Proceedings of the Special Senate Committee on Aging

Issue 2 - Evidence, December 3, 2007


OTTAWA, Monday, December 3, 2007

The Special Senate Committee on Aging met this day at 12:31 p.m. to examine and report upon the implications of an aging society in Canada.

Senator Sharon Carstairs (Chair) in the chair.

[English]

The Chair: Good afternoon, colleagues. As you know, we are studying aging in Canada. I have to apologize; a couple of our colleagues are not with us for obvious weather reasons. One of them, I know, has just landed and is on her way. Others will hopefully make it later.

We have a number of panellists with us this afternoon. From the Canadian Institute for Health Information, we have Mr. Jean-Marie Berthelot, Vice-President, Programs and Mr. Christopher Kuchciak, Program Lead, NHEX/ OECD. We also have Mr. Marc Lee, Senior Economist with the Canadian Centre for Policy Alternatives.

Mr Lee is coming to us on videoconference, along with Mr. Robert Evans, Professor of Economics, University of British Columbia. We also have Mr. Joe Ruggeri, Professor, Department of Economics, University of New Brunswick. We want to welcome you all this afternoon.

Robert Evans, Professor of Economics, University of British Columbia, as an individual (by video conference): I am pleased to have been invited to talk to this group because this is a subject that has intrigued me for a number of years.

I gave my first talk on the impact of aging on the health care system in 1982 to a meeting of the Canadian Hospital Association, as it then was, in Winnipeg. The first paper I know on the subject was put out by the Economic Council of Canada in 1978. The most recent one I know is the package I sent down to your staff, from a group in the Office of the Actuary in the U.S., published a couple months ago in Health Affairs.

In the interim, my group has done quite a bit of research on this subject and so have a number of others. They all tend to point in the same direction.

Metaphors are powerful and effective because they are graphic; they capture an idea in a way that can be communicated very quickly. They are also potentially deceptive, and the most deceptive metaphor in this field is that of the ``grey tsunami'' — the idea that we will be overwhelmed by a wave of grey that will flood and wash away the existing structures of the Canadian health care system. This is profoundly misleading because it paints the picture as if there were some massive single event that will unleash catastrophic forces.

The appropriate metaphor is that of a glacier. Each of us ages one year at a time; we do not do it instantaneously, nor does the population. It is not some sudden shock. Like a glacier, the aging of the population will transform the landscape over a period of decades, but it does not operate on a time scale of months or years. The claims that are being made for the grey tsunami are precisely that it does operate on a time scale of months or years, and those claims are false.

That the escalation of costs in the health care system can be explained by population aging is true to a small degree, but that degree is in the neighbourhood of 20 per cent, at best. It is true that people of older ages on average use more health care and generate more costs. It is also true that the proportion of the population in those age groups has grown. If those two facts are put together, we have a prediction of growing per capita health care costs.

That is quite true; but when we actually look at the escalation of health care costs, we find that 80 per cent of that is being driven by other factors and forces. Those are the ones we want to keep our eye on. This notion that we will somehow be overwhelmed by an aging population is either coming from people who are not reading the numbers or who have another agenda.

That is not to say that there are no problems of cost management and cost containment in the health care system. That would be silly and naive. We know that is not true. However, we also know that those pressures are being relatively well managed in Canada and most other developed countries, excluding the United States.

We know we are seeing a slow creep in the share of our income going into health care. It is up to 10.6 per cent in the current estimates — up from 10.4 per cent from the year before. There is a slow creep; but a considerable amount of focus should be devoted to exactly where the money is going.

For example — and it is a leading example — last year the Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research put out a massive and valuable document looking at patterns of cardiac care in this country. It turns out there are wild variations in patterns of hospital admission for the major cardiac care categories — myocardial infarction, congestive heart failure, angina, generalized chest pain.

If we look at Vancouver as the base of 100, we will find the rates are 50 per cent higher in Toronto, 75 per cent higher in Halifax and 200 and 300 per cent higher in regions outside the metropolitan areas — and we do not know why. These kinds of clinical practice variations are a primary place to look for what is driving the escalation of health care costs.

I would argue that the myth of runaway costs associated with aging, which we have called in some of our work a ``zombie'' — an idea that is intellectually dead but will not lie down — serves to distract the attention from the real and hard issues involved in maintaining an effective, efficient and humane health care system. It is a total distraction, which is what zombies are — they stalk around making a nuisance of themselves.

The Chair: Thank you very much. I particularly like your metaphors. Mr. Lee, can we hear from you, since you are also there on live television?

Marc Lee, Senior Economist, Canadian Centre for Policy Alternatives (by video conference): Thank you to the Senate for having me here today by videoconference to speak to this issue of population aging and the impacts on the public health care system. I wrote a report on this issue that was released in September by the Canadian Centre for Policy Alternatives. I believe you have copies. If not, I can arrange for you to have some.

In that report, I isolated the different cost drivers in the public health care system. To be clear, I am looking only at the public health care study not total health care, which includes the private component. In 1975, Canadian Institute for Health Information, CIHI, data was used to develop a historical overview of how these factors have affected health care costs and then projected forward to 2056 based on Statistics Canada's population forecasts and the average health care inflation rate over the past decade.

My finding reinforces those of past studies on this issue that population aging, in and of itself, is but a small contributor to rising cost pressures in the health care system. Based on current projections, there is little to suggest a demographic time bomb that is about to go off.

The main cost drivers, in addition to an aging population, are population growth and health-care-specific inflation. When these three are put together, we are able to determine a minimum amount of annual public spending increases that are necessary to maintain the existing level of services while accommodating a larger and older population.

On this basis, public health care spending must increase by 4.4 per cent per year in the near term in order to maintain a sustainable level of services — by the 2030s, this rate slows as population pressures ease. Overall, population aging alone requires only about 1 per cent per year in additional public expenditures. As Mr. Evans commented before me, while the demographic changes over the span of a quarter of a century are profound, this change happens relatively slowly, and the associated annual increase due to aging is actually less than either population growth or inflation.

The share of public health care spending relative to our total income or our GDP is what really matters for sustainability. That is, as long as our nominal GDP growth averages 4.4 per cent per year or more, then we do not have a sustainability problem. If future economic growth rates are consistent with those in the past decade where the average growth rate was 5.6 per cent or in the past two decades where the average was 5.4 per cent, public health care expenditures will fall as a share of GDP over time.

In my paper, I estimate public health care spending relative to GDP for a few scenarios of nominal GDP growth — a slow, a medium and a fast rate. Even in the worst case scenario, if GDP growth were to slow to 4 per cent per year, a level well below historical trends, existing levels of service could be maintained with only a small increase in public health care expenditures relative to GDP over the next three decades. Public health care expenditures on this basis would rise to 8.4 per cent of GDP by 2038 — about 1 percentage point of GDP, or an extra penny per dollar of our total income — would peak around 2038, and, thereafter, would fall back to about the current level of approximately 7.6 per cent by the year 2056.

I have not yet mentioned something that is essential in thinking about health care expenditures: The enrichment or expansion of public health care services over time. My study tries to distinguish annual spending increases required to maintain the same level of services, while adjusting for changes in demographics, from additional spending that expands the suite of health care services available under the public umbrella.

This issue of enrichment is historically significant. The average Canadian receives one and a half times more health care services than his or her equivalent received three decade ago. Therefore, one important reason that health care spending is higher today than it was several decades ago is that we are providing more services, such as increased long- term care services, more extensive drug coverage, new surgical techniques and new diagnostic technologies.

The real challenge for financing the health care system is advances in these technologies — the unlimited potential to expand the realm of the possible. For example, in B.C. today, compared to 1990, an 80-year-old person is twice as likely to have a knee replacement, cataract surgery or a coronary bypass.

