as a result of that, and the Canadian Public Health Association, as Canada's premier agency in public health, was asked to take on the function of secretariat for the coalition.

The members of the coalition currently include the Canadian Public Health Association, the Chronic Disease Prevention Alliance of Canada, the Canadian Medical Association, the Canadian Nurses Association, the Canadian Institutes of Health Research, and, of course, many distinguished individuals, such as Dr. Maureen Law and Dr. Monique Bégin, who share and hold the values of public health in Canada.

The coalition is unique in that it pulls together all these independent and diverse organizations, which had been debating issues of public health and had already made statement on public health. Those of you who sit on committees such as this often know how difficult it is to get consensus in our broadly diverse country. As these groups came together, we were amazed at how very similar our points were on public health. We decided that we needed not only to form this coalition but also to expand it as quickly as possible and engage the Canadian public in debates about public health and its future in this country.

Even we are discussing and debating the issue of infectious disease in this committee, it is chronic disease in this country that kills the majority of our population. Four chronic diseases — heart disease, cancer, diabetes, and chronic obstructive pulmonary disease — cause three-quarters of all deaths in Canada. Thirty-five per cent of all deaths are caused by heart disease; seventy per cent of premature deaths and two thirds of chronic disability are preventable. We believe that public health is the foundation of all of health care, which looks after these chronic diseases as well.

Dr. Maureen Law, Member, Canadian Coalition for Public Health in the 21st Century: Health care is what we call a ``downstream'' focus — that is, we pick up the pieces after the illness has occurred. It provides clinical services to individuals. It is involved with diagnosis and treatment. The approximate total current spending on health care is $110 billion per year.

In contrast, public health has an ``upstream focus'' — that is, attempting to prevent illness and to promote the health of Canadians. It is really the foundation for the well-being of our population. At the moment, we are spending about $2 billion per year on public health.

It is important to recognize that the public health system and the health care system should not be viewed as separate systems. They are really components of a single health system. We absolutely need this comprehensive approach. Both components of the health system must be adequately funded, effectively managed and delivered, and appropriately monitored. When the public health component is fragmented and starved for resources — as it is at present — the health care side suffers the consequences in avoidable demands and costs.

The two components have to be strongly linked. For example, public health experts must be integrated into the communicable disease response teams in health facilities such as hospitals. Practising physicians have important roles to play in prevention and promotion in addressing issues such as tobacco and obesity. They need to be supported in that role by the local public health officials. Of course, effective disease surveillance requires close collaboration of the public health and health care components of the system.

Public health is not only about this comprehensive health system; we also need to think about multi-sectoral approaches. It is clear that the health of Canadians cannot be protected by the health system working in isolation. The actions or inactions of many other sectors greatly influence our health. We cannot be protected from communicable diseases if our water is unsafe. We cannot be protected from respiratory illnesses if our air is polluted. We cannot reduce tobacco use without the cooperation of the ministries of agriculture and industry. We cannot persuade Canadians to adopt healthier lifestyles without the involvement of our education systems. These are only a few of the many examples we could cite.

Having said that, I understand how difficult the implementation of this concept of multi-sectoral approaches — or what we sometimes call ``healthy public policy'' — can be in practice. Some body has to have the mandate, the leadership, the dedication and the resources to pursue such a policy relentlessly. It is an important reason for the creation of a national public health agency as proposed by the coalition members and many others.

I know from my own experience as a deputy minister of health and welfare how frustrating it can be not to have the time to pursue these multi-sectoral approaches in a long-term, sustained way when you are constantly distracted by the crises of the moment.

Finally, this comprehensive system has to have strong international links. Canada has international obligations, such as those under the international health regulations concerning communicable diseases, for example, and more recently tobacco control. If we are to meet these obligations, we must immediately strengthen our public health services, especially in relation to surveillance and communication.

With increasing globalization, we also have much to gain from these international links. We need to know about new developments around the world in relation to communicable disease or possible biological or chemical terrorism, et cetera. We are not alone in dealing with those issues. We need to learn from other countries and share with them what can be done on this broad range of common interests.

Moreover, although we still have one of the world's healthiest populations, we have been falling behind in international comparisons in recent years. We need to take a good look at the countries that are have moved ahead of us on that scale to learn from their actions. I think that is particularly true on the public health side.

Ms. Wilson: I would like to briefly review the principles that the coalition has established and then speak to each of them in a bit more depth.

In coming to this consensus, we looked at principles from all of the organizations that are part of the coalition and were able very readily to come to certain principles that we felt were overarching.

The first is that public health is a national responsibility and it requires a pan-Canadian approach with shared leadership across sectors. By ``pan-Canadian,'' we mean that Canada needs to have government, non-governmental organizations, and the business sector all working together with clearly defined accountabilities and national leadership. The public expects no less from our government. The public health focus on population and communities complements the work done by our excellent health care system. Funding for public health should be viewed as essential and strategic to provide the foundations for the entire system. We must be prepared for future public health issues by investing now. The model that comes to mind is the Boy Scouts' ``Be Prepared,'' as opposed to ``just-in-time responses.''

The coalition is suggesting that $1 billion be immediately reinvested in public health and that this base funding be doubled within five years. We are suggesting the creation of a national public health agency, led by a national public health officer. We are suggesting a pan-Canadian system with strengthened health human resources and a national information and communications system for public health. We think this will require a reform of legislation at the federal and provincial government levels to clarify roles and responsibilities and, obviously, funding mechanisms to support accountabilities.

