Skip to Content
 

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

Issue 6 - Evidence - November 3, 2011


OTTAWA, Thursday, November 3, 2011

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:28 a.m. to examine the progress in implementing the 2004 10-Year Plan to Strengthen Health Care.

Senator Kelvin Kenneth Ogilvie (Chair) in the chair.

[English]

The Chair: Honourable senators, I call the meeting to order.

[Translation]

I welcome you to the Senate Committee on Social Affairs, Science and Technology.

[English]

I am Kelvin Ogilvie, a senator from Nova Scotia and chair of the committee. I will ask my colleagues to introduce themselves.

Senator Seidman: Senator Seidman from Montreal, Quebec.

[Translation]

Senator Verner: I am Senator Josée Verner from Quebec City.

Senator Demers: Senator Jacques Demers from Hudson, Quebec.

[English]

Senator Braley: Senator Braley from Ontario.

Senator Hubley: Senator Hubley from Prince Edward Island.

Senator Merchant: Senator Merchant from Saskatchewan.

Senator Dyck: Senator Dyck from Saskatchewan.

Senator Eggleton: Senator Eggleton, deputy chair of the committee, from Toronto.

The Chair: Thank you very much. I want to remind us all that we are continuing our study, as directed by the Senate of Canada, to examine progress in implementing the 2004 10-Year Plan to Strengthen Health Care in Canada. This is our ninth meeting. The overall title of this meeting is prevention, promotion and public health.

We have five presenters this morning. I will introduce them as I call them to speak. We have an agreed order and I will call them in that order. I would remind my colleagues that because of the number of witnesses, I would implore you to be efficient with words in putting your questions so that we can get all of your questions on the record.

With that, I will start with the Public Health Agency of Canada and ask Dr. David Butler-Jones, the Chief Public Health Officer, to begin his presentation.

Dr. David Butler-Jones, Chief Public Health Officer, Public Health Agency of Canada: Mr. Chair and members of the committee, thank you for inviting me to speak today. It is a pleasure to be here this morning to discuss progress on the public health aspects of the 2004 health accord.

[Translation]

I would like to start with a description of what is meant by public health.

[English]

Public health is the organized efforts of society to improve health and well-being and to reduce inequalities of health. Put simply, it is about promoting good health, preventing disease, protecting the population and prolonging life.

While care is about the individual and about treatment for disease and injury, public health focuses on the whole population, preventing the need for that treatment. While health care is primarily a provincial and territorial responsibility, public health is the responsibility of all levels of government and involves all sectors of society — health, transportation, justice, education, environment and beyond. These are all connected, and our health and prosperity rely on the interplay between them. The level of success is dependent on all sectors acting together. Public health is a team sport, with the shared goal of a healthy population, the added benefit of which is a more sustainable health care system. Together, public health and health care make for a complete health system.

[Translation]

Since the 2004 health accord, the public health landscape has changed for the better in Canada.

[English]

The accord helped put public health on the agenda and made it part of the conversation. Before the accord, public health was rarely if ever on the agenda of federal, provincial, ministerial or deputy ministers' tables, let alone a top-of-mind issue for Canadians. However, in the wake of the SARS outbreak in 2003, the momentum was finally there for calls to action on a more collective approach to addressing public health challenges in Canada — among them, calls for a national immunization strategy and the Pan-Canadian Public Health Network. While these initiatives predated the accord by a few months, they were validated by this renewed focus on public health.

[Translation]

These are some of the areas I want to touch on today.

[English]

The context surrounding the timing of the accord is important here. SARS occurring a year earlier was truly a national wake-up call, if not for the world. The untimely deaths, illnesses and costs it created were the salt on the wound of a badly fragmented system.

There was a recognition that during an emergency is not the time to be exchanging business cards. We needed to build trusted relationships and practised networks that transcend borders and jurisdictions before an emergency. The network has since been one of our most important success stories and has provided a means of facilitating effective coordination between provincial, territorial and federal players.

This new level of collaboration became indispensible during coordinated efforts in the 2009 H1N1 pandemic. In terms of collaboration, the way jurisdictions, communities and individuals came together to address H1N1 was unprecedented. It resulted in Canada having one of if not the best response in the world.

[Translation]

Canada's management of H1N1 was not our only success.

[English]

We have used the Pan-Canadian Public Health Network to negotiate and sign two memoranda of understanding on information sharing and provision of mutual aid during health emergencies with provinces and territories. It was also used to negotiate the declaration on prevention and promotion, which was endorsed by ministers of health and healthy living last year, then endorsed by ministers of sport and recreation and engaging ministers of education.

We are working together to address, for one, childhood obesity as a particular concern. Otherwise, this may be the first generation of children not to live as long as or as healthy as their parents. Mixing policy and practice and different levels of government and experts keeps us all on the same page, working toward the same aims. It is much more powerful when we are all rowing in the same direction.

The PHN provided a mechanism that allowed us to get down to work on helping Canadians avoid preventable infectious and chronic diseases. On the former, we have the National Immunization Strategy, and on the latter, the Pan-Canadian Healthy Living Strategy. I will begin with the NIS.

Through the National Immunization Strategy, the Government of Canada is collaborating with all jurisdictions to prevent diseases by maximizing equitable and timely access to vaccines for all Canadians. The government has also supported immunization through trust funds, including through a three-year, $300-million trust to introduce four new childhood and adolescent vaccine programs to prevent meningitis, pneumonia, chicken pox and whooping cough. All provinces and territories now have publicly funded immunization programs for these diseases. Today, twice as many Canadian children and youth in every province and territory are protected from the dangers of these.

The federal government created a second three-year, $300-million trust fund in 2007 to support the introduction of human papillomavirus vaccine. By the time this funding ended in 2010, all jurisdictions had introduced this vaccine.

Immunization works because it allows Canadian to entirely avoid certain illnesses. This federal leadership has improved the immunization landscape in Canada, which has resulted in the unprecedented introduction of vaccination programs and higher vaccine uptake across the country.

While immunization rates in Canada are high and the occurrence of several diseases has been reduced, the risk of exposure remains, and improving immunization continues to be a priority. We are working closely with our colleagues in the provinces and territories and stakeholders to renew the National Immunization Strategy and ensure this important program remains relevant and effective. The health care system does not incur costs to treat diseases that people do not get.

[Translation]

This is a crucial point.

[English]

It has been said many times that it is far better to have a good fence at the top of the cliff than a good ambulance service at the bottom. Canadians suffering with chronic diseases like diabetes, cancer, heart and lung and kidney disease, to name just a few, are being hospitalized across the country and this carries a huge personal, social and economic burden. Much of this disease burden is in fact preventable.

The prevention and promotion agendas have benefited from increased attention in the years since the accord. The Pan-Canadian Healthy Living Strategy was a commitment from all jurisdictions to take more coordinated action in prevention and promotion. Governments have been able to fund critical activities in these areas.

Our own federal contribution to this pan-Canadian approach is called the Integrated Strategy on Healthy Living and Chronic Disease. The integrated strategy commits $69.9 million every year to promoting healthy eating and healthy weights, increasing physical activity and implementing disease-specific prevention strategies.

Mr. Chair, from the Public Health Network to the National Immunization Strategy and the pandemic plan, to new programs, surveillance, research and partnerships, our collective public health efforts have grown from the vision within the accord less than a decade ago. As a result, we have since contributed to healthier Canadians in a healthier world, and to sustaining our publicly funded health care system.

[Translation]

However, there is much more work to do.

[English]

As agreed to in the Declaration on Prevention and Promotion, a better balance between prevention and treatment must be achieved. Surveillance, research and knowledge sharing can always be improved and more attention can be given to collaboration — quite simply, working together toward common objectives.

As I have indicated in my annual reports to Parliament on the state of public health in Canada, the role of public health is to help find collective solutions to ensure good health across the population, to improve health overall and to minimize the gaps in health. I am pleased to say the inclusion of public health in the 2004 accord has clearly benefited Canadians, and we look forward to the future.

[Translation]

Thank you very much, Mr. Chair and honourable senators.

[English]

The Chair: Thank you very much. I will now turn to the Canadian Task Force on Preventive Health Care and invite Dr. Birtwhistle, Vice-President, to present.

Dr. Richard Birtwhistle, Vice-President, Canadian Task Force on Preventive Health Care: I am pleased to be able to present the Canadian Task Force on Preventive Health care to you. I think you have a PowerPoint presentation in front of you that I will lead you through.

The task force was reconstituted by the Public Health Agency of Canada, PHAC, in 2009. We have been working diligently on trying to produce our first guideline, which will be coming out imminently.

The mandate of the Canadian Task Force on Preventive Health Care is to develop and disseminate clinical practice guidelines for primary and preventive care, based on a systematic analysis of the scientific evidence.

We are 14 members on the task force, 7 of whom are family doctors. All of us have expertise in methods around guidelines and in epidemiology. As I said before, we are established and funded through the PHAC.

The task force structure is the task force itself, but we also have a number of people who are really helping us with our work. We have a task force office at the PHAC that has scientific officers and directors that help with the development of the guidelines, as well as thinking about knowledge translation strategies for helping to make the guidelines useful and getting them out.