In the same vein, highly technologically-intensive end-of-life care poses some particularly challenging ethical dilemmas in cases where quality of life or health status is not ameliorated in spite of great costs. According to a few important studies, it is not so much the rise in cost as one ages as it is the expenditures made in the final year of life irrespective of age that is an important determinant of the curve in average per capita expenditures based on population aging groups.

In my modeling, as long as economic growth rates are consistent with those of the past, if we maintain the current level of public health care spending relative to GDP, then we would still have room left over to accommodate new technological advances or expand the system in other ways. This is not unlimited, and if we want more technology or more expansion of other services, we will have to pay a greater share of our income in order to have it. That means being more rigorous about the costs and benefits of different kinds of technologies through actions such as health technology assessments, which were recommended in the Romanow report.

By the numbers, the historical average enrichment in the public health care system has been just under 2 per cent per year going back to 1975. Based on the medium growth scenario, a 1 per cent annual enrichment rate would increase public health care expenditures from 7.4 per cent in 2006 to a peek of 8.5 per cent by 2038. Again, this would fall back to 7.7 per cent in 2056 because those population-aging pressures would abate by the early 2030s. Such a scenario would provide the average Canadian with 63 per cent more health care services than they receive today.

To conclude, I agree with Mr. Evans that it is a myth that an aging population will render the public health care system unsustainable. The good news is that the challenges facing the system are not demographic factors beyond our control but rather technological factors that, while profound, are suitable to a public process that is well within our control. Like every other policy area, we need to make choices, and to do that, we need a healthy democratic debate on how to move forward.

Jean-Marie Berthelot, Vice-President, Programs, Canadian Institute for Health Information: Good afternoon. On behalf of the Canadian Institute for Health Information, CIHI, would like to sincerely thank you for your invitation to appear today. As many of you are aware, Canada's health care leaders established the Canadian Institute for Health Information as an independent organization dedicated to answering fundamental questions about Canadians' health and the health system through a systematic approach to data collection, sharing and analysis. It is not CIHI's role to forecast or to offer recommendations but rather to provide timely, accurate and comparable health information. I have provided to the clerk of the committee copies of two reports in French and English that are relevant to the committee's study. I have a few charts for today's discussion. The first report is the National Health Expenditure Trends, 1975-2007. The second report is a summary of a specific study called Health Care Use at the End of Life in Western Canada. In some ways, it references Mr. Lee's comment on those associated expenditures. As well, I will speak to three figures on spending in relation to gross domestic product in Canada and abroad.

[Translation]

We have also prepared a short document that sets out some key points of the impact of the aging population on the health care system.

At the moment, the document is only available in English. Please accept our apologies. The French version will be provided to you in the next few days together with a complete English version. My comments will be largely in English. But I will be pleased to answer your questions in English or French, as you prefer.

[English]

I will begin with health care spending in Canada. CIHI tracks health spending in the national health expenditures data base, which is well known for health spending and is being used by many researchers in Canada. It provides an overview of health care spending by spending category and source of funding. It contains a historical series of health expenditures and statistics by province and territory. The last report was released on November 13 and includes data from 1975 to 2007.

In 2007, Canada is expected to spend $160 billion, increasing from $150 billion for health care in 2006. This includes both publicly-funded and privately-funded health care in Canada representing an annual increase of 6.6 per cent over 2006 or 3.2 per cent after adjusting for inflation and population growth.

For the eleventh consecutive year, health care spending is expected to outpace inflation and population growth. Since 1997, the trend appears to be due to reinvestment by federal, provincial and territorial governments after a period of fiscal restraint during the early and mid-1990s.

For the eleventh consecutive year, the public sector share of spending on health care is expected to remain relatively constant at about 70 per cent. Provincial and territorial governments account for more than 90 per cent of health care expenditures by all levels of government in Canada. Health care spending by these levels of government is expected to surpass $100 billion for the first time, which represents 65 per cent of all health care spending in Canada.

We were asked to address two questions before this committee.

The first is the health care costs associated with different age groups. Our report shows that in 2005 — the latest year available for age-specific data — per capita, health care spending by provincial and territorial governments was highest for infants under the age of 1 year at about $7,400 per infant. For Canadians aged 65 years and over, it was about $9,500 per person. This is in contrast to other Canadians, aged 1 to 64 years, where the average was $1,700 per person.

We have to acknowledge that there is also a great variation among the different age groups for seniors, where the costs increase as age increases. For seniors 65 to 74 years of age, it was about $6,000; for those aged 75 to 84 years, it was about $11,000; and for seniors 85 years and above, it was about $21,000.

The second question asked was in regard to the impact of population aging on health care costs. CIHI figures show that seniors aged 65 years and over accounted for an estimated 44.2 per cent of provincial and territorial government health spending in 2005, a proportion that has not changed significantly since 1998 when it was 43.6 per cent. This represents a relative share increase of 1.4 per cent in terms of the total spending allocated to seniors between 1998 and 2005.

During the same period, the population of seniors aged 65 years and over increased from 12.3 per cent to 13.1 per cent, a relative share increase of 6.5 per cent. This means the proportion of seniors has increased by 6.5 per cent since 1998, but their share of the provincial and territorial government health spending has increased by only 1.4 per cent.

Recent trends show an improvement in provincial-territorial government fiscal capacity. Provincial and territorial government revenues have exceeded expenditures since 2004. This surplus increased to $8.4 billion in 2006. Provincial and territorial debt charges were 13.8 per cent of total expenditure and 15.8 per cent of revenues in 1993.

This situation has changed. Lower interest rates led to a lower debt charge of 9.8 per cent of expenditures and 9.6 per cent of revenues in 2006.

In 2006, provincial and territorial governments spent an average of 39.2 per cent of their total program spending — that is, total spending minus debt charges — on health care. Levels were similar in 2004 and 2005, with 2004 setting the record high at 39.6 per cent.

CIHI's report shows real increases in health care spending. Countries make choices about how much to spend on health care, and this spending is the result of those choices. Aging pressure is only one of many factors accounting for increases in health care spending. To illustrate the situation, health care spending was compared to the proportion of gross domestic product in relation to the proportion of seniors in high-income countries that are members of the Organisation for Economic Co-operation and Development, OECD. No relationship was found to exist between the proportion of seniors and the GDP spent on health care.

For example, Japan has close to 20 per cent of its population aged 65 years and over while its total health care spending is below 8 per cent. The United States has 12 per cent of its population aged 65 years and spends more than 15 per cent of its GDP on health.

Looking at the 19 countries for which data is available in 2004, there is no relationship between the portion of seniors in the population and the GDP spent on health. Choices are made about how much is invested by a society in health care and in other areas.

We also examined the increase in the proportion of seniors over a 25-year period and the increase in the health care spending to see if aging was a driving factor. Data was available for 17 high-income countries. Again, no relationship was found between the increase in the proportion of seniors and the increase in the proportion of the GDP devoted to health. It must be acknowledged that Japan comes out as a real outlier in that area. Japan has seen more than a 100 per cent increase of its population of seniors but only a 25 per cent increase in terms of its GDP dedicated to health.

Canada's data was also examined to see if there was an association. At the provincial level, the relationship between the per capita spending on health and the proportion of seniors does not correlate. For example, Quebec has approximately 14 per cent of its population who are seniors and spent close to $2,600 per person on health care in 2005. Alberta, which currently has a very positive economic situation, has less than 11 per cent of its population aged 65 years and over, but spent slightly under $3,200 per capita. This is not to say that aging will not have any impact on health care spending. It is only to illustrate that health care is complex, and aging is only one of the many factors related to health care spending.

CIHI also reviewed the Senate committee preliminary report released in March 2007. We can provide information on two questions identified for further study.

First, with respect to falls prevention initiatives reducing the number of falls in recent years and the exploration of medical interaction in regards to falls, we have observed between 2000-01 and 2005-06 a reduction of 13 per cent in the age-adjusted hip fracture hospitalization rate in seniors. This indicates that the risk of hip fracture is decreasing in seniors.