The coalition is able to bring some synergy to this as a national issue. Because of the diverse range of organizations and their members, we believe that we can play a role in assisting committees such as this; taking the pulse of organizations across the country; and potentially taking the pulse of the public on issues that are germane to your debate.

Even though we have spoken about the broader public health system and the issue of chronic disease, we would like to remind the committee that a study in the Journal of the American Medical Association looking at the outcomes of the SARS epidemic and looking at 144 patients, of whom eight died, concluded that diabetes and other co-morbid conditions were independently associated with poor outcomes. In other words, SARS did not generally affect the healthy individual; it tended to affect most dramatically those individuals who were already ill.

In a society such as Canada, where more than 85 per cent of the population has one or more major risk factors for one of the chronic diseases, we cannot ignore chronic disease in all of this. As a coalition, we have a web-based survey in the field, and we are prepared to deliver the results of this survey to this committee in a timely fashion to form part of your deliberations.

Rebuilding public health requires an investment in people, systems and the nation. Such investment will assist us in building sustainability in the longer term for our health care system. Additionally, we would expect it to divert potential patients from utilizing the extreme amount of health care resources that we, as individuals, use now in this country.

The study of public health and this concern is not limited to Canada. In 1998, in the United States, the Institute of Medicine did a study on the future of public health, which they defined as what we do as a society to collectively assure the condition in which people can be healthy. Just this year, they did another study of public health entitled, ``The Future of the Public's Health in the 21st Century.'' You can see how their focus changed from the future of ``public health'' as an entity to the recognition that we are really talking the future of the ``public's'' health in the 21st century.

The vision that drove them was healthy people in healthy communities. They made the point that government agencies cannot do this alone. This needs to include public health systems, government health agencies, the health care delivery system, academia, communities, schools, business, and the media.

They found, in the United States — under the glare of their national crisis, which was precipitated by the anthrax scare — the following things. As I cite them, I would like us to think about some of the things that we have found already in our system. In the U.S., they found: vulnerable and outdated health information systems and technologies; an insufficient and inadequately trained public health workforce; antiquated lab capacity; lack of real-time surveillance; ineffective and fragmented communications networks; incomplete domestic preparedness and emergency response; and communities without access to essential public health services. The points that the Institute of Medicine discovered in the United States' public health system resonate clearly with us in Canada.

With respect to investment, we are asking that Canada move from a ``just-in-time'' delivery system as it applies to public health crises to a ``be-prepared'' system. We need a seamless pan-Canadian system, one that starts with the foundation of public health and flows through primary care into health care; one that is adequately resourced, with delineated roles and responsibility, and specific lines of authority in emergencies in this country.

The short-term priorities we have isolated are: the ability and the requirement to build local public health capacity; a $1 billion investment to improve the capacity that we have; a national public health agency that will build on existing expertise in this country, which is arm's length from government and reports to Parliament through a medical officer of health; and a chief public health officer who, in an emergency and at all other times, becomes the hub of public health activity for this country.

In terms of mid-term priorities, we hope to double the funding base for the Canadian public health system over the next five years to expand the public health agency concept with the broad responsibilities and independence that is required. We have centres of expertise right across this country. We need to be able to link these centres in a very coordinated fashion, to ensure they are all working toward the same goal.

We need to strengthen our public health human resources. We need to be able to provide on-the-job training for current public health professionals to deal with new and emerging issues, and to find a way to make public health resourcing a career in this country — a career that attracts health professionals.

Dr. Law has already mentioned the national information system, our surveillance system. The Auditor General of Canada has reported to Parliament over the last three years of the necessity for improving surveillance in this country. I think we saw recently, in our epidemic of SARS, that our communications system does need some work.

In the longer term, this will require a consolidation of federal legislation and a potential review and consolidation of all public health legislation across the country, supported by new funding mechanisms to support these types of accountability.

Where are we left? We are saying that we are in a paradigm shift — a new way of thinking about health for the public of Canada. Public health is a public good because many aspects of human potential — be they employment, social relationships, public participation — depend on health. In this respect, our mandate to create conditions for people to be healthy is a shared social good in our country.

There is some question as to whether or not the public understands what public health is. In April 2003, the Chronic Disease Prevention Alliance of Canada did a Decima poll of 2,001 Canadians. I am pleased to report that the majority of Canadians — between 89 and 93 per cent — either strongly agree or somewhat agree that public health is about sewage and sanitation, promoting healthy lifestyles, protecting the quality of our water and protecting against infectious disease. The public seems to understand the broad scope and mandate of public health.

In July 2003, in the midst of what we were going through with SARS, West Nile, et cetera, Decima did another poll on the confidence of the public in steps being taken to control these threats. They said the lack of public concern may be due in part to widespread belief that the necessary efforts are being made to address these hazards. Seventy-four per cent of Canadians feel that public health authorities are currently doing everything they can to protect Canadians from these types of public health risks.

Public health to the public is rather like air conditioning. When it is working, everything is fine; when it breaks and the heat rises in a room, we all know what we are missing with our air conditioning. We have a job to do with helping the public understand that, yes, these are the components of public health, but also helping them understand that they should be as concerned about our public health system infrastructure as they have been about our health care system. It is only by getting the public mobilized, and putting these two pieces together, that we can ensure the health of Canadians in this country.

We appreciate the opportunity to speak to the committee, Mr. Chairman. We would like you to know that this coalition is prepared to carry out any work that the committee would find helpful in your deliberations. We are certainly looking forward to this committee's future deliberations on the broader aspects of public health.

Senator LeBreton: Listening to that presentation, we have a tall order in front of us here. It is mildly depressing to think of the work that needs to be done to bring the assistance into place.