We also have an evidence review and synthesis centre. This is the place where a lot of the systematic market reviews of the particular subject are done. It is currently at McMaster University and is funded through a partnership between the Canadian Institutes of Health Research, CIHR, and PHAC.

We also have a number of stakeholders who are really important in our work in giving us advice about what the important topics are around prevention from their perspective.

I will just take a moment and talk about how evidence-based guidelines are developed. First, there is a group in the task force that creates the topics, but we accept information from the public through our website through various groups who may have topic suggestions for guidelines that we want to develop.

We set certain criteria for whether we are going to select a topic or not. Obviously, one of those would be how important it is for the public health of our country and disease burden as to whether there is any new evidence out there.

A workgroup is established of a small member subcommittee of the task force and key questions are developed to answer around each guideline. Those questions clearly are often around what the benefit is of whatever screening manoeuvre or preventive manoeuvre you are going to do versus the harms. Increasingly, we are recognizing that there are both of those things.

The next step, once the key questions are developed, is that the evidence census and review centre assembles the evidence. This takes a number of months doing comprehensive literature reviews. The guidelines and the evidence are assessed using a system called the grade system, which is grading a recommendation's assessment, development and evaluation, and it is used to rate both the quality of the evidence and the strength of the recommendations.

The workgroups then work through the systematic reviews and the literature searches and then draft recommendations that are based on the evidence review. Those drafts are peer-reviewed and discussed within the small group before going to the task force as a whole.

The final thing is debate at the task force about the recommendations that happen before they are published.

We have a dissemination strategy that involves both knowledge translation through publication and developing tools that can be used by practitioners as well as the public to interpret and use the guideline.

We are also planning on doing research on the effectiveness of the dissemination implementation and evaluation strategies as part of our looking at the task force impact on preventive care in this country.

What does the task force bring to prevention? I think it brings credible, appropriate, easily accessible guidelines that will improve preventive care in Canada. It has evidence-based guidelines in the area of preventive health care to help ensure efficiencies in the health care system. We have linkage with PHAC for capacity building in the public health system and, finally, some accountability around benchmarking the types of preventive tests and programs that happen across the country.

Thank you for your attention.

The Chair: Thank you very much, Dr. Birtwhistle. I will now move to the Canadian Public Health Association and invite Debra Lynkowski, Chief Executive Officer, to present.

Debra Lynkowski, Chief Executive Officer, Canadian Public Health Association: Thank you for the invitation to be here today. I represent the Canadian Public Health Association. We are Canada's only non-governmental organization that focuses exclusively on public health. Our membership is nationwide and we represent over 25 different disciplines that deal with quite a broad range of health and social issues.

I was going to speak to you about progress, what remains to be done and our recommendations, but I heartily agree with all of the progress outlined by Dr. Butler-Jones, so I will not repeat that. I want to flag for you that he probably neglected to say that one of the other areas of progress is that the creation of the Chief Public Health Officer's position has been a huge benefit to this country. His work has been exemplary. We have only to look at the response to H1N1 and the profile of the CPHO, of the Public Health Agency of Canada and the local public health response to say we actually got this one right.

We do have a few areas that we still are lagging behind in. Dr. Butler-Jones talked about the National Immunization Strategy. I agree that there has been significant progress there, but, as he said, it has to be a priority to continue to improve that. The NIS lags behind in terms of creation of a registry and in educational programs for the public, because we know there is still an anti-vaccine movement in terms of a research plan and in terms of harmonized schedules for immunization across the country.

The 2004 plan also talked about a pan-Canadian public health strategy that looked at indicators and outcomes for health status for Canadians. That is still something we need to develop. That was reiterated in the Senate's own report that was led by Senators Keon and Pépin regarding the need for a population health strategy. We need to move on that if we are to have an impact.

You have a detailed brief in front of you and I do not want to repeat everything in it. I want to highlight some of the recommendations for any new health agreement. Dr. Butler-Jones alluded to some of them. In it, we call for a shift in focus from health care to health equity as a guiding principle of any new health agreement. We urge that any new agreement include public health and figure that prominently so that we are focusing on disease prevention, injury prevention and health promotion and surveillance. We recommend better coordination between the Canada Health Transfer and the Canada Social Transfer because a lot of how our health is determined actually falls outside of the health sector. We need to look at those non-health factors.

We strongly urge that any new accord include meaningful commitments to public health human resources infrastructure and surge capacity. Our capacity to respond to H1N1, while exemplary, tested the limits of everyone on the ground. It also delayed many other public health programs, some of which will not be caught up.

In closing, I want to leave you with some overall observations and a challenge. None of this is in the brief. When we were preparing this we took out all of the briefs we have done to parliamentary committees for the last 10 years. Essentially, we cut and pasted the things we have been saying for many years. What that says to me is, while we have made progress, we have not made enough progress, and we have to move further and faster.

What stands out for me is that public health continues to be funded at 5 per cent of all health expenditures. When Dr. Naylor did his report, he said it was 2 to 3 per cent. I told that to a reporter once, who said, "Then there has been significant progress." Five per cent of all health expenditures are targeted at preventing illness and keeping people healthy, and we wonder why we spend 95 per cent on acute care and in curing the sick. We need to change that balance because the math defies all logic.

We seem to respond to public health and there is a flurry of activity when there is a crisis. We ably deal with those crises, whether it is SARS, H1N1, Walkerton or listeriosis. Everyone in public health rises to that challenge, but when the flurry of activity ends there is a silence again, and as it relates to funding, public health is lumped in with all other health funding. When we talk about initiatives that are cost-cutting or that there is no new money, it does not make sense that in an area that has been chronically underfunded for decades we do not look at new investment for that area specifically.

The challenge to create a healthy, productive society takes decades. That takes political commitment, commitment from organizations such as ours, that spans decades. That is the challenge for Parliament, for the Senate and for all of us who are working on this so diligently. That is where the real change will come about.

We have all of the answers already. I know you have read it, but the report done by the Senate in 2009 was brilliant. If all of the recommendations in there were implemented, we would make huge progress. If we implemented the recommendations in the CPHO's reports, we would make huge progress. Our challenge as a nation is to finally implement that which we so strongly recommend.

I leave you finally with this thought. The evidence says that the average lifespan of Canadians has increased by more than 30 years since the 1900s and 25 of those years are attributable to advances in public health such as immunization, water safety, et cetera. If we want to maintain that legacy and further those advances, we need to make sure that any new health agreement prominently figures disease prevention and public health.

As a final thought, what you can do as an individual to protect yourself, your family and those around you is to get your flu shot as soon as possible.

Karen Cohen, Chief Executive Director, Canadian Psychological Association: Thank you, senators, for this invitation to CPA to join you today. As you may know, CPA is a national professional association of psychologists. There are about 18,000 regulated practitioners of psychology in Canada, making us the country's largest group of regulated, specialized mental health care providers. I want to give you a bit of our perspective on the implementation of the 2004 accord and then talk a bit about the role of psychological factors in health.

The Chair: Slow your presentation. The translators are finding it hard to keep up with you.

Ms. Cohen: In terms of health human resources, I think some of the discussions we have been having since 2004 have evolved to talk about supply in relation to need. It is really important that we look to the needs of community when it comes to mental illness and health promotion and that we respond to those in ways that are cost- and clinically effective. We would like to mention that improving access is not only about reducing wait times for publicly funded services, but also about enhancing access to services that are not publicly funded, which is an acute issue in mental health. The 2004 accord talks about mental health in relation to home care, the challenge being that home care is not the intervention that best addresses the majority of problems experienced by Canadians when it comes to mental health, namely anxiety and depression. For those kinds of problems, we are looking at psychological and other kinds of community-based treatments and supports.

Finally, investment in research is really an important need when it comes to mental health, but in the full range of biological, psychological and social inquiry. Any condition, be it mental health or not, is impacted by this variety of factors.

It is clear, when we talk about health promotion and illness prevention, that we need services and supports that support health. However, as I am sure all of us know, building the recreation centre is easier than getting people to it. There are a lot of factors that impact whether or not people behave in healthy ways. A lot of those are psychological factors. Good health correlates with self-worth, peer connectedness, school engagement and parental nurturing, as well as healthy behaviour. Poor health is correlated with poor mental health. Many chronic diseases, like heart disease, diabetes and stroke, are risk factors for depression. Depression itself is a risk factor for first and recurrent cardiac events. One in 20 Canadians will experience a mental disorder in a given year. Seventy per cent of these, as I am sure Dr. Manion will explain in more detail, begin before young adulthood. Depression is the fastest growing category of disability costs. In 2003, the economic burden was estimated at $51 billion.

The strongest evidence for return on investment in mental health and mental health promotion are services and supports geared to children and youth that reduce conduct disorders and depression, deliver parenting skills, provide anti-bullying and anti-stigma, promote health in schools and provide screening in primary care. Health-promotion and illness-prevention efforts, however, also benefit people living with illness and at points in between. Positive mental health and good health behaviour not only maintain health but also help a person to manage chronic illness. Some of us will get those illnesses.