The second question was with respect to what is being done to meet the anticipated need for geriatric and gerontological health professionals.

Between 1995 and 2006, the number of geriatric specialists in Canada nearly doubled from 111 to 204. The number of nurses employed in geriatric or long-term care has remained relatively stable since 1995 at about 26 per cent. The briefing will provide more information in terms of the human health resources and its impact on aging.

Joe Ruggeri, Professor, Department of Economics, University of New Brunswick, as an individual: I am honoured to have been called to share with this committee the findings of my research on the fiscal implications of population aging.

Population aging has important impacts on economic performance, the fiscal health of the nation and the equity aspects of federal transfers.

On the fiscal side, the debate on the impact of population aging has been one-sided. It has focused on the burden that seniors allegedly impose on the health care system, often exaggerating its dimensions, but it has ignored the contributions seniors make to society in general and to government coffers in particular.

Last year, I completed a detailed study on the fiscal benefits received and the contributions made by different age groups. My general conclusion is that, at the national level, even moderate growth rates will be able to finance the existing system of public funding of health care in Canada; we can afford even better quality health care if that is what we value. Further, we can reduce the burden on the health care system by pursuing policies that enhance environmental quality, improve conditions in the workplace and reduce poverty.

On the fiscal federalism side, where I will focus mostly, there are two fundamental issues: The adequacy of the federal contribution to provinces and the degree of interprovincial equity in the federal contributions. I will confine my comments to the second issue.

With respect to equity, two issues must be addressed. The first issue is whether the recent changes to the financing of the Canada Social Transfers, CST — which later will be extended to the Canada Health Transfers, CHT — meet horizontal equity criteria. The second issue is whether a case can be made for a special supplement to the CST based on interprovincial differences in the age distribution of the population.

With respect to the first issue, I have shown in a recent paper published by the Caledon Institute of Social Policy that this equity principle has been violated in the new fiscal arrangement for the CST introduced in the 2007 federal budget. It will be violated again when these arrangements are extended to the CHT.

With respect to the second issue, it is important to emphasize that of the three national programs in Canada — health care, post-secondary education and social services — only the first one touches on the entire population. Moreover, health care is the only national program whose costs are strongly influenced by the senior population.

Recent estimates by the Canadian Institute for Health Information show how widely per capita government expenditures for health care vary by age group. For example, in 2004, the average health care cost to the New Brunswick government for a person in the 75 to 84 age group was nearly seven times the average cost for a person in the 25 to 44 age group. This means that the per capita health costs in each province are affected by that specific province's age distribution of population. We must look at this issue on a province-by-province basis, not just on a national basis.

Estimates and projections by Statistics Canada show that the age distribution of the population, and in particular the proportion of people over 65 years of age, varies among provinces, and that variation will expand over time.

In 2004, the share of the population 65 years and over in New Brunswick was just less than 1 percentage point higher than Canada as a whole. This difference will increase to 2.2 percentage points in 2014 and 5.1 percentage points in 2030. In 2030, 28.2 per cent of New Brunswick's population will be over 65, compared to 23.1 per cent of the Canadian population as a whole.

It is the combination of different per capita health costs by age group and the interprovincial variation in the population age distribution that puts into question the use of equal per capita Canada Health Transfers.

The extra cost of health care in New Brunswick, caused by its faster growth rate of population aging, will increase over time. In about 10 years, it will be very substantial and, in my view, it will be the single most significant threat to the long-term sustainability of the New Brunswick fiscal system. It will also apply to provinces such as Prince Edward Island and Nova Scotia; it would have also applied to Newfoundland, but they may have enough financial clout by that time.

The numbers from my original paper have been reworked based on the recent information from the Canadian Institute for Health Information. The results are the same. In 2004, the actual per capita health care spending by the New Brunswick government, excluding capital spending, was $2,479. If New Brunswick had the same age distribution as that of the country as a whole, this value would have been $2,380. This means that the higher level of population aging in New Brunswick increased provincial health care spending in that province by an average of nearly $100. It is not very much, and that is why no one is paying much attention to it. However, the per capita differential spending increases to $296 in 2014 and to over $1,000 in 2030.

Therefore, when we multiply these per capita values by the New Brunswick population, we obtain the total difference in the cost to be borne entirely by that provincial government. In 2004, the extra cost for the New Brunswick government for the higher level of population aging was only $75 million. This extra cost will increase to $225 million a year in 2014, and $782 million in 2030.

I calculated these numbers for every year from 2004 to 2030, and discounted them by the rate of inflation of 2 per cent, which is the same rate that is usually incorporated in the estimates of health care spending. Over the entire period from 2004 to 2030, the cumulative value of this additional cost to the New Brunswick government will amount to $6 billion at today's dollar value. To put it into perspective, this amount equals the total budget of the New Brunswick government in 2006-07.

In conclusion, unequal rates of population aging across Canada will have serious implications for provincial budgets and also for regional economic and fiscal disparities. The inequities introduced in the proposed new formula for allocating cash payments to provinces will aggravate the situation.

I have three recommendations. We need to restore interprovincial equity in the basic structure of the CHT financing, which assumes equal per capita costs. We need to introduce a special, and separate, cash supplement for provinces with faster rates of population aging. Finally, we should recognize that the interprovincial dimensions of population aging go far beyond health care financing. Therefore, I suggest the establishment of a joint federal- provincial task force to conduct a thorough study of the economic and fiscal impacts of population aging and its effects on fiscal federalism.

The Chair: Thank you very much. I wish you had been a ``fly on the wall'' last week when we had the discussion of per capita funding with the Department of Finance Canada. They seemed to think that everything smelt like roses.

Let me begin our questioning this afternoon with Senator Keon.

Senator Keon: There is so much to go into, but I would like to start with Mr. Ruggeri. As our chairman mentioned, the financial people told us last week that the formulas are there. They have the formulas in the transfer payments and in the financial equity to compensate for the kind of problems you have just described. If one province has more needs because of an aging population, the transfer payments and the equalization payments will find a way of balancing that out.

I was not satisfied with that because I feel they are looking at the situation from a very high level, but when we get to the ground, that is not happening. Would you expand on your recommendations? You are calling for another look at this.

Mr. Ruggeri: Yes. The programs that we have are based on equal per capita payments. Equalization is just an equal per capita payment and is not directly related to health care. If health care costs are higher in New Brunswick, it would be because of population aging. Equalization will not take that into consideration because, for them, age is irrelevant for that program. Equalization is not really aimed at that and is not geared for that. The Canada Health Transfer was set up in a manner, before this budget, that took into consideration or at least took care of the equal costs.

The basic assumption between both programs is the per capita cost across the country. That is why this needs to be a separate supplement. The way that the equity in this program was introduced was the combination of the cash transfers and the value of the tax points, which was the total value of resources acquired by the provinces starting in 1977 with the establishment program financing and later on in 1995, so that every province received equal per capita transfer of total resources, a combination of the two.

However, in the 2007 budget, the system has been changed where the cash is equal but the tax points are not because they are not equalized to the top, as they used to be. The system we have now, and whenever it will be extended to 2014-15 to the Canada Health Transfers, will provide more total per capita resources to the provinces that have the least pressures on health care. These will be Alberta and Ontario, whose population on average will be much younger than in the Atlantic regions and even in Quebec.

Senator Keon: Mr. Lee, perhaps you could start, but I would like the whole panel to respond to this. The difference between Canada and Japan has been raised already, and it is very curious. I wonder if it does not have to do with the philosophy of end of life, which, as you have told us, is expensive in health care whether it occurs in the first year or last year of life. For some reason, the Japanese are not seeing the increase in cost as the elderly spend their last year.