You specifically talk about consolidating all levels of government and working on this, but you say we have to change from a ``just-in-time'' delivery system to a ``be-prepared'' system. Is there any sense that this shift is starting to take place, or are we basically starting at ground zero in making this transformation? Is there any work being done anywhere on this?

Dr. Wilson: The SARS experience made public health recognize that the capacity to surge was not there. If you lack capacity overall, you lack capacity to surge. During that time, public health officials tell us that everyone was diverted from the myriad of other activities into looking at the implications of SARS — and rightly so. We need to be able to have that capacity, but infectious disease does not happen every day of the week. Many public health units are starting to look at just this very issue, but it is my understanding that no formal work is being done in that. I do not know if Dr. Law knows of anything in that regard. It is a concern, but nothing formal.

Dr. Law: In a sense, all of public health is about being prepared. It is not that people are not thinking about avoiding problems, for instance. I do not want to give the impression that someone suddenly wakes up one day and says, ``We have imported a communicable disease,'' or ``the water is not safe there,'' or something like that. Obviously, people think about those potential problems all the time. That is what public health is about. However, the resources to do it properly and the resources to respond to emergencies have been lacking. It is not so much that the whole system needs to think differently; it is a matter of building on what is there, getting it adequately funded and, especially, getting it properly coordinated so we know who is taking responsibility for what and that all the pieces are fitting together.

Senator LeBreton: With the SARS outbreak and as the whole system shifted to focus on this new disease and away from other areas — and we have had other witnesses say that other areas severely suffered because the whole focus there — many other things got dropped off the table.

Now that the SARS outbreak has been controlled, has the rest of the system recovered from the shift to the focus on SARS? Alternatively, are they still trying to catch up in areas that suffered because the attention of everyone was focused on SARS?

Dr. Wilson: I can offer an anecdotal response to your question. I was speaking at a meeting of Ontario public health nurses last week in Toronto, and they were certainly indicating that the system is taking some time to recover and regroup. As Dr. Law has said, as well as regrouping and getting back to business as usual, they are now heavily involved in trying to understand the types of resources that will be required so that they are ready for the next piece that comes.

The shock to our system has been that it can happen here. We have been very fortunate in Canada for many years, thinking that these things occur somewhere else, and it has been quite a shock to our system overall. It is not, ``if it is going to happen,'' but it is ``when will it occur the next time.'' Again, fundamental public health is all about trying ensure right now that it does not occur.

For example, the World Health Organization is putting out a plea to ensure that people get their flu vaccine because if SARS arises again during the winter flu months, it is important to be able to distinguish between what is flu and what is not flu at that time. That is a message that has not necessarily gotten out well to the Canadian public. We are still under-immunized against flu every year, as we can see by the elderly in our emergency departments.

Senator Morin: I knew Dr. Wilson in another life and she has been extremely active at the Heart and Stroke Foundation. She also did some excellent work in South America.

You have quoted from a document from the Institute of Medicine in the U.S., and I think we will try to get it. It is from 1998; is that correct?

Dr. Wilson: The first report was in 1988. The second report came out in April 2003.

Senator Morin: If we could have these references, that would be helpful. Could we also have the list of the organizations that are part of your coalition? I know you mentioned them, but we do not have them in the documents.

Dr. Wilson: Certainly.

Senator Morin: Do I understand that all the organizations in the coalition agree with the creation of a national public health agency? ``Consensus'' means they all support the creation of such an entity?

Dr. Wilson: Yes.

Senator Morin: In other words, there is widespread support for this agency, if all the organizations agree. Do have you any provincial organizations within your coalition? You have no governments in your coalition.

Dr. Wilson: The Chronic Disease Prevention Alliance of Canada is essentially a coalition of coalitions. In every province, there is a Chronic Disease Prevention Alliance, and in many of those, people who work with provincial governments and public health sit around those tables, but not formally as in ``this government has joined this coalition.''

The Canadian Public Health Association, of course, has public health associations in 10 provinces and one territory, and, often, many of the people who form provincial organizations are employees of governments in that they are medical officers of health, public health nurses, et cetera. However, the representation is not formal as in ``the Government of Saskatchewan has joined the coalition.''

Senator Morin: Senator Roche raised this point yesterday and he may want to elaborate. There is, as you realize, tension between the provinces and the federal government on all health issues. It would have been extremely interesting to hear that some provincial governments, through the coalition, have agreed on the creation of this agency. However, you are not prepared to say that?

Dr. Wilson: No, I am not, sir. That would have been too simple.

Senator Morin: I would like to come back to the $1 billion. Resources are extremely important in this field. Many of the problems we face are a result of lack of resources. I think the figure is $110 billion for the health care and $2.5 billion is for public health. This figure has been stable.

How did you get to the $1 billion figure? This is important. If we want to help you get more resources, we cannot just pick a number out of the air and say, ``$1 billion'' and have everyone bow to our statement and give us a cheque for $1 billion. We must justify that and have evidence.

In our report, we recommended $200 million a year, and that was based on a figure given to us by Health Canada. We have a breakdown of it — so much on this and so much on that.

You are coming up with $1 billion. Do you have a breakdown on how you justify this $1 billion?

Dr. Wilson: You are quite right. It is extremely important to ensure the figures are accurate. We have not done an economic analysis with experts in looking at this. The Canadian Public Health Association is currently looking at some of these issues in terms of alternative financing.