Treatment for mental disorders will be needed for some, and there are barriers to getting it. Psychologists are not funded by provincial health insurance plans, and their services are not sufficiently accessible to Canadians with modest incomes or no insurance. Other countries have recognized this. The U.K. has invested about 400 million pounds to make psychological therapies more accessible, and Australia has also enhanced access to psychologists through its publicly funded health insurance plans.

We have several recommendations that I will leave you with. The first is targeted transfers for mental health proportionate to the burden of illness in Canada. The second is health promotion and illness prevention upstream, with a focus on children and youth. The third is that intervention for mental health and illness, when necessary, needs to be collaborative and integrated across public and private sectors to include funders, organizations that deliver care, health professionals who provide it and those of us who receive it. The fourth is that there needs to be research into the full biological, psychological and social determinants and treatments for mental health problems. Finally, we call on government and other funders to help us improve access to effective psychological services for people with mental health problems who need it.

Ian Manion, Executive Director, Ontario Centre of Excellence for Child and Youth Mental Health: Thank you very much for recognizing the importance, in any health dialogue, of child and youth mental health. I think there has been a great deal of progress since the 2004 accord. We have heard of a lot of the wonderful accomplishments. I think, though, that the landscape has changed. We also recognize that the dialogue around mental health in general, and child and youth mental health in particular, has been more prominent and should be represented in the 2014 accord.

There are several recommendations we would like to make to the group. It is all in the brief, but I will go over them briefly. The first recommendation is to address the inequities in the Canadian health care system by identifying child and youth mental health as an explicit priority in the 2014 health accord, with dedicated funding for reform and innovation, based on measurable outcomes. Fifty per cent of adults with mental illness tell us that it first appeared before they were 14, and 70 per cent say it appeared before they were 18. We know that, in our country, $51 billion a year of economic burden can be attributed to mental health and that it all starts with child and youth mental health. In many ways, child and youth mental health is probably the best barometer of how we are doing as a nation in health and well-being. Increasingly, in terms of children's mental health, we cannot say we are doing well as a nation in health care or health prevention.

Our second recommendation is to increase investment in health research, with immediate emphasis on applied research in child and youth mental health. Through talking with families and service providers, we know that they want effective tools, based on research, that can help them meet the family's needs across the full continuum of care, from prevention to early identification to intervention and, yes, to chronic care. Increasingly, we are aware that young children with mental illness do become older children, adolescents and adults with mental illness. We can decrease the burden of that by identifying things quite early.

Our third recommendation is to establish a pan-Canadian child and youth mental health surveillance system to obtain ongoing and reliable nationwide incidence and prevalence data to support informed decision making at all levels. Currently we are making decisions for child and youth mental health based on data from the 1980s, and mostly from regional studies, not national studies. We do not have good data to look at the scope of the problem. We cannot make decisions around mental health human resource planning without up-to-date data, and we cannot tell whether we are making a difference or not without having integrated data, particularly as it relates to child and youth mental health.

The fourth recommendation is to develop and implement a national suicide prevention strategy that is supported by a full continuum of evidence-informed mental health services. We know that roughly 25 per cent of children and youth report to us having significant issues, ideas and concerns around suicide. For 90 per cent of the young people who take their lives, we can identify a mental illness that was part of the complex web of factors that contributed to that suicide. In this community, it is part of the dialogue on a daily basis. You open the paper, and you cannot help but see another person who, without the effective tools to cope with their mental illness or with the other stresses of their life, has decided to cope by taking their life. It is time for us to do something significant in the area of suicide prevention.

The final recommendation is to develop and implement a universal parenting program. In many ways, the biggest yield we can have, both in health and mental health for children and youth, is by effectively equipping parents to deal with their children at all levels and with the transitions that those children face into the school system, into high school, out of high school and into adulthood. Parents are clamouring for assistance, not just when things get so bad that they are beyond their means, but at the front end of care, in their primary role as the effective teachers and caregivers for their children. Thank you very much for your time, and good luck with your very important work.

Senator Eggleton: Thank you for your presentations. I would like to explore further the Pan-Canadian Healthy Living Strategy, initially with Dr. David Butler-Jones, but certainly with anyone else who wants to come into it. My understanding was that there were three targets to be achieved by 2015, including increasing the proportion of Canadians who make healthy food choices by 20 per cent, the proportion of Canadians who participate in regular physical activity also by 20 per cent and the proportion of Canadians of normal body weight, based on the body mass index or BMI, also by a 20 per cent target. Can you tell me how we are proceeding on this? Are we on track to meet these 2015 target dates? How far along the path are we at this point?

Dr. Butler-Jones: The short answer is no, which is part of the challenge.

These are not our targets. These are shared targets across jurisdictions in terms of recognizing the challenges. As I said before, it is a challenge particularly for this generation of children if something does not fundamentally change the situation they will be in as they grow into adulthood. We are making progress but, also, it is reflected, I think, in the declaration on prevention, the framework for tackling childhood obesity, the emphasis of multiple ministerial groups, the focus on the after-school period with education ministers and others and the realization that we need to make much more effective progress.

It is not just about governments; it is about communities and industry. We are starting to see some of the changes in industry. For example, we have seen McCain reformulating all their products and other companies reducing salt. They are not bragging about it because they do not want to scare people, but they are actually reducing the salt and sugar content in their foods, et cetera. We are making progress, but there is a lot more progress to be made. I would be surprised if we were to hit those targets, but we need to step up the efforts.

Senator Eggleton: How can we help do that? What kind of push can we give? Is there something relevant to the upcoming 2014 accord that we should be pushing on in this connection?

Dr. Butler-Jones: One of the things that, at least, I am hearing and I think is reflected at the table here and elsewhere, whether it is from professional associations, NGOs, ministers, deputy ministers and others, is that whatever we do, and not specific to the accord but moving forward, if we do not get primary care and public health right, we are in a pickle. It is not just about money. It is also about how we work in concert and how we work together.

Two things changed the tobacco challenge and made it actually a much more positive thing. The first is the recognition of the effect of second-hand smoke and the efforts around addressing exposure to smoke, and the second is when all the organizations, governments, NGOs, and communities started rowing in the same direction. In other words, you did not have a lung tobacco strategy and a heart tobacco strategy. The NGOs worked together, and governments worked with them and with other groups and communities to actually change the face.

Similarly, whether or not on obesity or other issues, some of it is about funding or some of it is about how we direct the funding or use the funding that we have. Some of it is how we direct our resources, not just funding but people and how we act. For example, when you look at something, the clinical intervention, so back to whether it is preventive practices or guidelines, just that five- or ten-minute intervention and two minutes of it spent about not just how we diagnose and treat the current condition but how it might be prevented in the future and what advice might we give to the patient or the family so they can avoid it in the future.

Senator Eggleton: That is what this is. It is intended to be a prevention kind of program.

Dr. Butler-Jones: Yes, but it is really about having that inculcated throughout the system at all levels, not just doctors or nurses and not just in the community, but that each reinforces the other.

For example, in the early days, I remember talking to patients with a kid with asthma or an ear infection and saying, "If you want to quit, I can help you, but if you do not smoke in the house, then your kid is half as likely to have those problems." It is the teachable moment. What struck me is how effective that couple minutes of intervention was because of the time they were there with the kid, the kid is in pain, et cetera and the number of people who then stopped smoking inside and then eventually quit because it just felt stupid, et cetera. It is a mix of those things; specifically governments and NGOs and individuals have a role. It is about creating opportunities for healthier choices for everyone.

Senator Eggleton: There is still a long way to go, though.

Dr. Butler-Jones: A long way to go, yes.

Senator Eggleton: Mental health was not part of this strategy. I am talking about this specific strategy. Dr. Manion has given us some excellent recommendations regarding youth. How should we get mental health either into this strategy or into the health accord?

Dr. Butler-Jones: That is more of a political question that I will defer. I can say it really is about thinking about health comprehensively. What are the interests of all jurisdictions moving forward that collectively we can do better, whether it is mental health or prevention and promotion. It is not a battle and it should not be a battle between prevention and care. It should be if we want the best possible outcomes, what are the investment strategies and approaches on the prevention and promotion end, on the treatment end and on the care end that gives you the best outcomes.

The purpose of the health system is better health. It is not about how many beds and hospitals. It is about do we actually achieve better health. We have tended to block it as separate silos. If we think of it as a system, we will invest in those areas that have been spoken of today.

Senator Eggleton: I do not. One of the areas I would like to talk about is social determinants of health, because that keeps getting raised by our witnesses. That is quite a broad area. It affects health, and it is everything from housing to education to poverty, et cetera. How should we get social determinants of health into the next accord? Anyone else can respond on this as well.

Dr. Butler-Jones: The social determinants, health services, including public health, is one element of the various determinants of health, but it is not the exclusive element. On the prevention agenda, it is not just Ministers of Health. It is ministers of sports and ministers of education and ministers in other sectors that must be engaged. That is at the political, governmental and bureaucratic level.

We just came back from the Rio summit on social determinants of health, and the declaration there is worth reading because it does speak to the various ways in which, at each level, we can better coordinate our activities so we are not working at cross-purposes and are gaining the synergies, because a healthy population is good for the economy, and a good economy is good for health. It is a virtuous cycle. Making those interventions, the health sector can deal with health, but it can also engage other sectors, not in a health imperialist way, such as, "You must do this because it is important to health," but, "What do we have to offer collectively that makes for a functional, successful and healthy community?" That is where it is crosses sectors, and breaking down some of the sectoral barriers is absolutely essential to that.