I have never seen or heard of any data that has drilled down on end-of-life situations as it affects aging — forget about the first year of life, but as it affects aging. Here is an enormous opportunity for some useful interventions. Senator Carstairs, in her work with a palliative care and so forth, has contributed much to this. We are now reaching a point in Canada where people want to die at home rather than in the hospital, comfortably rather than hooked up to expensive equipment and such.

Mr. Lee, do you know of any data bank that can take us specifically to the fundamental terminal events at end of life that would sort out the effect of this on the increase in the health care costs to the aging population?

Mr. Lee: Listed in the references to my paper are a couple of studies that are relevant to that question. I would be happy to provide all of the gory details, should you wish them.

Hogan and Pollak did a study in 2001. They divided the population into over 65 years of age and under 65years of age, and then further split it into two groups, people who were in their final year of life and those who were not. They found that there is a pure aging effect. It essentially doubles for the over 65 years of age group compared to the under 65 years of age group, both of which are not in their final year of life. However, they found that for both the under 65 and over 65 age groups, there is a tremendous increase in the costs for that final year of life. For the under 65 age group, not in the final year of life, it is approximately $368 per capita per year. For the over 65 age group, not in their final year of life, it jumps up to $670 or so. For all groups in their final year of life, there are different numbers for men and women but ranging from $30,000 to $50,000 per capita per year. Those are some pretty significant findings that put some empirical data to the question you are posing.

Another study was done by Kim McGrail and others, who also looked at this in the context of long-term and acute care spending, using microdata. They have come to a similar finding that most of what is happening is really what is happening in this final year of life. The pattern that we see in terms of average per capita spending by different age groups can be explained, in large part — at least the degree to which the over 85 year olds deviate from groups aged under 65, with this end of life and simply the demographics of what is happening in that particular age group.

Senator Keon: Doctor Evans, before you respond, let me try to focus this. Do you know of any information that separates that last year of life in the elderly and the terminal events in that last year in Canada as opposed to Japan?

Mr. Evans: As opposed to Japan, no, I do not. I do know a little bit about the last study that Mr. Lee referred to because it was done at our centre. Kim McGrail is one of my associates. There are several important things you need to keep in mind about those numbers. The big component of cost in that last year of life is long-term institutional care. Once we start talking about people over 85 years of age, we are talking about a high proportion of people in long-term institutional care. If a person has been in long-term care, in institutional care, in a bed, for a year or two years prior to death, which is often the case — some people do come back out into the community but most do not — that does create a large loading of cost in that last year.

The costs are not in the television picture of heroic measures being applied to keep people alive for another 24 hours. The costs in that last year of life, particularly for the very elderly, have to do with forms of institutional care.

I can speak from personal experience about people wanting to die at home. Within the last two years, I have lost both my mother and mother-in-law, who were able to die at home, exactly what they wanted, as a result of effective, high-quality community support in Ottawa and Victoria. Those were, as much as any death can be, good deaths. Spending two years — that is long, but it happens — in an institutional setting is not a good death, but it generates a lot of costs.

As for the palliative care, as a member of the royal commission in B.C. nearly 20 years ago now, we had a chance to talk to many people running palliative care programs on the ground and found that the term covered a multitude of sins. It ranged from the classic palliative care concept, which the Zorzas pioneered with the death of their daughter, in which the setting is made as home-like as possible. It is in the home, if possible; if not, it is in a home-like setting, and the heavy-duty, high-tech interventions are withdrawn.

There were one or two programs that were exemplary in that form, where one could say to oneself yes, I could die here too — though not today perhaps.

There were people who labelled palliative care as simply the addition of some sort of psychological support services to people in regular wards or in intensive care units. In other words, the concept of palliative care had not gotten through and was a way of loading additional services on to the process of dying.

I have a concern here with Mr. Lee's language, when he talks about enrichment of services over time. There is no question that we are doing more things to the elderly, and for the elderly, whether or not they are in that last year of life. Those utilization-by-age curves are going up in terms of everything but actual in-patient beds. Much more is happening.

However, the point I want to emphasize with the comparison between Vancouver, Toronto and Halifax with respect to cardiac care is that it is not clear whether what is happening has any benefits to the patient. More detailed studies done in the U.S. of those geographic, clinical variations show that in that context — we do not know if it is true in Canada — the more intensive servicing is associated with higher mortality, not lower, after adjusting for the condition of the patient.

The term ``enrichment,'' used in all innocence, carries with it the implication that this is actually doing people some good. The answer to that is yes, in many cases it is; and in many cases, it is not. We need to focus our attention on sorting those areas out. Senator Keon will remember some of the data I presented in Ottawa about a month ago, from the report from the Canadian Institutes for Health Research and the Heart and Stroke Foundation of Canada, which illustrated that very powerfully.

Senator Keon: Mr. Berthelot, did anything come up in your CIHI data that shed light on this issue that I have raised? Are we confusing aging with end of life from a medical-economic point of view?

Mr. Berthelot: We just did a study looking at end of life in four Western provinces, but we focused on people who died. We did not have a control group, and I think we should look at that.

It is mainly a repetition of what other witnesses have said, which is that there is clearly an increase in the end-of-life costs. That increase seems to be larger for terminally ill patients than for those who suffer a sudden death. We looked at the proportion of people who died in hospital, and it varied significantly. Two-thirds of terminally ill patients died in hospital; for those with organ failure, it was 60 per cent; and for sudden deaths, it was about 30 per cent. Depending on the disease people have, there is an impact.

We also have to acknowledge that with aging come chronic conditions, which, in themselves, will generate some costs. I am not aware of a study that looks at the impact of end of life specifically and removes it in aging. However, we know that aging is also related to arthritis, which needs hip and knee replacement; it is related to heart disease and cancer. Obviously, people do not necessarily die when they are diagnosed with a disease, so there is also an increased cost of diabetes and other chronic conditions.

We always use Japan because it is a counter example. However, if we look at the current spending in 2004 and the proportion of seniors, Italy, Japan and Germany are very close in terms of the proportion of seniors. Italy is below Canada in its GDP and Germany is just a bit higher. Even in countries that are more Western-style cultures, we see a great variation in the amount of gross domestic product devoted to health or health care. It is not just a Japanese phenomenon; they are perhaps the most extreme example, but we see it in other industrialized countries.

The Chair: Mr. Ruggeri, you mentioned something that was very interesting. I must say that my orientation was to recognize that there was a per capita deficit; that if some provinces that were aging more rapidly than other provinces, and the same per capita sums of money were being given for seniors programs — putting aside health care programs, which obviously would be a significant part — then the exact same anomaly that you made reference to would be created.

We had the Department of Finance people here last week, who mentioned not only the equalization argument, but also if there is a seniors population, there will be fewer children in primary school. There will be monies that can be saved on the education file to put into the seniors' file.

I do not buy that argument, but I was interested in your suggestion of doing not one thing, but two things. You were saying that we should solve the per capita problem, but we should also have a supplemental program. Would you like to differentiate what you mean by those two suggestions?

Mr. Ruggeri: The fundamental structure of the programs that we have to deal with fiscal federalism — which is really equalization and the combination of the Canada Social Transfer and the Canada Health Transfer, that used to be one lump until a couple of years ago — should remain the same, so there is clarity of purpose and accountability. We can see where it goes.

These programs have been developed over quite some time. They are all on the revenue side and were developed with the assumption that the provincial per capita costs that the federal government supports are equal across the country. That component should remain there because that is the foundation, and it makes it easier to compare the equity of what the federal government does.

In equalization, the grant is on a per capita basis. The formula has been changed in a manner now that penalizes the smaller provinces — particularly New Brunswick and Prince Edward Island. That is a change that they made in the structure, but the fundamental principle is there.