However, we did some calculations around the Government of Ontario and what was being spent in terms of looking at public health in Ontario in the budgets. It is around $34 per person. We took the figure of $34 per person and extrapolated what would seem to be a reasonable figure. We agree that more work needs to be done on this.

Senator Morin: Is Ontario now spending $34 per person?

Dr. Wilson: Yes. That was the figure for 2001.

Senator Morin: Are you saying that that is the acceptable level?

Dr. Wilson: We are saying that it needs to be increased. We use that to get our $1 billion figure.

Senator Morin: It should be increased by how much?

Dr. Wilson: To a total of $1 billion.

Senator Morin: Why is it not $2 billion? Yesterday, we posed the same question to the Canadian Public Health Association, CPHA, and the response was: ``We put in $1 billion to impress you.'' Well, I was impressed but that was the only reason we were given and the answer to this is actually extremely important.

Dr. Wilson: Absolutely, it is important.

Senator Morin: We cannot help you increase your resources unless you give us the arguments. The rest of it is easy to figure out in respect of the agency, the director, et cetera, but when we are talking about the dollars and cents, those at the receiving end of the request need a clear argument in support of our suggestion. We have heard many presentations by many people of many different principles. However, no one has helped us with the extremely important information on the exact resources required at the national and provincial levels and, if there is a need at the provincial level, whether it should come from the federal funds that will trickle down to the provinces with accountability — as you mentioned in your last bullet point — which is excellent. All these things are extremely important because the rest are simply words. The bottom line here is the dollar figure.

Dr. Law: Please permit me to point out again that the coalition has only been in existence for a few months; we have no secretariat to speak of. We have one person who does some part-time work on that from the Canadian Public Health Association.

The coalition has not, therefore, been preparing an economic analysis of the needs. Rather, it has been operating on what its member organizations are suggesting would be reasonable. The truth is that we do not know whether it should be $700 million or $1.2 billion. We do not think it is $100 million but it is somewhere up there — in the neighbourhood of $1 billion. Much more work would need to be done to figure out exactly how much and how it should be spent.

One of the difficulties we have in looking at this question of the amount that is needed is that it is difficult to get a handle on how much is currently being spent and how to categorize the expenditures. The federal, provincial and municipal funding is fragmented. Gathering the data is a big job to determine what is currently happening. In respect of the National Health Agency, we can look at what is spent, for example, by the CDC on a per capita basis and decide that perhaps we need something similar, which would be in the order of $1 billion. However, we would then have to take into account the existing pieces and how much would be incremental. There are many big questions that would need to be addressed.

One reason that public health people are not clear about how much more they need is that no one has ever given them any prospect of having anything but budget cuts for so many years. The concept of figuring out how much they actually need to do the job properly is far from their minds. Now, because people are talking about public health, finally, they are starting to come to life and think seriously about how much they would truly need. It is clearly a great deal more money than they have now but exactly how much, I think no one is in a position to say for certain.

Senator Morin: You realize that someone has to do that work.

Dr. Law: That is right and some organizations are beginning that work. CPHA has been trying and the Canadian Medical Association, CMA, has been doing some work on this as well. I know they will be talking to you about that.

There are funding constraints for all these professional and voluntary organizations to do the kind of work that would be needed to determine a good answer to your question. However, I do not argue your point that it does need to be done.

Senator Morin: Last year we had, from Health Canada, a good breakdown of what they are now spending in that area. At that time, they said they needed an extra annual injection of $200 million. That was their figure two years ago.

Dr. Law: That is a starting point.

Senator Morin: Health Canada knows how much they are spending.

Senator Trenholme Counsell: I want to ask you further about the formation of the coalition because it is so new.

Dr. Wilson: Yes, it was formed last May.

Senator Trenholme Counsell: It was not formed in reaction to SARS?

Dr. Wilson: No.

Senator Trenholme Counsell: What led you to form the coalition? What was the impetus for that?

Dr. Wilson: Like all things, there comes a synergy of circumstances. The coalition I represent is the Chronic Disease Prevention Alliance of Canada, which was formed by the Heart and Stroke Foundation, the Cancer Society and the Canadian Diabetes Association and the three national coalitions, the Canadian Council on Tobacco Control, the Network for Active Living and the Canadian Dieticians Association, to look at our three common risk factors which are physical inactivity, tobacco use and healthy diet.

As we began our deliberations about how to get the public not only to hear these messages but also to take action, we realized that much of this needed to go through public health. The Heart and Stroke Foundation had had some experience with the Canadian Heart Health Initiative, whose goal was to integrate heart health messages through public health. However, there was not enough capacity in public health to take up that activity. We stopped at that point and realized that we needed the Canadian Public Health Association and the Canadian Federation of Municipalities with us so we brought those two groups on board. Then, as we began to look at the minister's healthy living agenda, we decided that this was about the public health system infrastructure and capacity so, in a way, disease- based organizations backed themselves to the fundamental place that health occurs — in the communities, and the foundation for that is public health.

At the same time, the Canadian Medical Association had had much foresight in opening their Office of Public Health and they were already looking at issues around public health. The Canadian Nurses' Association were already involved because of their work in public health. There seemed to be many organizations realizing, at the same time, that to get the most effective job done for the health of Canadians, public health seemed to be coming up as the key foundational piece. It was as simple or as complicated as that.

Senator Trenholme Counsell: It seems like a vast undertaking. At yesterday's committee meeting, I asked about all of these wonderful, numerous, and seemingly overlapping, non-profit groups and associations. I understand then that Diabetes Association, the Heart and Stroke Foundation and the Lung Association are linked to you formally?