Mr. Manion: In terms of how to integrate mental health, I am consistent with Dr. Butler-Jones. Every time you have a preventive effort, talking about family doctors asking specific questions, there is a question about mental health that can be done every single time. Mental wellness checks are as important as physical wellness checks. It can become part of the training that we do fundamentally. It could be part of the discourse we have every time. It can be part of what we check for in the workplace. It can be that systematic in our approach. Prevention without mental health does not make any sense, and health without mental health does not make any sense. They are not two solitudes; they are two sides of the same coin.

Senator Hubley: Welcome to you, and thank you for your presentations. My question is along the same line. According to the Report on the State of Public Health in Canada, 2011, we learned that Australia, Finland, Sweden and the United States have developed national suicide prevention strategies. However, the report states that Canada can address suicide prevention as part of a broader wellness strategy that promotes mental health, prevents mental illness and also includes the broader determinants of health. Do you feel that that is strong enough, given the recommendations that we heard from Dr. Manion? What recommendations would you have in order to address the issues of suicide a bit stronger in our public health systems?

Mr. Manion: The irony is that Canadians helped develop most of those international policies in other countries. We have a huge amount of capacity here — knowledge, research, experts in the field — that have been guiding others to develop their policies for years. I think having a strong policy on suicide across the age span but with a focus on young people is necessary but insufficient.

The best way to prevent suicide is to have strong systems of care that look at providing support along the full continuum. When you prevent mental illness, you are decreasing the rate of suicide. When you are educating young people about health and wellness and equipping them with tools to cope with difficult times, you are actually having a huge impact on suicide. When you are looking at social determinants of health, decreasing abuse and trauma through effective parenting, you are having an impact on suicide.

Above and beyond a specific strategy on suicide, we have to understand how all the other aspects of health are contributors to a situation that could lead someone to suicide. We cannot put all our efforts in one direction. It must be a holistic approach and a loud signal that we will not tolerate the levels of suicide we are seeing across the country, especially in certain groups and communities. We must be able to do much better than that.

Dr. Butler-Jones: I think those might have been my words; everything does occur in a context. If you look at the work, we know that on many reserves, for example, adolescent suicide is a huge challenge.

However, when that was studied, looking at different communities that had more control — in other words, they are actively involved in land claims and have some control over health services, police, education, et cetera — the suicide rates virtually disappear. When you look at the social determinants, the basics in place — roof over your head, et cetera — I was struck by the fact that there are poor communities that are very functional and more affluent communities that are not.

Once you have the basics in place, the two things that actually make a fundamental difference are, first, do you have some sense of control that what you do influences your future, that you can make a better future, in which case you do that? Second, do you have people that love you and that you love? For adolescents and children, if those two things are not in place — and for adults as well — then the chances of good health are poor.

Senator Champagne: I was reading an article this morning that mentioned that there are many websites that young people look at to give them ways to commit suicide successfully. Should there be a way for the government to ban those sites or to do something about them? That worried me this morning; and as you brought up the suicide problem again, I thought that maybe this is something that we should recommend our government to do.

Dr. Butler-Jones: It is probably a question for Justice, but from my understanding, it is counselling to suicide, which is what the sites are doing. I thought that was illegal in Canada.

The challenge for websites, whether it is about how to produce a bomb or how to commit suicide, is that they are all over the world. I know law enforcement agencies are addressing that. Dr. Manion, do you have more specific information on that?

Mr. Manion: I think you are absolutely right. There are people that are watchdogs for these kinds of sites right now. They proliferate like crazy; you cannot control them in a systematic way.

The better investment and strategy is where you provide young people with different kinds of information at a fundamental time, before they reach the point where they are looking for maladaptive ways of coping. Mental health literacy in schools and in the workplace, equipping people with appropriate skills to cope with or even tolerate distress will go a lot further.

Increasingly, we are looking to how young people turn to the Internet; but they turn to something more than the Internet, and that is to their peers. Where is the opportunity to engage the peers, young people themselves, in finding solutions to this problem? I do not think anyone in this room will find a solution to social media and the negative aspects of it. However, if we engage young people creatively, they can tell us how to use it more effectively to promote health and wellness and to prevent illness and tragedies.

Senator Hubley: As a quick comment on that, on Prince Edward Island, which is a pretty idyllic place to grow up, the suicide rate among our young people is the leading cause of death after accidental deaths, which is hard for me to believe.

Mr. Manion: We know right across Canada that suicide is the second leading cause of mortality after accidents, but we also know that the risk for death by suicide is higher in rural communities, for a variety of different reasons. We know that young men die more often by suicide, but young women think more about suicide and attempt it more often.

It is a very complex area. We need to understand not just some of the variables — there is lots of research on the variables. We need to do research on the solutions — effective programs to prevent suicide; post-intervention in the communities, when the risks go up; and understanding such subtleties about why certain communities are affected.

I know the studies Dr. Butler-Jones was referring to. It is not, by definition, a certain type of community that will be at risk; but there are things within a community that can be protective but also place that entire community at risk. There are a number of rural factors that we know increase the risk, even in idyllic situations.

Senator Merchant: If the objective of a health care system is better health, to keep people as healthy as possible and provide the care they need when they need it in a timely, quality and cost-effective manner, then we have to think about new innovations.

We have heard from other people about multidisciplinary settings. Are there any pilot projects that you are aware of that are in the works right now that would help us to set up systems in the next accord that would function better?

Dr. Butler-Jones: In Canada, ironically, my first specialty was family medicine. The way I was trained in the 1970s was in multidisciplinary care and clinics — social workers, psychologists, physicians, nurse practitioners, et cetera working together, bringing each of their collective skills to bear on the issues from a prevention standpoint. We were well connected with public health locally to link our prevention activities clinically and at the community level as well.

However, people came out into practice with fee for service, and you could not bill for a nurse practitioner. Suddenly the schools for nurse practitioners dried up.

There are a number of community health centres that do aspects of that. Some are better than others, but there are lots of models in Canada where people try different things to provide some success.

I think former Senator Keon and perhaps Senator Eggleton were looking a bit at Cuba. Not to argue for the Cuban system, but one thing it does well is link all the levels of care. It is not a series of isolated silos. You have a physician and a nurse that look after your basic care. If you need more complex care, you go to the polyclinic or to a hospital, as needed.

In your basic care, every patient is classified in terms of do you have a chronic condition or risk factors, and there are protocols to ensure people have access to that. If there is only so much penicillin, you have criteria for this; you have some prevention programs. It is more of an integrated system. That piece of it is worth learning from.

We see elements and examples of that across the country. There is a lot written by the College of Family Physicians, the Canadian Nurses Association and other professional associations. There is actually a lot of good evidence there and work that we can draw on.

Again, it is not fractionated care. In Canada, we have moved to specialized care; you need a specialist for everything. In my view, good generalists can do most of the basic stuff, make the right links and see you as a whole patient, as a whole individual, as part of a family and a community, not as a body part. That is one of the big challenges in Canada.

We are starting to see in medical schools and elsewhere more training of family physicians, better integration of multiple disciplines into teams, et cetera. However, by and large, we are not trained in teams; we are trained as isolated or individual professions.

There is a real desire to be more integrated. I think we are seeing a lot of improvement in that. We are seeing more young women particularly going into medicine and family medicine that are more willing to work in rural areas.

However, nurse practitioners are not a substitute for lack of a physician. Nurse practitioners have their own set of skills, which are valuable in the city, the country and everywhere. It is about blending the series of skills, providing appropriate levels of care to the individual and then having a system of care so that if you need more complexity, it is there.

One last illustration: I used to teach family medicine. If I had a patient I was worried about, I would call up the surgeon or the internist or whatever it was, explain what I found and what I had done, and they would be seen that day or the next one. There was no waiting list for people who really needed to be seen.

For others, it could be three or six weeks or whatever — fine, if this changes, come back. Again, it is thinking of it as a system of care, not just my few minutes with a patient. It is about how that fits with the rest of the system and what is happening in the community on the public health and prevention side.

Senator Merchant: We have been told that it is not that the system needs more money necessarily, but it is how we manage our services. I think that should be kept in mind because we can throw a lot of money at things, but it does not necessarily produce the results that we want.

Dr. Birtwhistle: I want to give a personal reflection because I am a practising family doctor. I practise in a health care team that has nurse practitioners, nurses, a pharmacist, a social worker and a dietician. This team makes my life a lot easier. There is no question that I think we provide better care. Taking smoking as an example, I can talk about smoking to patients as they come in, and I do frequently, but our team has actually organized a program in which there is support, phone calls and medication if people need it. This team is highly functioning in terms of cross-over with public health and others, and models of care in primary care are crucial in terms of how you put this together. The evidence for this very expensive team is not there yet because this has just started across the country. However, I think it important to encourage thinking about this as a future model of care.