With respect to health care, if we just look at that component, it is basically the same principle. We assume that the per capita costs are equal, and then we maintain equity in that respect. It used to be done in that way for all the components, including post-secondary education and social services.

Now that it is split in a change made this year in the budget, we have moved away from that equity principle. I did not bring copies of that paper with me. It is only in English and was published a couple of months ago by the institute where I do the actual calculations. It shows how in 2006, every province was receiving exactly the same per capita amount combined in the tax values, but now it has changed. Of course, this difference will increase in the future.

My first point is that we should fix the equity and establish it in the fundamental program. With respect to this other issue of having more seniors and not having as many students, a study was completed in 2000 at the University of Ottawa and was published in the Canadian Tax Journal. The CHIC at the time looked at the component to determine whether one was offsetting the other. They found there was not much of an offset. That is because the per capita cost of an elementary school child might be a bit less than that of a high school student but not as much as the per capita cost of health care with respect to age. There is no federal money there anyway. For the federal government, it is only with post-secondary education, and there is not much difference between the cost per student in New Brunswick and in Alberta.

Therefore, it is the large variation in the age per cost and the much larger disparity in the age distribution of the population that create this problem. This should be a separate program so that we know it is related to a particular issue that has a beginning and an end.

This population problem will not last forever. We have heard already that after 2030, it will not be as bad. There is no need to restructure a program for a temporary issue, but rather deal with this separately so that we know what it addresses.

The Chair: Thank you. That was extremely useful.

[Translation]

Senator Chaput: Mr. Berthelot, you gave us some statistics based on age. For example, you indicated that health- related costs are $6,000 for every person between the ages of 65 and 74. Even though the number of Canadians between the ages of 65 and 74 has increased, health service costs for that age group have not increased. Is that what you said?

Mr. Berthelot: That is not quite what I said. I was talking about everyone over 65. I said that the increase in that population is 6.5 per cent of Canada's population as a whole, whereas the increase in health care costs for people 65 and over is only 1.4 per cent. Therefore, the population is seen to be aging, with more people aged 65 and older.

We also see — for the public system, not for the health care system as a whole — that overall costs for services provided by provincial and territorial governments have increased less rapidly than the proportion of the population of 65 and over.

Senator Chaput: Did you go as far as to identify the factors, to find out the reason?

Mr. Berthelot: We did not identify all the factors. As Mr. Evans said, a number of factors explain why health costs have increased: they include technology, the fact that more services are offered, the inflation rate. Those factors play a role.

As to specific factors for older people, Statistics Canada's studies show that older people today are healthier than those of 30 years ago. Is there a direct link? I cannot tell you.

Senator Chaput: Could the factors that make older people healthier today be the same as the ones that mean that health costs will not increase so drastically after 2010?

Mr. Berthelot: In the last 30 years, the health care system has constantly evolved. In the mid-1990s, we saw a reduction in health spending in Canada. Health spending as a percentage of the GDP has stabilized and even gone down.

The system is constantly evolving. Is it just people's health that will determine the amount of resources spent on it? I think that the picture is much bigger. In the last ten years, we have noticed a reduction in hospitalization rates. We do more day surgery, we have moved towards more ambulatory care, we provide more services at home. The system is reforming itself, which influences the costs. Hospital expenses as a percentage of total expenses have noticeably gone down in recent years. In 1975, it was 75 per cent, today it is 28 per cent.

The system is constantly changing and this affects health care expenses for all age groups.

[English]

The Chair: Mr. Evans, you have given us some of the best vocabulary that we have heard to date. In respect of the burden on seniors in our society, have any of you looked at the tax contributions of seniors that might offset the proposed enormous burden on the system? You have all laid myth to the burden concept, so let us move to the positive aspects.

Mr. Ruggeri: This is exactly what I did with that booklet I circulated to the committee. I was concerned about that myth because in two months I will be joining this group of so-called ``budget busters.''

The Chair: Some of us are already there.

Mr. Ruggeri: I did not feel comfortable with it, so I decided to argue the point. I divided the total Canadian population into three separate groups: One is called ``dependent,'' although only the younger ones are truly dependent; one is comprised of those in the labour force; and one is comprised of those over the age of 65 — erroneously considered dependent because, as far as I am concerned, my children are more dependent on me than I am on them.

I took the expenditure figures of the federal and provincial governments and calculated the amount of taxes that can be assigned to each group. The dependent children were assigned to their parents and others were assigned to the people over the age of 64. I did not include all the benefits that are provided to society as a whole and the benefits provided through inheritance and bequests. As well, I did not include the potential in the future of people over the age of 65 who continue to work once all provinces have eliminated the mandatory retirement age. Not even including those, the seniors would receive a net benefit, but this net benefit would not increase over time.

One of the factors not being recognized is that more and more people over the age of 65 will have increasing wealth or income because more of them will receive CPP, private work pensions, and more of them will have huge amounts of taxable RSPs. With the changes between ages 69 to 71, seniors can afford to play for a couple of years, but after age 70 they start to draw down and become part of the income stream.

Therefore, even when we look strictly at the fiscal side, the per capita burden of seniors will not increase. In fact, the per capita burden of young people will increase faster than the per capita burden of the people over the age of 65.

The Chair: I like that.

Mr. Evans: Are you sure you want me to answer this? I just crossed over the 65 age line at the end of last month, so I am a shade ahead of you, Mr. Ruggeri. I will demonstrate why economics is known as the dismal science. While I do not question your calculations, I question their implication.

I am still at work for a time, and I hope that counts as a contribution. When that ends, as it will fairly shortly, I will fall back on my private pension, my CPP and all of those sources of my wealth, which I will draw upon for my income. If I get hit by a truck the day after I cease work, that wealth will not vanish. It will no longer be drawn by me, but it will still be there. The private pension rights will go back to the other members of our group; the CPP will be less of a burden on Her Majesty and so on. In other words, I am drawing down wealth, but I am not actually producing any wealth.

Therefore, to calculate the benefits that I generate after I retire from market earnings is, I think, a conceptual error. The country will be better off fiscally if I drop dead the day after I cease work. Those are the brutal facts.

I would not suggest that the best way to improve the fiscal situation of Canada is to introduce a non-voluntary program of euthanasia for people over the age of 70. However, I would urge you not to focus on the contribution that we make through taxes on previously accumulated wealth because that wealth and those taxes would remain whether we are there or not. The contribution we make is who we are.

I would like to believe that my family, which now includes a few grandchildren, would rather have me there than not. The contribution we make is not a fiscal contribution. If you focus your attention on those numbers, that may be good politics — I have never had any competence in politics, and the people around this table know far more about it than I. In terms of the actual conceptual basis of economic analysis, it is wrong.

The Chair: We have begun a debate here. I will hear from Mr. Ruggeri.

Mr. Ruggeri: I agree with half of it, which is to say I agree that the contributions made by people over the age of 65 are more on the non-financial side. If we leave that aside, you and I will live to whatever our average life expectancy may be, and the government will get the benefits of what we have accumulated. Therefore, we will be paying our way. That is why I believe that, conceptually, nothing is wrong.

Due to what we have accumulated through our life of work, we will be paying our way, and, therefore, we should not be viewed as a burden. Whatever extra we do is a net contribution we provide to society.

Mr. Evans: I do not disagree with that. We both know how the numbers work. I am saying that yes, all of those tax benefits and savings we have accumulated — some of the savings that did not have tax benefits, as well — are all there; we will draw down on them, and that is what we will use to pay our way. I do not question that. The point I am emphasizing is that all of that accumulated wealth would still be there and would redound to someone else's benefit if we were not in the picture. I am sure you will agree with that.

Mr. Ruggeri: Yes, but on average, when we do the calculation for the country as a whole and look at the fiscal burden and whether we will be able to afford health care and so on, we must make the average assumptions of people that have been made through these population projections.

Mr. Evans: Sure.