Dr. Wilson: Yes, they are formally linked.

Senator Trenholme Counsell: Are they members of your coalition, if you will?

Dr. Wilson: Yes, they are.

Senator Trenholme Counsell: How many people are working in the coalition?

Dr. Wilson: In the Coalition for Public Health in the 21st Century, there are six national groupings, however, all of them have many other organizations as part of them. The Chronic Disease Prevention Alliance of Canada, as one member of the coalition, represents 25 other national organizations and 150 individuals and coalitions in every province of the country. It is quite massive.

Senator Trenholme Counsell: Do you see this ceasing to function if we had a national public health agency? Would all the things that you are doing become part of such an agency?

Dr. Wilson: To say, ``part of such an agency,'' would be too extreme. Not-for-profit agencies that are concerned about health issues will not go away if we have a public health agency.

Senator Trenholme Counsell: Someone needs to embrace and coordinate them. It seems to me that you are doing just that. If there were a national public health agency, it would want to certainly pay a great deal of attention to and be inclusive of all these groups because they are doing important work.

Dr. Wilson: Absolutely. Such an agency could provide the focal point for the linking and the coordinating.

Senator Trenholme Counsell: Much of what I have heard is the same as I heard 50 years ago, when I was working in public health. It has not changed. It is really the same feeling of the forgotten cousins, or the anxious cousins.

It seems that much of it has come about because of SARS. That has been the stimulus, and that is a good thing.

I see two issues. One is infectious disease control and how Canada will deal with that in better way. It seems Canada has been struck by two things we were not expecting — SARS and the hurricane in Halifax. I do not think we ever expected that we would have either of those things. It is Canada's turn to suffer and learn how to be prepared. Communicable disease is one thing.

The other issue is that I believe that if we are to control health care costs, we must get the public — in other words, Canadian citizens — to take responsibility for their own health. That is what public health is largely about. I believe that passionately. I do not think we will ever control the spiralling costs if we do not start to preach individual responsibility for health and individual responsibility for how we use our health care dollars. Yours is a very noble and important contribution to all of this.

Dr. Wilson: Thank you.

Senator Keon: I apologize for being late and missing some of your presentation, especially yours, Dr. Law.

Your slides are interesting. They cut through a lot and come down to a focus. I would like you to elaborate on the concept of integration as it relates to public health and the overall health system. We talk about integrated health systems, and integrated health delivery systems and so forth. As far as I can see, you are talking about an integrated health system; however, your first slide produces a bit of a two-headed monster. Then you go over to the third slide and talk about a comprehensive health system. You do not use the word ``integrated.'' In your recommendations, you talk about the national public health agency. Dr. Joseph Losos was here yesterday talking about the same thing, fundamentally.

Would you both expand a little on where you see the public health system fitting into the overall health system in Canada with the national and provincial components and, we hope someday, with the regional health authority components and so forth?

Dr. Law: It is unfortunate that you missed my presentation, because I actually made the point that that list makes it looks like there are two systems when, in fact, it has to be one system with these two important components.

One thing that has been really encouraging to see in the last year or two in particular is that the health care side is starting to realize that there is another component to the system to which they need to be better linked. A good example of that is the activity of the Canadian Medical Association, which has finally started to take public health seriously and to realize that the health care part is not the only part of the system. I think now they are starting to see that there are many linkages.

There is the obvious point that if you can prevent something on the front end, you do not get the added costs and trouble in the health care side, but then other points come out. For example, during the SARS crisis, we should have had public health experts and physicians in the hospitals with the teams responding and helping. That would be one type of linkage. Another is when physicians in their offices are counselling patients about diet and tobacco and all those things, they can use some help perhaps from the public health people to support their efforts. We cannot have a good surveillance system unless both sides are working together.

People are beginning to realize now that these are not two separate systems, in fact. Although we talk about the public health system, in my view, we should really be thinking more about the public health component of the whole system. I was making the point also that it is not even just the health system that is concerned with the health of Canadians, but there are all those other sectors as well that we need to be working with if we are to achieve better health.

Senator Keon: I suspect some day we will have regional health authorities — at least where the population can sustain them — and the public health arm would come in under that at the regional level? Do you see that?

Dr. Law: I think it is a reasonable prospect.

Senator Keon: It would still link to the commissioner at the top, of course, which is quite possible.

Dr. Law: Yes, I guess. I have not really thought about that too much. It seems like it would be reasonable.

Dr. Wilson: The challenge sometimes is with the word ``integration.'' There is a lot of fear around that word. Many people feel that by ``integration'' we mean, for lack of a better word, ``smushing'' things together and losing some components in the process.

Senator Keon: It gets confused with ``ownership.''

Dr. Wilson: Exactly. If we look at a health system, it is all iterative. People live in a community. In fact, with heart disease, we often say people develop heart disease in the community, and they all too often die in the community of it, and everything that happens in between times, as they go through the system, puts them right back into that community. Even if you have someone, for example, with heart disease who has been treated in a health care system and is discharged, they are back again in a milieu where they need a supportive environment in order to maintain life style changes or whatever else there is.

There have been arguments made that if you were looking at health from a community basis, that it should be public health that has the overview of the health of the public. How many hospitals do we need? How many elderly care institutions? How many psychiatric facilities? Through surveillance, we should be able to tell, on an ongoing basis, the health of any particular population at a local level, et cetera. You then deploy your resources in a mix that makes sense for that community. To do that, there must be connector lanes between pieces. We often operate in silos with primary care that are a bit disconnected from public health, often primary care disconnected from our health care system and discharging patients from hospital back to where and to what.