Mr. Manion: I agree. It is not a matter of just pouring more money into things. It is understanding how we are using the money. The family health teams are an amazing model. There is some good research coming out of that now. Do we know the various skill sets that we need within that team across jurisdictions? Do we have enough of those skill sets? Are we training enough social workers and psychiatrists and psychologists to be able to meet the needs in different jurisdictions? We do not have that national health human resource plan to tell us whether we are creating the right kinds of skill sets to equip those teams to look at the health needs holistically of the people across different communities.

Ms. Lynkowski: Briefly, beyond the health care team, the success that is happening with regard to addressing the social determinants of health and health inequities happens at the community level. There are some communities that have exemplary programs with regard to this. I believe it is because there are relationships there that go beyond a systems approach. They really look at the level of education of a person and income, and communities come together to actually address some of those root causes of the problem well up front as opposed to dealing with it after the effect.

Senator Seidman: I would like to explore further the child and youth mental health issues. You may know that Dr. Robert Boulay, President of the College of Family Physicians of Canada, testified before this committee just two weeks ago. During that meeting, I asked Dr. Boulay a question about the collaborative position paper that was written by the College of Family Physicians of Canada and the Canadian Psychiatric Association in 2010. In that paper, a vision was presented for the partnership between primary care and mental health providers, including the integration of mental health services in primary care settings. Specifically, I wanted to know the extent to which mental health services could be integrated into the primary care system and what barriers we would face. My particular interest was in child and youth mental health. I asked witnesses to address this focus. You can understand, then, why I was rather taken aback when Dr. Boulay candidly responded to my question with these words:

Child and youth mental health services in Canada are bordering on a national embarrassment. We need to push forward in that realm.

This statement was frank, and it was very poignant. I am hoping that you, with your expertise, can help us understand the barriers that we face and explain how a future health accord could work to address some of these challenges.

Mr. Manion: Thank you for your question. I think you have put it quite well in terms of an embarrassment. There are a number of barriers. One of the barriers we face too often is that the Canadian population does not believe that children and youth can suffer from a mental illness. They do not think it is a reality. They do not understand that the majority of those who will have lifelong mental illnesses actually experience them during childhood and adolescence.

The other issue we have talking about children and youth is that it is not just one sector. We cannot just talk about health and primary care. We cannot look at those needs without talking about education and child welfare and youth justice and recreation. Unfortunately, each one of those sectors has a different language, different culture, different barriers and different policies that guide them. All of those differences create barriers to integration, to holistic care and to preventive efforts. We need to develop a common language and a national understanding of how relevant mental health is to our children and youth and how we have an opportunity to actually do some significant prevention during primary school, high school and key transition periods. We need to start to understand that and train that across all disciplines, for anyone that works with a child, thinking about police officers and dentists and teachers. They all have a role to play. That is when we will have the right kind of impact and a better appreciation of a system of care that looks at things in a holistic manner.

Dr. Butler-Jones: It was a previous Senate committee and review that gave rise to the mental health commission looking at a number of these issues. I think that is really important.

To reiterate on the issue of the integration, our mind is not separate from our body, nor is it separate from our culture. We need to have an integrated view so that we are thinking about mental health issues along with physical health issues in other areas.

One area is children, and we just assume kids will be fine. Another area is people with chronic disease or chronic pain and the mental health implications of that. We tend to focus on the physical ailment and not even acknowledge sometimes the mental components of it. There is huge opportunity as professionals and as communities to come together in a different way, which I think will benefit everyone at the end of the day.

Ms. Cohen: In terms of early identification of problems for children and youth, as Dr. Manion said, it is not just through primary care. We need to have resources in schools and in the communities in which they live where those kinds of problems are likely to be most early identified. The challenges are infrastructure in terms of how health care is delivered. The bulk of providers of specialized mental health care are social workers and psychologists, and those services are not funded. If we have an infrastructure that is funded fee for service, it makes it more difficult to access that care in a timely way, in addition to the stigma.

Senator Seidman: You are getting at some interesting issues. If we specifically look at improving access to services, for example, and wait times and improving the knowledge and training of health care workers — and I think you were already starting to touch on that — as well as the other settings and professionals who can deliver the kind of programs that you might be talking about, do you have something specific to offer in those areas?

Mr. Manion: A significant amount of work has been done on access and wait times in general health procedures. Increasingly, we are looking at how that has to be applied now to the mental health questions. Unfortunately, when a population does not understand mental health or mental health care, often they will go to the most specialized provider as quickly as possible, creating bottlenecks in the system. We do not have a lot of pediatric child and youth psychiatrists in Canada, but not everyone with a mental health concern should be going to see a psychiatrist necessarily. That is for a certain kind of problem. There are community-based providers, psychologists and social workers that have tremendous skill sets that can meets the need across the continuum and decrease some of the bottlenecks that are created in our system, but there must be a mutual understanding and respect for the various roles in that system that I think we are lacking, for all the reasons that have been mentioned, including the lack of cross- training. We do not train our professionals to understand other professions. We train our professionals to work in silos, and then magically we expect them to work as teams when they get out. That has to change.

Senator Martin: I have so many questions. I will try to focus to the 2004 health accord. In terms of mental health and the growing need and concerns that we have as Canadians, would you say that the 2004 health accord made a difference in how we have done? Although we say we are not doing a good job, did it assist in ensuring that we do a better job with mental health? If not, what should we be looking at in the next accord? I am asking specifically about the language of the text that needs to be there so that we can focus. I think this is an area that we must focus on. We all agree around this table. My first question is with regard to the 2004 health accord and what it did or did not do and what we need to ensure we have in the next one.

Mr. Manion: When you talk about the 2004 accord in terms of explicit mention of mental health in the accord, it was incredibly limited. It was subsumed in small pieces under other things, which did not give it the chance to be highlighted for some cohesive and focused action.

As has been mentioned, other Senate committees have looked at the issue of mental health, such as the Out of the Shadows at Last report that spawned the Mental Health Commission of Canada, which I think has gone a long way to changing the dialogue nationally. They were awaiting recommendations and a plan from the commission, but the 2014 accord cannot wait. We must acknowledge that this is something that has to be part of conversations now.

I will be honest with you in that I was a little disappointed when I looked at all the different themes and testimony of how we are trying to get mental health in the back door as opposed to being the primary focus. Leadership goes a long way in this respect. If it is an add-on, it will always be the poor cousin, and it must be a focus.

Ms. Cohen: One of things that has happened since 2004, whether a direct result of the accord or not, is the Primary Health Care Transition Fund that was funded by Health Canada. There were two aspects. One was enhancing interdisciplinary care in general across health care providers, and the other one was the Canadian Collaborative Mental Health Initiative, which looked specifically at collaborative care in mental health.

There has been a lot more discussion and recognition about the importance of collaborative care in terms of providing accountable and effective service. As Dr. David Butler-Jones mentioned, there is a lot more recognition that working collaboratively makes people's jobs easier rather than harder because there is a team upon whose expertise you can rely. Where we have stopped a bit is at the barriers. We know how to do it better, but there are further infrastructure barriers in the way of doing so.

Dr. Butler-Jones: I would not attribute it to the accord, but I think with the Mental Health Commission, with the investments in research and the kinds of conversations taking place, there is a greater visibility now. At the time the accord was written, it did not have the same kind of visibility. Maybe the fact that it did not have that visibility contributed to having new kinds of important conversations moving forward.

Senator Martin: My question is about these barriers. How do we begin to dismantle or attack them? Can the accord facilitate that?

Dr. David Butler-Jones and Dr. Birtwhistle, you described this integrated or comprehensive centre to provide the kind of health care services that we need and that it should be a trans-disciplinary system. We know that it exists in different places. We know it is the way we must go. I, for one, had to be the quarterback to help navigate my father through the system with many specialists. Not understanding the system myself, I have seen firsthand the importance of doing this for patients who use the medical system. How do we transition towards that? Can the accord in some way facilitate that? We know what we need to do.

Dr. Butler-Jones: I think that is a fair question, and you will provide your advice as to how it could be done through the accord, per se. I think it is essential.

One of the challenges is that we have structural problems. For example, I was responsible for setting up primary care reform in Saskatchewan when I was there a number of years ago. One of the biggest barriers was not finding physicians and others who were interested in working in teams and using a different model of payment, et cetera. There was a rule in Saskatchewan that if you wanted to do that as a new graduate or coming into the province, you first had to build up a fee-for-service practice and then convert it to the new model of payment. That is a very fundamental structural barrier.

We have systems where the incentives are identifying the one issue for today because I only have time for one issue. How does the patient know what that one issue is of the 4 or 5 present? You have to do as Dr. Birtwhistle and his colleagues do, actually work through and then figure it out. You may have to come back and deal with them later, but how does the patient know that? If you just have a regular prescription, why would a patient have to come in for an appointment, take time off work and try to find a parking space just for a renewal of a prescription when their blood pressure is well-controlled and they are managing it at home?

Again, these are structural problems that we have created by the systems we have created, and those are just a few examples.

This is a chance to step back. In the conversations around the accord, independent of what the future looks like in terms of accords or not, there is a real appetite for the conversations and the planning around how we can address these things more effectively.