Mr. Ruggeri: If we have so many people on average of a certain age in the future, and we look at their incomes and wealth, this is what will happen in reality. The length of time one of us lives individually will not really change those numbers. The fundamental point is that, overall, the population of Canadians who are aged 65 and over now, as well as every single group from now on over the next 30 or 40 years, will be paying their way. They are not this burden that has been mentioned; you mentioned this right from the very beginning.

My point is that the country has spent billions of dollars on people such as us, for education and so on. They have spent billions of dollars for health care and to keep us healthy. People over the age of 65 want to be able to continue to contribute within a different framework rather than being seen as a burden. Being seen as a burden raises the issue of how to reduce this burden rather than how we can optimize their contribution. That is where I am coming from.

Mr. Evans: There is very little difference between us. I would just make one point, and that is that the payments that we — you, I, all of us over the age of 65 — hope to continue making out of our accumulated wealth are not included in the gross national product.

Senator Keon: I have a fascinating question. What are the benefits to Canada if Mr. Evans and Mr. Ruggeri continue to do exactly what they are doing until the age of 75?

The Chair: It is being said that neither of you should take retirement; you should continue to work for the next 10 years.

Mr. Evans: The University of British Columbia would be delighted to have me continue for the next 10 years. However, my issue is that they would propose to cease paying me.

Mr. Ruggeri: That is exactly the same situation in New Brunswick.

The Chair: Panellists, I want to thank you all very much. This has been extraordinarily useful. We have had a very good dialogue in terms of obtaining new information. We have also confirmed information we thought we understood and, indeed, did understand. There have been new ideas shared with us today, which I believe will find their way into our final report, barring of course another prorogation or a dissolution for an election campaign. Thank you very much.

Honourable senators, we will now hear from our second guest this afternoon. Ms. Gillis is appearing on behalf of the Public Health Agency of Canada. Welcome to the Senate. Let us begin with your opening remarks and then move to questioning.

Margaret Gillis, Director, Division of Aging and Seniors/Office of Voluntary Sector, Public Health Agency of Canada: Good afternoon. The Public Health Agency of Canada is pleased to be able to present its information to this Special Senate Committee on Aging. Within the agency, work is focused on health promotion, the prevention of chronic and infectious diseases, injury prevention and emergency preparedness. The agency is working on four main areas with respect to seniors: active aging, emergency preparedness, mental health and falls prevention.

You have asked for information in three specific areas related to seniors, the emergency preparedness work that is being done, Age-Friendly Cities and Age-Friendly Rural and Remote Communities and, finally, Healthy Aging in Canada: A New Vision, A Vital Investment. I will begin with our work on emergencies and seniors.

During the past two years, the agency has worked with partners within Canada and across the globe on the issue of seniors and emergency preparedness. Our work is focused on developing links with partners to develop tools, guidelines and strategies to ensure that information on seniors in emergencies is widely disseminated and integrated into emergency management plans.

Natural and man-made disasters, such as flu pandemics, hurricanes, earthquakes and wars, have highlighted the need for governments and non-governmental organizations, NGOs, to address the emergency planning needs of vulnerable populations such as seniors — or vulnerable seniors, more specifically.

Of course, older people are not a homogeneous group. They have varied needs, challenges, capabilities and contributions. Past disasters have told us that older adults may be more vulnerable to their impacts, so it is crucial that emergency planners know how to respond. Also, those who care for seniors and older persons themselves need to understand what they need to have available in order to ensure that they are not vulnerable to disasters.

Vulnerability is not simply a factor of age — we heard that a lot from our last presenters — but a consequence of a range of health, social and economic factors, which, with increasing age, can place seniors at risk and impact on their ability to prepare for, respond to and recover from a disaster.

How and where did our interest in seniors and emergency start? There were basically two main catalysts, one a document and the other a conference.

In 2002, the world gathered in Madrid for the Second World Assembly on Ageing. The key outcomes of the assembly were the adoption of the Madrid International Plan of Action on Ageing. Three key policy themes were identified in that plan: older people and development; advancing health and well-being into old age; and ensuring enabling and supportive environments.

The plan contains specific recommendations recognizing seniors as vulnerable populations in emergencies but also as primary caregivers in many instances and as contributors in rehabilitation and construction. The work currently being done responds to the Madrid recommendations — for example, sharing of best practices and developing guidelines, among others.

The second catalyst was the Presidential Symposium on the 2004 Tsunami and Older People, held at the International Association of Gerontology World Congress in June 2005. The symposium demonstrated that older people are often given low priority when it comes to relief distribution, and that few international agencies have programs specifically tailored to respond to seniors' needs.

With these two events in mind, in February 2006, the Public Health Agency of Canada held a meeting in Toronto with an expanded network of stakeholders. The goal was to facilitate the exchange of knowledge among international, provincial and territorial governments and NGOs.

Participants expressed the need for a larger international workshop, to provide a platform to increase the international awareness that was lacking. This gave birth to the Winnipeg workshop, held in Winnipeg in February 2006. In minus 40, we gathered about 100 brave souls, both domestic and international, in the workshop.

The workshop, we believe, positively impacts seniors in two important ways. First, the expert guidance generated from the participants will serve to integrate seniors more fully into emergency preparedness policies and practices. Second, it opened an important dialogue among experts from various fields — gerontology, emergency management and health care — as well as seniors themselves to achieve a common understanding of the impact of disasters on older people around the world and in Canada, and the action required to integrate seniors' needs and contributions into emergency preparedness policy and practice.

The key outcome was to mobilize networks to influence change to emergency planning and practice. To do this, we structured the agenda so that participants first achieved a basic, common understanding of current evidence and status of seniors and emergency planning activities within Canada and at the international level.

As for our next steps, collaboration will be key with governments at all levels, non-governmental organizations, the media, the private sector, academics and of course seniors themselves. Seniors must and will be included as full participants in this process.

The agency has now set up two steering committees — one domestic, one international — to oversee the next steps to sustain the momentum on this issue. At the suggestion of Dr. Alexandre Sidorenko, head of the United Nations Programme on Ageing, Canada has been asked to discuss emergency preparedness and seniors at the United Nations Commission for Social Development in February 2008. Preparations are also under way for a second international workshop on seniors and emergency preparedness to be held in Halifax, March 18-21, 2008. Work at that conference will consist of the development of tool kits, best practices, key messages and strengthening networks and partnerships.

On another front, we are pleased to learn that the United Nations Inter-Agency Standing Committee has just approved that the World Health Organization and HelpAge International will co-chair an 18-month process to develop guidelines for older persons in emergencies. The World Health Organization tells us that Canada's leadership was instrumental in the decision of the United Nations to carry forward on this issue.

I will speak now about Age-Friendly Cities. In 2006, a partnership was established between the World Health Organization and the Public Health Agency of Canada for a project entitled Strengthening Healthy and Active Ageing. One of the goals was to develop an age-friendly tool kit for urban communities in several countries to serve to guide action to globally improve the age-friendliness of urban communities.

The World Health Organization Global Age-Friendly Cities Project involves 33 cities in 22 countries. Canada not only provided some of the funding but also actively participated in the project. Four Canadian cities were among the 33 that conducted focus groups. They were Saanich, British Columbia, Portage la Prairie, Manitoba, Sherbrooke, Quebec and Halifax, Nova Scotia.

The Global Age-Friendly Cities Project has been a success both domestically and internationally. On October 1, 2007, Canada hosted an international event at Canada House in London, England, to celebrate the International Day of Older Persons. At the event, the Minister of Health was presented with Help the Aged U.K.'s international award for Canada's leadership on seniors' health issues.

The celebration also included the formal World Health Organization launch of the Global Age-friendly Cities: A Guide. During the launch, the Minister of Health announced the federal government was providing funding to support the second phase of the project. The purpose of this phase is to initiate the implementation of the guide and support the sustainability of local projects and local age-friendly networks abroad and in Canada.