We are talking about the seamlessness of this system so that, as patients go through this system, everything is connected.

Senator Keon: My point is that when you come down to the application of it, the people in the trenches in Toronto, for example, said they were dependent on an ``old boys' network.'' There was no organization chart in place. There was no structure in place, no connectivity with public health, and the hospital sector was doing its own thing and so on.

With respect to the practical application, Dr. Law will recall that when she was with the restructuring commission, I wrote a brief saying that public health should be part of an integrated delivery system for Ottawa-Carleton. I have believed that for a long time. I think we have to take that step and say it. I just want to know what you think about that.

Dr. Law: Personally, I think you are right. They do belong in regional health authorities, where those exist. I can see that some of my public health colleagues would be anxious, because historically they have tended to suffer when funds are allocated. It is tough for them to put up arguments for their kinds of prevention activities and health promotion activities, especially on the mental health side and in the face of demands from hospitals and peoples' concerns about waiting lists and waiting times in the emergency rooms, et cetera. I know that there would be some anxious people. However, in principle, it is the right way to go. We have to build in protections — at least initially — to ensure that public health gets its fair share.

Senator Keon: We have a unique opportunity this morning, because Dr. Law has served locally here, in Ottawa; she has served in the national department of health, and as a deputy minister; and she served at World Health Organization. I asked Dr. Losos yesterday if he thought the World Health Organization is capable of providing the structural framework to handle the global safety net. He said he thought it was. Many Americans think it is not, that it does not have adequate scientific resources, adequate personnel and adequate financing to be dabbling in things at that level.

You have been there. What do you think, Dr. Law?

Dr. Law: First, let me clarify that my role in the World Health Organization was on its executive board, and that was a while ago now. More recently, I have been working for the World Bank. Sometimes people think I was at WHO when I was not.

I have some reservations about the current capability of WHO to deal with all of the things it has on its plate. I would be a little bit worried. It does a very good job with many of its expert committees. It can come up with norms and standards that are useful. The WHO is relatively starved for resources to do the job that is needed. Because I have worked from the World Bank side in countries, I know well that often WHO has a fair amount of expertise but does not have the funds to do much about it. It was reliant on the World Bank and other sources for funding. In addition, sometimes it just did not have enough money in its country budgets to bring in the expertise that it might have around the world.

Having said that, I still have a strong commitment to it because it is, after all, our premier international health organization. It can call on anybody anywhere, if it has the resources to do it. No one turns down helping out WHO on committees or on assignments. It is amazing the people it can call upon when it needs to do it. However, they need more resources.

Senator Morin: Dr. Law, if not the World Health Organization, what else?

Dr. Law: That is a point. There is no other organization. In my view, it has to be WHO. That is why I would be the first to say that WHO ought to have more resources to do the job to carry out its mandate fully. It does not do a bad job in view of the resources it has. However, it does not have that much.

Senator Morin: Dr. Losos told us yesterday that in the U.S., there is a movement — and I thought the World Bank organization was involved — to have another organization do the job. We were told yesterday that there is a movement within the U.S. and amongst other international bodies to have another body replace the World Health Organization.

Dr. Law: I have not heard of that and I cannot quite conceive of it, to be honest, because the World Health Organization is an organization of member states at the United Nations. One hundred ninety-two countries belong to WHO. I cannot imagine that somebody in the United States can find an alternative to that.

It might be that there is some specific activity that they think can be better done by bringing together some other group — perhaps the CDCs of the world or something like that. I do not know. I have not heard about it.

There is a global fund for fighting AIDS, tuberculosis and malaria, to which Canada and others contribute, but it is very much involved with WHO for the expertise.

Senator Morin: Concerning the lack of resources at WHO, has there been a study or is there a document or any evidence showing that there is a lack of resources? This is one area where we could perhaps help. If there is evidence of a lack of resources at that level, have there been any publications or document that would help us get a handle on this?

Dr. Law: There was a Commission on Macroeconomics and Health that was chaired by Jeffrey Sachs, an economist from Harvard, I think. It is a lengthy report. It focuses on what resources are needed internationally for health for a variety of purposes. I do not recall off-hand how much it actually said about WHO in that respect. I am sure there would be material in that report somewhere. I cannot imagine that they did not address the resource needs of WHO, among others.

Senator Roche: Mr. Chairman, I would like to come in immediately behind Dr. Law and her references to WHO. The record will show that it has performed an outstanding service on behalf of bringing up global health standards. Mr. Chairman, if we are going to touch WHO in our report, perhaps we might want to bring up some of the background to support the statement I just made.

You are doctors, and there are doctors and health care specialists on this committee, I am just a poor layman here, trying to figure out this whole thing. I have to dissent immediately. I know when I am in the company of experts.

However, it is precisely that point. We have many people watching this on television now, some of whom are wondering whether this study we are doing — to which you are admirably contributing this morning — is going to help to insure them against more infectious diseases, such as SARS, which is really what stimulated this study. Is it going to cut down line-ups? Will they get the health care they need?

I was struck by a phrase that I heard earlier — that people are starting to come to life now on public health care matters and take responsibility for their own health care as a big step forward. I see that connected to the title of your organization. I am intrigued by it: the Canadian Coalition for Public Health in the 21st Century. That suggests to me you are doing some forward thinking.

Because of the constitutional problems of this country, we have been forced into a form of reactive and confrontational thinking with respect to the use of the public health care dollars — federal, provincial — and on how and where it is spent.