Senator Martin: It would be great to see what the structural barriers are and if we could dismantle 40 per cent or else. I know that is not possible, but try to attack those barriers. It would be great to get a list of those key structural barriers from you, Dr. Butler-Jones, for consideration in our report. I am sure we have a running list as it is, but are there specific ones?

Dr. Butler-Jones: Another running list or something in addition. For example, the College of Family Physicians, the Canadian Nurses Association and others have focused on the challenges in primary care and the way forward. It is really about what we need to do now as opposed to what some of the problems were in the past. What kind of system do we think would serve us well into the future?

When the Hall commission was established in the 1960s, they went around the world and looked at what the best match and the best system would be for us, and then we could look at how to get there. If there were barriers to getting there, they looked at how to identify them. I am not sure we have had that kind of conversation, but there is a huge appetite for it today.

Dr. Birtwhistle: To put one of the barriers on the table, and hopefully it has been improving, it is a political barrier in terms of a physician giving up turf. This is an issue that physicians have had difficulty with over the years. It is changing, but it is still there.

Senator Dyck: I want to return to the topic of suicide amongst youth. The statistics you provided to the committee are quite shocking. I knew that the rates were high within the Aboriginal population, particularly up North in Nunavut, and other groups are also at risk. Given that the Aboriginal population is relatively young — half of the population is under the age of 25 — and because it is growing rapidly, they are particularly at risk.

With regard to the Canadian Task Force on Preventive Health Care and the model that you presented, Dr. Birtwhistle, how would various groups interact in terms of designing preventive structures? Is there a mechanism whereby people from the school, parents or organizations that youth might be involved with after school, can have input? It seems to me that, relatively speaking, a young person probably does not see their family doctor very often, I would guess maybe once or twice a year, unless there are other health problems. With something like suicide, because often those thoughts are kept to the person themselves, they may not interact with the family doctor.

Within a model of health care, how do we reach people like that? Is that covered by the kind of structures that we have in order to cast as wide a net as possible in order to pick up those first signals? Those signals may not come through the typical medical care system.

Dr. Birtwhistle: I think you have expressed the point very well. I do not necessarily think that the primary health care or medical care system is the way we will move this forward. I think it can be part of the solution once things are identified but often, you are right, young and healthy individuals do not see their doctors often or even visit the health team often. I think it is in other places that the antenna must be put up in terms of trying to move this forward with regard o the identification.

Mr. Manion: I think we have to be careful. Often when people are beginning to have mental health concerns, it shows as physical symptoms. We have done research where we have asked young people about risk and suicide, and roughly a third of them who had suicidal thoughts told us they never told anyone before. Half of the young men told us they have never told anyone before, yet they just told us. Therefore, sometimes asking the question explicitly should be part of the examination.

If a young person is presenting with some physical symptoms because of a problem with anxiety or is self-medicating through using substances, that is the opportunity to find out how that young person copes with things, including going as far as thinking of ending his or her life. If that is the case, what steps has that person they already taken?

We also know that in many communities there has been a huge impact on suicide by never discussing suicide, focusing instead on wellness. Some of the isolated communities we have worked were having suicides every month with people as young as age 10, which, on a monthly basis, is a huge proportion of the population. Going in, working with the natural caregivers and having the community own the prevention and wellness efforts has resulted in no suicides over the last three years.

There are different ways of getting at this question. Part of it is through primary care, part is asking the hard questions at times, even with the family, and that is where parenting comes in, but part is also looking at the holistic approach we have all been talking about today.

Dr. Butler-Jones: I have a story to reinforce the point of asking the questions, actually listening and the importance of that contact. I was working in the tropical disease clinic and a patient came in, a recent immigrant from the Philippines, who had problems. They assumed it must be a tropical disease; they had had myriad tests, multiple specialities, et cetera. I listened to her for a while and we chatted. Basically, she was being abused in the family, and it was a physical manifestation of abuse in that case. Taking the time and having the time to listen is essential, whether it is a physician, nurse, social worker or psychologist.

The other point is to reinforce the issue of the role in communities and having alternatives for kids. One of the worst things we did in the 1990s to save money in the education system was cut back on after-school programs, bands, orchestras, art and all the things that kept some of us in school. The irony is when you have daily physical activity, orchestras and so forth, kids actually do better in their academic subjects, but those were the first things we cut. That is a simple, practical way, along with having adult mentors such as good teachers, Scout leaders and so forth. It is a huge impact in terms of that positive avoidance of the alternative.

Mr. Manion: We have data that shows that when young people are meaningfully engaged in things like after-school and community activities, they are physically healthier, engage in less risk-taking behaviour, are less likely to become depressed and are less likely to become suicidal.

Dr. Butler-Jones: One good example is the Ranger program in the North. I do not know whether you are familiar with it, but it is one alternative.

Senator Dyck: You are describing the kind of mental health or well-being aspects of having after-school activities. Has anyone ever done a study that shows the economic benefit in terms of maintaining a healthy community with those kinds of supports? Many times, unfortunately, it seems to fall down to how many dollars we will save if we bring these programs back by making people healthier. People would rather cut the programs out to save money instead of investing in well-being. Has there been that kind of study?

Mr. Manion: There have been some studies. Some of the work of a giant in child and youth mental health, Dr. Dan Offord, was about looking at community response, the determinants of health, the role of recreation in terms of improving health and mental health outcomes. Sadly, sometimes for financial reasons, when we try to replicate this work, we cut the guts out of these programs so that they are no longer effective. We are not implementing them with fidelity. I think that we are lacking information in terms of mental health economics. That is an area of research that we should be connected to. There are very few, I think, talented researchers that look at mental health economics, especially from a child and youth perspective, and that is an area in which we can have some increased capacity.

Dr. Butler-Jones: Ministers of sport and recreation, ministers of health and ministers of education are working together and focusing on the after-school period for a whole range of reasons. One is adult mentorship. Another reason is when you think of adolescent or youth crime, most of it occurs in that after-school period. It goes on and on. The evidence is clear that small investments in this area — they do not need to be large — have a tremendous impact not just in terms of day-to-day issues but also with respect to those kids' future, their sense of purpose, mentoring and desire to become something.

Ms. Cohen: It is certainly true we know more about what is clinically effective than cost effective. When it comes to programs and issues that have an impact on mental health, the impact is over a great period of time and across sectors. Therefore, you may invest in schools and see the outcome years later in the workplace. That is a challenge because the value of that program is not immediately obvious as it is with cardiac surgery for someone who has a heart problem.

Senator Braley: Many of my questions have been dealt with by Senator Dyck. She did an excellent job.

We have to keep people healthy from birth through the teenage years through adulthood and into older age. My children are in their 40s, and my grandchildren are youngsters, from age 6 months to 22.

I see the education system has not been adjusted so that things like eating good food and ensuring you have exercise all occur as part of the curriculum. I can teach mathematics or history, but there is also just living. I do not know the facts that are needed, and I am sure my children do not know the facts for the grandchildren. There must be a correlation of education and health at the provincial level, but to what extent? Do we tackle that by starting to educate the children as they enter the school system? The parents may not have had the opportunity to do it properly. Then we have to have the social system tie into it so that when a person shows a physical problem, it is immediately identified and can be partially or fully dealt with. I do not know if I have tackled the thing right, but we have to look at how we keep healthy and then reduce the health costs in a major way.

Mr. Manion: There is more work being done in school health than ever before. For example, the Canadian Association for School Health, or CASH, is looking at the best knowledge available to answer the questions you have raised.

With respect to mental health, a national project is looking everywhere in the world at the best programs that are school-based that can help us in terms of the mental health literacy not just of students but also of staff so that we can answer some of those questions.

One of the problems is it cannot be on the backs of teachers. Teachers are very busy already. They have a skill set that can be enhanced around identification. However, it will be through partnerships across sectors, for example, education working with service providers in health, mental health, child welfare and youth justice to understand the holistic needs of their students. The school can be a place where much of this can happen, but we must think about whose role is to do what piece. Part of it will be in the curriculum and part of it will be having the right skill sets within the school system. However, a greater part will be breaking down some of the silos between education and the other sectors, so it can be a community response, maybe based in the school, but using the best tools from all the different players at the community level.

Dr. Butler-Jones: I would certainly agree with that. CASH is one forum nationally. There are other fora. As I said, ministers and deputy ministers across the sectors are starting to recognize the importance of getting there and thinking coherently about how we approach it. We often say we should do it in school while realizing the tremendous competition and pressures, but we can assist that, whether it is a public health nurse or whatever to help facilitate that. There are different ways to encourage that.

At the same time, it is not to take away from the parents' responsibility. It is not a substitute for it; it has to be complementary to that, and there is also the issue of supporting parents and communities to support kids.

As for the tools and resources, for example, the options in the cafeteria, there is a lot of good evidence that if you put the salad bar before the checkout, people pick up salads. If the better foods are well lit and the chips and gravy are stuck in a corner, people pick the brighter foods. There are many simple things, ironically, that can encourage that.

Mexico has banned pop from all its schools. Hydration is an issue in Mexico and many schools did not have clean water. First, they made sure every school had clean water, and then they removed the soda pop. Is that the answer? It depends on the community, and each school board is so different. However, to the extent we can help cross- jurisdictions identify the best practices and find easy ways to implement them, we are more likely to be successful. It is complementary, however, and it is important that we support parents as well as the kids in school.