Not only have Canadians cities participated in the Global Age-Friendly Cities Project, we have moved the project out to explore the realities that seniors experience in our rural and remote communities — those with under 5,000 people.

In September 2006, the Federal-Provincial-Territorial Ministers Responsible for Seniors endorsed the Age-Friendly Rural and Remote Communities Initiative. The project is being coordinated through the FPT Healthy Aging and Wellness Working Group, which is co-chaired by Manitoba and the Public Health Agency of Canada.

Interest across Canada was great. At the beginning of this project, we had hoped to find three communities to participate; in the end, we had 10 in eight jurisdictions. We are also producing the age-friendly rural and remote guide for early winter. We just received approval of the guide from the FPT Ministers Responsible for Seniors last Friday.

We believe that both the Age-Friendly Rural and Remote Communities Initiative and the World Health Organization Global Age-Friendly Cities Project will assist jurisdictions to identify barriers, as well as possible solutions, best practices and actions needed to move forward on healthy aging in the communities.

As a next step, the agency is exploring ways to work within Canada, either through the FPT network or bilateral arrangements, to continue momentum on this work. There has been a growing appetite for further collaboration by domestic partners, such as the provinces and territories, the Canadian Institutes of Health Research and NGOs, as well as a number of initial partners who are interested in our work.

Finally, I will give you some information on Healthy Aging in Canada: A New Vision, A Vital Investment. At their ninth meeting in September 2006, FPT Ministers Responsible for Seniors endorsed the report Healthy Aging in Canada: A New Vision, A Vital Investment, and the background paper entitled From Evidence to Action. The report embraces a vision of healthy aging that values and supports the contributions of older people, celebrates diversity, refutes ageism, reduces inequities and provides opportunities for older Canadians to make healthy choices that will enhance their independence and quality of life.

The new vision document is grounded within Planning for Canada's Ageing Population: A Framework, produced for FPT Ministers Responsible for Seniors in 2002 — in particular its health, wellness and security pillar — and recognizes the vital importance of supportive environments.

Supportive environments are the key mechanisms where governments can focus attention, build momentum and see results in moving forward with healthy aging. The agency, working in partnerships with provinces and territories, NGOs, researchers and the private sector, will facilitate the creation of age-friendly communities and move healthy aging forward in Canada through that venue.

In closing, I would like to thank you for the opportunity to come before you, and wish you well with your work.

The Chair: Thank you very much. I was somewhat amused that you took your conference to Winnipeg in minus 40 weather because I did the same thing for our palliative care conference. I must say it focuses the mind beautifully because no one wants to go outside.

Ms. Gillis: It was funny because all the Canadians stayed inside, and all the people from India and Jamaica went outside.

The Chair: They wanted to see what it was like.

Ms. Gillis: Exactly.

The Chair: I will begin the questioning this afternoon with Senator Cordy.

Senator Cordy: You provided an overview from the federal perspective. I would like to look at how it filters down. Formerly, I was a member of the Standing Senate Committee on National Security and Defence. We traveled to all the provinces and tried to determine how much they were actually receiving. Unfortunately, it appeared they were not receiving what people in Ottawa thought they were.

How do we ensure that the plans developed at the federal level with a number of stakeholders filter down to the provinces and to the municipalities? It is the front-line workers, such as the police officers or the military, who need this.

Ms. Gillis: Are you asking me about emergency plans or age-friendly cities?

Senator Cordy: I am talking about emergency preparedness.

Ms. Gillis: With the international and domestic subgroups, we have involved people from the provinces in emergency preparedness who are first-line reactors. We are working with some of the provincial people and the Canadian Red Cross. We have involved partners who are key stakeholders. We knew we could talk amongst ourselves in the seniors' community without having collaborative relationships. However, involving those provincial people in the development of the guidelines and the work that we are doing would facilitate it moving down the line. In the international scene, we have witnessed the movement of the World Health Organization and the UN to adopt our information on seniors.

On the domestic level, we are also getting positive reaction from our partners, in regard to both emergency preparedness and seniors.

That having been said, there is much work to be done.

Senator Cordy: Looking specifically at seniors, their needs may or may not be different than the rest of the population in a given municipality. Are seniors identified as part of a plan, both nationally and within a municipality, so that a senior who may be physically incapacitated is red-flagged by the fire department or by the emergency services within a municipality?

Ms. Gillis: That is one of the goals we want to work on achieving. I am not sure that happens in every community yet. One of the areas identified in our work is the importance of identifying buildings that have a large population of seniors. In most communities, assisted living buildings are already identified by emergency planners, but there is more work to do in identifying all vulnerable populations within the community.

Senator Cordy: I would agree that facilities for assisted living or homes for seniors in a community have been red- flagged. It is the seniors living independently in their own home or with another family member who would be more at risk.

Ms. Gillis: That is the impetus for our work, because we saw in Louisiana that community-dwelling seniors were not identified. Part of our work aims to initiate that process in a more widespread manner.

Senator Cordy: The issue of communicating a plan to a community is important. I heard someone speak about communications with respect to a disaster that had happened in France. The biggest problem was not deaths directly attributed to the explosion but that people all took the same route to get out of the town. Emergency vehicles were unable to reach the people in need.

Ms. Gillis: That example is broader than only seniors. It is a responsibility of the local responders.

An impetus for us was following 9/11 in New York City. The city planners had an agreement with the humane society that in a disaster situation, they could cross emergency lines. However, the city planners did not have agreements with many of the caregivers. When the site was identified as a crime scene, they cut off all transportation into lower Manhattan. People were left in their beds for up to seven days without help, often not knowing what happened — the sky went dark and the phone went dead.

A number of recommendations came out of that situation, which we have adapted in our work for seniors. We want to ensure emergency groups speak to community groups that provide assistance to vulnerable populations in an emergency.

Senator Cordy: That would also be true about communications. In Halifax, following Hurricane Juan, most people experienced power losses for several weeks. The weather was fine, so there was less impact.

Do you have plans in place for seniors specifically given that they are less likely than a teenager to have a cell phone and such?

Ms. Gillis: Not specifically, although let me explain where we are now, so you will understand why I am not answering directly.

The big policy pieces have been done. A policy document for governments and NGOs was prepared that discusses these issues you raise. In Halifax, the next step is specific tool kits for distribution to the communities. These kits will have questions, such as those you are asking now, about the methods of locating seniors and ensuring they have the information they require.

Probably the best example in the developed world in terms of responding to seniors and emergencies is the State of Florida. They experience hurricanes regularly. If you recall the summer that Hurricane Katrina occurred, there were four or five others that had hit Florida, and there was not the loss of life that occurred with Katrina in the Gulf States.

They have developed a number of best practices plans that they bring to our conferences. We look to Florida for direction in terms of seniors living in high-rises for example. After the electricity goes out, the elevator does not function and the stairs must be used. Often they are not able to use the stairs, so we must ensure those seniors get water and food. They have done much work in this area, which they have been sharing with us in Canada and internationally.

Senator Cordy: When a plan is developed relating to seniors — or even overall emergency preparedness plans — is evaluation included as part of that?

Ms. Gillis: Yes. We are not at the evaluation point yet with the policy piece we are presently involved with. When looking at the best practices that will be happening in the second workshop in Halifax, many of those have evaluations programs incorporated, for example, post-9/11 or Hurricane Katrina. We will be using those.

Moving this forward is work for us as we implement it directly into the community.

Senator Keon: With respect to the age-friendly cities program, the tool kits and the connections through the World Health Organization with the other countries, is there twinning of some of the cities you have mentioned in Canada and those overseas?

Ms. Gillis: We will have to hire you as a policy person because that is one of the issues we were discussing. It came from a discussion with one of our NGO partners as a possible next step.