Many of these things need to be sorted out in respect of what we want to do for the future. I would like to hear your vision of the future. Would you talk about prevention and people starting to take better care of themselves? Will that not save us a lot of money? I have never been convinced that pouring more money into the health care system would perform some miraculous thing. The system needs proper funding, to be sure; but it also needs a better-coordinated consensus between the federal and provincial governments as to how the totality of the health care of the people will be met.

Do you think that it is true that the more we employ preventive measures — get people to prevent things from happening, deleterious consequences from bad behaviour — that the more money will be saved, thus, perhaps a better overall health care can be devised without necessarily bankrupting all the provinces as they fear would happen. You can see that I am bringing a non-professional view to this. I am bringing a view that says we ought to do much more in prevention.

In the field in which I work — in war and peace — we have learned that if you can stop wars from happening, it is preferable to going in and cleaning up the mess afterward, not to mention a lot less expensive. However, to get the political attention, you have to be able to quantify the upstream savings from prevention. How do you quantify it? How do you sell it and how do you send out that message for the 21st century? You may consider that a broad-based question, and perhaps not professional enough. However, that is where I am and that is where I think a lot of people are.

Dr. Wilson: That is an excellent, question, senator. I think that more and more people are asking that question.

For the record, I am not a medical doctor. I am a nurse with a doctorate. I got my professional start working in critical care, teaching a post-graduate course in intensive care nursing, and now I am in public health. I came to the realization that lives are not necessarily saved one person at a time over and over again. I think that picks up on a bit of the concept that you are talking about.

These are my own personal experiences; I am not speaking on behalf of the coalition. We have lived in a society — because we have such excellent health care in this country — where sometimes people believe that it does not really matter what they do. We have such excellent care that someone can make them better if they get ill.

We have a second challenge because of the circumstances in which some people live — whether they are unemployed, lack education, et cetera — that inhibit people from potentially living their lives in a way that might be healthier for them.

We get into a mug's game if we try to say that if we put all our money in prevention, we will save money over here. As we age, we are all going to develop something. The last time we checked, life was a terminal condition. If we can keep people as healthy for as long as possible, then potentially, when people reach the end of their four score years and 20 or whatever it is, the resources they consume at the end of life are truncated — they are very short. They are healthy for as long as possible, and when they die, they die quickly. They do not start to deteriorate in their 50s or 60s and go into this long decline with co-morbidities such as diabetes, heart disease or other chronic conditions that have a huge impact on their quality of life, their ability to work, their ability to enjoy their life.

This is not about being an either/or situation. It is about using the evidence we have from research to look at where interventions make sense and what types of interventions we need. We are saying that public health is the foundation of healthy living. It is what our communities look like. It is how healthy those communities are. Do they have walking trails? Do they have bicycle trails? When we throw up a new apartment block, is there green space? Are there friendly communities that enable people to be healthier?

You are right; it is a huge challenge. In the debates about health care and health care dollars, it has started to resonate with people that resources are finite. There is only so much money; now we are really arguing about how we best deploy those resources in a way that keeps healthy people healthy for as long as possible.

We have a bit of a turnaround. I used to joke around medical school that if I were in charge of medical training, I would start every would-be physician out in the community. I would not even let them see a hospital until they had been in their training for two or three years, because basically most people are born healthy and it is our job to keep them that way. Our system is we train health professionals. I am a nurse and that is how I was trained, that people are ill and it is our job to make them better. I think we are starting to think in different ways, but we have a long way to go.

I do not know whether I answered your question.

Dr. Law: I wish we could say if you put X number of dollars into public health, you will save X number of dollars times two or three or whatever on the health care side. However, I do not think the science is good enough to give that kind of an answer. We know there are some obvious areas where you would get payoff; immunization would be a classic example — clearly, you save money if you immunize children, or if you immunize adults against flu, which is a very important thing.

Beyond that, it starts getting complicated to try to make the comparisons. For instance, a lot of people concerned about the effects of tobacco have tried to show the cost benefits of reducing tobacco use — even those are sometimes challenged. There is no quick answer, but it seems common sense, as Dr. Wilson said, if we can keep people healthy for as long as possible we will save.

How much will we save? That is not so clear, because we do not know how to factor in the increased costs at the end of life, when you keep people alive longer, for instance. It is hard.

Senator Morin: Premature mortality saves money — that is the problem. That is the issue, but you cannot promote that.

Dr. Wilson: That was the argument the tobacco industry made in eastern Europe in their study; that if people smoked and died early, the state would not have to provide for them later in life.

Senator Roche: Dr. Law, if indeed people are starting to come to life on public health care issues — and I think that is the case — if we can help them understand that taking preventive measures has its own reward on a tax basis, there must be some way to show how much money is saved by prevention.

Dr. Law: I do not have this in my head at the moment, but I think that there is some work from the World Bank along that line. We probably could find some of that information for you.

Whether that influences individual behaviour as much as convincing people that they will feel better and live more productively and feel happier or whatever —

Senator Roche: I took that for granted, absolutely. What I had in mind was if we could quantify it, the governments themselves might be more prone to get the message out in education campaigns, et cetera — in the way that the smoking campaign paid off — paid for with government funds, knowing that they would get a return. From the quantification point of view, government leaders would benefit. From the individual point of view, you may feel better about yourself when you take preventive measures.

Dr. Law: Those calculations are tough to do.

Senator Roche: You mentioned the World Bank.

Dr. Law: I spent a few years at the World Bank, which probably has more economists per square metre than any other place on earth. Sitting around and arguing about the methods for these kinds of studies is excruciating.