Ms. Lynkowski: The other thing is that for decades we have talked about literacy and promoting it, but it is only in the past little while that we have talked about the concept of health literacy for young people and adults. As we have growing expectations on all of us to take more responsibility in managing our own health and our care for our health, you do need strategies and tools to make that happen. There are several recent excellent reports in regard to how to do that at a community and a national level.

Senator Braley: Is it being done? How do we educate the parents? Is it only when they have a baby and they are going for their first baby training? It has to be a whole thing right across the system, like let us reduce smoking or eliminate it. It cannot be done any other way.

Dr. Butler-Jones: I totally agree. It is not just education or advertising, per se. For example, when you go through the grocery store, there should be clearer labelling so you know what is in the product; and you need to have health literacy so you know what actually matters. What we do in terms of school policies does make a difference. For example, what do you sell for the fundraiser at the school?

There are a number of things. It is not just when parents are first considering it. There are other supports throughout life that they can access, particularly as people become more net savvy. There is the downside because there is a lot of junk on the net, but there is also a lot of good information; people need to understand where to find the good and valid information.

Senator Braley: It is the one place where you have their attention because people want a better way of life for their children. You have their attention and you can combine a number of those things, so it is sort of a break point.

Mr. Manion: I am glad you are talking about the parenting issue. That is why it is one of our recommendations in terms of universal parenting. Sadly, a lot of parents only get parenting classes before they become a parent. Even then, we can argue whether the right parents are going for those classes. Where are the incentives to do that?

We also know that the parenting role changes over time. If you treat your 16-year-old like a 4-year-old, you will be in big trouble. Parents are clamouring for easy answers and guidebooks to how to raise their increasingly young adults with various issues.

There is also a knowledge base. We know more about parenting than any other intervention in the world. We have great evidence in terms of what works; we just do not use it. We do not have incentives to encourage parents to use the information. We do not have systems that make it accessible to the general public at all stages of development.

Part of it is finding effective ways of engaging families. The solution to that is to ask families how to engage families, not to sit back and try to guess how they want to be engaged. Not every family will be engaged in the same way because not all families are the same. We need to have a multi-pronged approach.

Then it has to be accessible and meaningful to them in terms of the kinds of information we are giving them so they can see it has an impact on their family situation. Then they can feel more competent and attached to their child, no matter what age they are, and continue their parenting role without being intrusive either.

[Translation]

Senator Verner: I am still a little stunned to see that, in 2011, we have to teach parents how to be parents. This is nonsensical to me.

My colleagues' questions are very interesting and so are the answers. I would like to address a different aspect with respect to the sharing of information between provinces, the territories and the government in crisis situations like H1N1 and SARS, which happened in 2003.

The analysts have told me that memoranda of understanding were concluded between the provinces, the territories and the federal government to make it easier to share information and to clarify the role and responsibilities of each level of government in public health emergencies. I am told that, in December 2010, the committee made recommendations that would make the sharing of information mandatory and the memoranda of understanding enforceable.

Does the agency still intend to make this issue a priority? Will steps be taken in the near future to make information sharing mandatory?

Dr. Butler-Jones: Access to information is very important. Our agreement with the provinces and territories is in place to receive information in public health emergencies and crisis situations. Cooperation is very important and so is respecting the entity that has jurisdiction in the provinces and territories. That is our arrangement. We have good cooperation with all the jurisdictions when it comes to access to public health information. During the pandemic, it was shown that cooperation was essential, and everyone cooperated.

Senator Verner: I simply wanted to mention a recommendation made by this committee last December.

Dr. Butler-Jones: We now have a formal approach with a jurisdiction in Ontario and we are working with the others for a formal agreement, in addition to a memorandum of understanding.

[English]

Senator Champagne: Dr. Butler-Jones, you were such a big part of that report that we made last fall.

Listening to all of you ladies and gentlemen today, I am alarmed. Dr. Birtwhistle, you were talking about how physicians of different disciplines work together; and Dr. Butler-Jones, you mentioned the fact that ministers of health and ministers of education sometimes do work together. What is alarming me is the fact that in most of our schools, we will have a nurse that can look after a scrape or a sprained ankle or wrist, but those who are supposed to be counsellors are not necessarily psychologists.

Are they really trained to recognize the seriousness of some of the problems that may arise from abuse, from bullying, from discovering a different sexual orientation? Maybe having someone trained to recognize the symptoms of the problems before it is too late would be something very important that we might recommend to our ministers so that they could get together and find a solution to that?

Mr. Manion: Currently in the province of Ontario, the ministries of education, health, child and youth services, and colleges and universities are looking at joint efforts so that in schools, teachers have screening tools that they are trained in; but that they are also being trained at the same time as community partners, who are service providers and health providers as well. They have a common language and understanding about how to use the tool.

Then once they identify someone at risk, they realize the limits of their role, and how they now have to partner with the other person from the community to hand off for their next part to be done. That person, whether it is a physician, a psychologist or a social worker, can work effectively with the family and the school and hand back. The goal is to have people reintegrated and be functioning within their systems in their communities.

There are good examples where that is currently happening. What we found in some of the work we are doing across the country is that it is very scattered. There are some school boards that have nailed this. They know exactly how to do this; they have wonderful partnerships, sometimes developed out of need.

Sometimes the poorest of communities have got this right because they have had no choice but to partner together and do it effectively. It is too much happenstance. It is not a cohesive approach to things across the country. You might be in a community where a school has it right or another community where they completely have it wrong and where the person who has the most responsibility for identification intervention at that early period is the least skilled person to do it. Some of the efforts that are required across the country relate to how we gather the best learnings from those who are doing it right and how we facilitate uptake and implementation of those same strategies right across the board with some clear markers for what we can track as success across the systems — not one system but the "systems" involved.

Senator Champagne: All over Canada we have read and heard about this young man in the Ottawa area. We are not talking about some place far away, lost in the great North, where no one could realize in time what this young plan was going through. It happens in our cities and in our small municipalities. It happens all over. There must be a way for all those people to get together and make sure that this does not happen again.

Mr. Manion: That is a good example of how complex the issues are because I know the situation quite well; I have been involved. I think that we have read in the media about the role of bullying. There was a piece related to bullying. We have heard the issue of sexual orientation; there was a piece of that. What we have heard less, however, is that this young man was suffering from depression and struggling with depression and was receiving some support. There are lots of players that could potentially be involved in this.

We talk about recreation. Sometimes the greatest bullying of individuals happens in recreation centres. This young man was a figure skater. We have some people that have experience with hockey players and the mindsets and the cultures that are developed and how tolerant and accepting we are of differences. There are a lot of different issues here and there is no simple answer to it. Some of that education and helping people become more accepting of differences, to be more aware of different ways of coping; can happen in schools and in families.

There was another tragic loss in our community where a young woman died by suicide. Her father was an assistant coach for one of the national hockey teams. He was quite frank and open about how in his house they talked about everything. They talked about sex, drugs and school. They never talked about mental health. They never talked about suicide. There are places beyond schools where these dialogues can take place. Increasingly, people are standing up and saying we have to do it better, but it is complex. We have to appreciate that the solutions will also be just as complex.

Senator Champagne: Let us hope that our people who make decisions will find a way to get together and help us avoid such sad stories.

Mr. Manion: That is where you have an opportunity to ensure that we have it incorporated in the accord as a frank target for action and not just a side conversation.

The Chair: Final comment, Dr. Butler-Jones?

Dr. Butler-Jones: I would like to just say how important this is. At the one level, there are many solutions and complexities to it. The reality is that sometimes there will be nothing we can do. Someone may be standing on the side of the subway tracks, in an adolescent hormonal whatever, wondering what it would feel like to jump in front of the train. They can act on it or not act on it. They are much less likely to act on it if they think, "Well, what would happen in terms of my family and friends and their view of what I have done? I have something to live for. I want to be a doctor." If no one cares, they might think, "Why do I bother? Life is the pits."

Senator Champagne: Or, "I have inoperable cancer."

Dr. Butler-Jones: Our job is to continue to make the healthiest and the easier choices, to create environments that are supportive to good health and good choices, respect that people will make choices different that ourselves but that we can create environments that will increase the likelihood that those choices will be positive and that, at the end of the day, we all benefit from that.

At the same time, sometimes we will do something really stupid and we will agonize about that. Maybe there was nothing to do about that, but this is an area where we can significantly reduce the numbers, the impact and the consequences in a range of areas. That is why I think this panel is focusing on the upstream, the factors — not just the individual choices but the context in which those choices are made that will allow for a healthier society, the end point being a better economy, better management and an ability to deal with those times when we do get sick in spite of everything and we need appropriate treatment.

Senator Demers: Thank you for being here this morning. I learned a heck of a lot more than I did when I first got to this room today.

With regard to Mr. Manion talking about the hockey player who, unfortunately, lost a child, they were both very good parents, too.