We released the age-friendly cities guide on October 1. It has a checklist with the types of issues that cities need to implement to become age-friendly. We are at that phase now. Hopefully, we will be moving into the implementation phase in the next year or two. It is interesting that your suggestion is the same as one that came from the NGOs.

Senator Keon: It would be of tremendous interest to look at some of the housing innovation that has occurred in Europe and Great Britain. We could learn a great deal from them.

Ms. Gillis: Absolutely. There are many such issues on the age-friendly topic and much to be learned from both developed countries and those that are developing on each of the eight checklists.

Senator Keon: Have you almost finished all of your policy documents on emergency preparedness?

Ms. Gillis: They are almost finished and will be released at the social committee meeting at the UN on February 11 to 14, 2008.

Senator Keon: I am probably being a little unfair because I have been on the committee post-SARS and I know Dr. David Butler-Jones very well. However, I do not know where you are in the lines of command in emergency preparedness. That was a big problem when SARS occurred. In reality, the head of the Canadian army truly called the shots. Although he could delegate to various ministers of health, he was legally in charge. Do you know whether there has been any change in that area?

Ms. Gillis: I am not as familiar with the actual responding first line because I am on the health-promotion side. I look at moving the seniors' issues forward, so I am not the right person to ask. I am sure we could take the question back to the Public Health Agency of Canada, PHAC, and ask someone who is a first-line responder at the national level to provide you with the answer.

Senator Keon: I will not have you take that question back because I am bugging them enough right now.

However, it would be useful to know about the concept of twinning and whether you are at the point of arranging a discussion on whom Canada should twin with in Europe and elsewhere.

Ms. Gillis: It would be an interesting piece to take to the World Health Organization because we have a number of developed and developing cities and countries involved, so it could be broader than Canada. We could consider beginning in Canada if we so choose. I will bring your comment back to the office because it is the second time we have heard this.

When we looked at pulling some of the cities in, Udaipur, India, was interested and became one of those in the work on age-friendly cities. The first question from one of the municipal officials was with whom they could twin.

Senator Chaput: Although I might have missed it, I did not hear anything about municipal governments partnering with you.

Ms. Gillis: They are doing so, in fact.

Senator Chaput: At what level are they implicated?

Ms. Gillis: All the municipal governments of participating cities in the international World Health Organization study were our partners. Some Canadian and international mayors participated in the launch at Canada House, in London, on October 1. We worked with municipal governments, and the results from that work on age-friendly cities was most interesting. To date, British Columbia and Manitoba have adopted the age-friendly ``communities now'' as we call it. We will have guides from cities and rural and remote communities as a basis for their active aging plans. Nova Scotia is looking at doing some more work using it as a centre, and Quebec is beginning to look at how they want to continue the momentum. We have had quite a bit of interest. As well, we have heard from other provinces that want to move forward, and municipalities are involved, which we reach through the provinces. Some municipal organizations partnered with us in the early work.

Senator Chaput: Would the guides be different for a rural community than for an urban community?

Ms. Gillis: That is a great question. Interestingly enough, we expected greater differences in the types of responses we received from older people in developing and developed countries and also between rural-remote communities and cities. There were fewer differences than one would have expected in developed and developing countries. Many of the same issues, such as lack of transportation, housing and surly bus drivers, are universally loathed. We found many similarities.

Similarly, there were the same types of concerns expressed by rural-remote communities and cities. Of course, access issues are often highlighted in rural communities. We are beginning to see much of what you have studied in this committee: Our rural communities are losing their young people. We have many older people living in rural communities, and the traditional support networks of the children are now in Toronto or Winnipeg or elsewhere. That information is starting to surface, and difficulties with access to health care is coming out more directly than we would see in the cities.

Senator Chaput: Is there a link?

Ms. Gillis: Yes, there is a link.

The Chair: What kind of components would you be looking for to be able to declare a city age-friendly?

Ms. Gillis: We identified eight determinants of health as the basis. If I may take you back one step, I will remind you about how the work was done at the front end — which I believe I told you about during my appearance before the committee about one year ago.

We asked seniors eight direct questions on determinants of health dealing with outdoor spaces, buildings, transportation, housing, social participation, respect and inclusion, civic participation and employment, and community and health services. We worked with universities, geriatricians and gerontologists to develop scientific questions. In the big cities, we spoke to eight different groups with different demographics. We spoke to civic leaders and caregivers. We asked them a series of questions on the eight determinants of health. We heard back from older people in their own voices what they needed in their cities to age healthily.

To get back to your question, we asked specific questions, so, based on those determinants of health, we had an overall vision of age-friendly cities. We created a checklist and gave this as a guide to cities who participated. They then look around their respective communities to determine where they have weaknesses and strengths. We use that as a guideline to make their cities more age-friendly. The common mantra is good design is good design: If we have good design for older people, then we generally have good design for children. Age-friendly is not only for seniors but also for others in the community.

The Chair: Does any money go along with this?

Ms. Gillis: Yes, there has been funding. Canada was so well acknowledged for its work because we funded many developing countries. Although it was not much money, it was sufficient to pull it together. The studies on age-friendly and rural-remote were funded by the provinces and the PHAC — from the FPT pot. Now, we are looking at other ways to move forward.

We have traditionally used the population health fund from the PHAC to fund the work. We will look at some version of that as we move forward and at how we will do the implementation phases. As I mentioned, we have had a great deal of interest from many communities wanting to move into the project.

The Chair: What types of coordination are you doing with other departments?

Ms Gillis: We work directly through Human Resources and Social Development Canada, HRSDC, which is the lead for seniors for the Government of Canada. We have been working with them, informing other departments. At this point, we have been working more closely, though, with the provinces and municipalities. That has been the major direction of our work.

The Chair: This takes you somewhat out of your comments for today, but an area that is of grave concern is the health care of seniors and, more particularly, their access to appropriately trained physicians and nurses. We heard that there has been a doubling in the number of gerontologists, but we know that the baseline for that doubling was so small that it was similar to increasing from 10 to 20. We still have a huge lack of gerontologists, and the number of nurses has not changed at all. What type of work is your agency doing, if any, with respect to attracting more physicians to enter gerontology?

Ms Gillis: Bear with me, because the new job I just started today is directly on that issue. I have only had a five- minute briefing, so I am not sure I can answer that question yet; perhaps in a few weeks.

From the perspective of the Public Health Agency of Canada, interestingly enough, some of those concerns came up on the age-friendly city discussion on health care access, both in rural-remote communities and in age-friendly cities. It was interesting because the concern was not so much about gerontologists as about primary care. Perhaps the second part to your question should be about the number of gerontologists we need and the amount of information front-line providers across the health spectrum know about seniors, whether it is nursing, occupational therapists or physicians, or the whole coordinated team. There are two pieces to that.

The Chair: As a little bit of advice, when I began my work with palliative care, a fascinating study came out of Edmonton, and another out of McGill, indicating that the average physician had one hour of training in their entire four years of medical school on palliative care, including pain management. I decided that, quite frankly, this had to change.

As of next June, no physician will graduate from undergraduate medicine without a core program in palliative medicine. We were able to accomplish that by giving the College of Physicians and Surgeons $1.25 million, which was a small amount of money, but they developed the curriculum and got it to the medical schools, and it happened. Gerontology will be the next area to tackle. If graduating physicians learned about dealing with seniors in their undergraduate program, we would not have the situation where seniors cannot find a family physician because when their gerontologist or family physician dies or decides to leave practice, the younger physicians will not take them. One reasons for that is they do not know anything about seniors.

Ms Gillis: That will just grow with the demographics. That is an area for me to consider in my new job.

The Chair: Thank you very much for your presentation this afternoon. It was very much appreciated.

Honourable senators, I would like to hold you in camera for a few minutes.

The committee continued in camera.