Taking a physician's — as opposed to an economist's — view, I found that they had to make so many assumptions in their models that they assumed away all human behaviour so that the models and the projections would work. This is, of course, my biased opinion and certainly is not what the economists would say. It is very frustrating work and people always challenge the method and they always have arguments to make about why this or that could not be true. It is tough but some work has been done on that.

Senator Morin: The other issue is that the savings occurs over the long term, not in the short term. Yet, politicians are not interested in the long term.

Senator Roche: This speaks to one of the big problems of the whole: the governmental system. It applies to many areas. In any event, do you think that we might ask our staff to look at the World Bank?

The Chairman: Dr. Law, if you have some data it would be helpful.

I have two short questions and the first is for Dr. Wilson. You quoted two Decima studies. I would like to see the exact question — in particular the one in which you said that somewhere between 80 per cent and 90 per cent indicated that a good environment is part of public health, et cetera. I am interested in that.

Having been in that business for a decade, I think you will find that if you actually asked people: What does public health mean? The vast majority of Canadians would say that it is the opposite of private health and public health is what we have in Canada. On the other hand, if you asked whether the following elements were components of public health, then people would say, yes. You have to be careful in jumping to conclusion. If the question were asked in the second way, it would not tell you what the public think the term ``public health'' means. The average citizen thinks public health is what we have in Canada and private health is what they have in the United States, which is why I would like to see the question.

The presentation has been interesting, good and helpful, but extremely theoretical. The blunt reality is that you will not get $1 billion dollars off the top. The provinces and the feds are arguing over $2 billion and whether they did or did not give it and for what it was promised. To start arguing for an additional $1 billion would be rather unrealistic. My guess is that government will glaze over and the issue will disappear. That is a pragmatic response.

Dr. Law, I will ask you to put on your old Deputy Minister's hat for this next question, which addresses the of pan- Canadian agreement you mentioned. The federal-provincial negotiations, in which both you and I have been involved over the years, are difficult enough, as we have seen over the simple idea of a health council — they can be nearly impossible to negotiate. I am not worried about the direction you want to go but whether it would be such a big reach as to prove undoable in one step and, therefore, it would disappear from site.

As a former Deputy Minister, what do you think of the direction you propose and the one or two short, feasible, doable steps in the next 12 months?

Dr. Law: Not all of that $1 billion would necessarily be federal dollars, of course, because there are provincial and municipal dollars in the public health system as well. Increases would need to come from all of those sources; the federal government would be only one source.

As I said earlier, I do not know for sure that that is the right amount of money. I just know that many more resources are needed to do the job adequately. Personally, I do not underestimate how difficult it is to do these things on a federal-provincial basis. Having been through many tough things such as the Canada Health Act and National Child Care with the provinces, I know how tough that is. When I came back after five years in Washington, I asked people if things were any different. Everyone gave me discouraging answers.

Senator Morin: Things are worse.

Dr. Law: That is what they said and I said that it was impossible.

With all the pressure from SARS, et cetera, perhaps this is the time for at least an agreement on a national health agency. There are many different models to be considered, some of which would, no doubt, be more acceptable to provinces than others. However, it could be a way to tie together what exists and to improve upon it in ways that the provinces know need to be done. I am certain that the SARS epidemic must have made it clear that there must be a national body to maintain an overview of what is happening across the country. We could at least have a decent surveillance system in place so that we could report to the WHO, under the international health regulations, what is happening across Canada, and bring that expertise back from the rest of the world to Canada.

I know that would not be easy. I am probably a bit less optimistic about that than some other members of the coalition, who have not been through the kinds of discussions that, as you said, you and I have experienced in the past.

Some of those efforts, however painful, did succeed because we now have the Canada Health Act and we have tobacco legislation. We have managed to do things in the past. I think we should go for it.

The Chairman: The Canada Health Act, as you know, was done over the objection of some of the provinces.

Dr. Law: Most of the provinces.

The Chairman: Right. I am not sure that you and I are on the same page, although I think we probably are. Your comment was about the change in people's attitudes and in governments' attitudes — provincial and federal — as a result of SARS. You then talked about a surveillance system, about which I would agree. I would infer, from what you are saying, that you are much more likely to reach agreement if you focus on epidemics and emergencies —on crisis situations — rather than on the broader kind of issue of public health writ large, which is the term of reference about which you spoke. Would you agree with that?

Dr. Law: Wearing my Deputy Minister hat, I would agree with that. What makes me sad is that you are faced with that all the time in government, especially in the federal system. By the way, the WHO has made the point that most federal systems generally have these headaches in the health sector, not just Canada.

It makes me sad that you always end up going for something that you know is not truly needed or perhaps what the public even wants. Canadians understand the need for having a proper, coordinated public health system but you have to go for what you can get and that is our history, I guess. As an individual, I find that rather sad. At least you have to know that it is not what is really needed and there is something that you can do now without losing that vision of what needs to be done overall.

When I was at Health and Welfare, I always thought we needed to know our vision of the right thing. Then, we would chip away at it — work at it over time, without losing site of the bigger picture. I would hope that if this committee were to make proposals in respect of what it can do now, what is doable and whether it can get through the federal-provincial system, it would then at least recognize in its report that this is only one piece and that much more would be done if you were directed to the kind of comprehensive health system that Canadians deserve and that they understand and want.

The Chairman: Thank you. As two former deputy ministers, we see the world in much the same way.

Senator Morin: We are making the assumption that the provinces would be opposed to a wider mandate. We do not know that at this time.

The Chairman: I thank the witnesses for coming today.

The committee adjourned.