I certainly will never blame teachers because I do not want to lose the friendship of my good friend Senator Martin, a good teacher. In the past few months, I have gone to five different schools across Canada talking about literacy — something that I struggled with when I was younger and, fortunately, overcame it. How do we start? We have to start from the bottom. All the questions were great today from both sides. How do we start when, first, kids go to school without breakfast? How do we start when 57 per cent — statistics are different everywhere — of parents are divorced, where some kids do not know where their father is and other kids live with their mother but she never comes home until two o'clock in the morning? That is not just 1 out of 20; it can be almost 50 per cent in some cases.

When I go into a school, I usually talk to principals and teachers. We have teachers right now that are getting beaten up after school or during class.

We then talk about mental health. We do not have enough people like you, which is the problem, because you are very competent. Where do we start all this?

When I speak to students, I always try to talk to two kids: one young girl and one young boy, 14 or 16. I remember a young girl who said, "I have no hope." It happened to be the case that she was a beautiful young lady. I said, "What do you mean?" She said, "Coach, I was listening to what you were saying. I have no hope. I live with my grandmother. My grandmother is X number of years old. She hardly knows what is going on in the house." For a 14-year-old not to have any hope, where do we start from a mental health perspective? We talked about smoking in the house; I never smoked. It is a worse problem than that in our society. I do not know where we start. Your help, or whatever you might say, would add to what I am trying to learn today.

Mr. Manion: Senator Demers, you are actually talking about the determinants of health. You are saying it in a passionate way, but you are speaking to the determinants of health.

It is sad that this generation of young people will probably have less earning power than their parents. The sense of hopelessness and commitment to a future and to a nation is not necessarily there.

You talked about the importance of parenting. We have to be careful, too, because some single parents are doing a magnificent job in raising their children — strong, capable and resilient. There are a lot of circumstances of a lot of intact families that are struggling with their parenting as well. We have to be careful in how we discuss that.

Clearly, there are areas of support well before young kids ever get to school in terms of what we are doing in preschool to prepare them. How are we allowing young kids to experience challenges so they can become more resilient in the face of those challenges?

We talked about determinants of health and Dr. Butler-Jones talked about countries that have healthy economies have healthy people in them because they have a sense of being able to work and a sense of purpose and a sense of self- esteem that allows them to feel well physically and mentally. That trickles down to their kids and their families. There are a lot of things that we can do from an early age, but it goes back it determinants of health.

When we talk about education, it is not formal education. Sometimes it is how we interact as human beings and how parents interact with their children and how that is transmitted to other relationships, including relationships between students and teachers and respectful relationships between students and teachers.

One of the best predictors of a healthy mental health outcome is having one significant person in your life that you feel a secure attachment to. It does not have to be a parent. It can be a mentor or a coach or a number of different things but that one single person. Where are we creating those opportunities for that one person to engage with that young person, whether they are 2 or 22?

Dr. Butler-Jones: I have two quick stories and then a specific reply to what you are asking. There are a number of reasons I got into public health, but here is one example.

A young single mom attempted suicide. I worked with her for six weeks in the mental ward of the hospital, to the point where she was able to go home. It was easy to realize why she did it. She was unemployed and had no family or friends who really cared about her. She was trying to raise these kids; she was in a terrible situation. She had every right to be depressed. I can help her to not be suicidal, but she is in an impossible situation. The only way to address that is by creating environments and by giving her significant people in her life. All of us have mentors, throughout our life, who have made that difference.

I worked with a child psychiatrist who was very wise. He said, "It is not about your parenting style or technique; most of the kids who are truly loved will turn out okay. It is the kids who are not that you really have to worry about."

If I have not mentioned this before, one of the best things we did for health in Saskatchewan in the 1990s was to provide dental and pharmacy benefits to low income families. You could come off welfare and not lose these benefits for your kids. Suddenly, there were thousands of people working. When we studied them, we found out that they were healthier, happier, contributing and feeling like they were contributing. The funny thing is that they were actually making more appropriate use of the system. This was more than a decade ago. Has any other jurisdiction in Canada done that? No, in spite of the evidence. This is not a health policy, but a social policy that contributes directly to health.

Specifically related to your question, Senator Demers, I would say start somewhere. You are looking at the big picture as a Senate committee. You are looking at the broad systemic issues. However, at the end of the day, it is about being practical. Do something. For example recognizing that kids came to school hungry, parent groups in a small health unit said that they would bake muffins and do a voluntary program. The health unit came along and said that they needed three sinks and this and that. The fire marshal said, "You cannot do this and that," et cetera. We had all of the groups sit down and ask how this could be made easy, so that when parents and teachers wanted to do this they did not run out of energy trying to navigate the various bureaucracies. Again, we create these barriers for good reasons, but they are totally inappropriate to, and a disincentive to, a community's ability to organization and address the issue.

I think doing something is important. As levels of government and professionals, part of our job is to make it easier for people to do the right thing.

Senator Eggleton: This has been a terrific panel and meeting.

Dr. Birtwhistle, you have described what your task force on preventive health care does, how it does it and who is involved with it. Does your task force have any recommendations with respect to the next health accord and things that, from your studies, you think should be in it?

The only other general question I have, and it does not have to be answered at this time, involves best practices, which were mentioned a couple of times. In particular, Dr. Manion mentioned that some schools have it right, while some do not. Do you have any information about where we can find best practices, either domestic or international? That is always good information for us to have because we can look at those further.

Dr. Birtwhistle: From a task force perspective, I think that we want to use our resources in the best possible place. If there are preventive activities going on out there that are not very effective, which I know there are, we should be labelling that and stopping the behaviour, and then using that money for many other things, including mental health, which I think has been highlighted here and is extremely important.

Senator Eggleton: Maybe you could put something in writing to us because you did say you had some recommendations. It would be good to see what some of them were.

Dr. Birtwhistle: I will summarize this aspect at the end.

Senator Merchant: I am not sure if there is a quick answer to this, but I was thinking that the Canada Health Act pertains to services delivered by physicians and in hospitals. We are now moving to a completely different model. We are moving the services to these integrated units. Does that present some difficulty in setting up these units? Do you have trouble dealing with the provinces or with the federal government about your funding models? How do you pay for some of these people who are not in those categories?

Dr. Butler-Jones: It is a mix. First, public health is local. It is essential that you have capacity locally, and then we can complement that provincially and nationally, do value-added, et cetera.

To come back to Senator Eggleton's question, our key activities include partly sponsoring this to fill a gap in terms of clinical guidance, and gathering best practices around the world and what I have in my reports, et cetera, through the best practices portal and the chronic disease portal on the website.

The provinces have primary responsibility. Public health is kind of shared. The Canada Health Act and the CHT were originally set up for the insurance system and have been modified a bit since the 1960s. We also have transfers to the provinces and to community groups. About one third of our budget is grants and contributions, for instance. There are different ways that we do it. Going forward, I think there is an appetite for a different kind of conversation. Part of what I am hearing — and I will not presume anyone's view — is that people want a different kind of conversation, not just to do with fiscal transfers, but with how we collectively can actually make this system work better. You then decide who and how and everything else that follows.

Senator Merchant: When people hear that, they start to worry about user fees. You open a different kind of spectrum there.

The Chair: If you could forbear, I will go to Senator Martin to get her question on the record.

Senator Martin: As an educator for 21 years in the B.C. school system, I have seen that there is one school psychologist for the district, sometimes two, and that it takes a year before a child that I refer is even tested. That is the reality.

When education and health overlap, like in the school system, and there is money that gets targeted for action for mental health, or for whatever other health services, within the school system, how do we ensure that that money is spent in that way? How is that accountability built in? I agree that we need to target funds for specific action on mental health and to ensure that schools have the kinds of health practitioners that can address the kinds of needs there face to face.

How do we follow that money? Can we ensure that the money that is targeted is actually spent in that way by the districts? I am not sure how that works at the provincial level when health and education overlap. What can be in this accord? Has it been in the accord in the past but not been fully accountable? I feel that accountability has come up again and again. How do we follow that money to ensure that the money that is targeted goes where it needs to go?

The Chair: I will go to Dr. Cohen, and then, if others of you have input, you can follow up after the meeting.

Senator Martin: They do their best, let me assure you. I have great respect for them, but a one-year wait, minimum, was the reality.

Ms. Cohen: I think you highlight what is really a critical problem. It has been identified to us in many ways. One of the promising things you hear family health teams doing is responding to community needs and staffing accordingly. If a school is in a community where certain needs are identified and where there is a certain incidence or prevalence of kids with learning problems or with other types of behavioural or hearing problems or whatever it is, that information is used to determine staffing in schools.

I think the erosion of other support services is similar to the erosion of other after-school programming and social supports. We are not listening to what communities need and providing those services.

The Chair: As all my colleagues have indicated, today has been another remarkable session in our study. We deeply appreciate the expertise you represent, the knowledge base and your ability to articulate significant aspects of the issues that we are dealing with.

It better be obvious to us that we do not live in a perfect world, as a couple of you alluded to in responding to questions. However, we clearly need to identify areas where we can actually make success and move forward. I hope that on reflecting on today you will think about that perhaps in ways other than you have up to this point. If you could provide us with some thoughts in those areas of specific examples, it could make a big difference to help move through a number of these issues, because what we clearly heard today, and have heard in other sessions, is that our problem is the silo issue.

This occurs in several aspects of the delivery. It is in the different — if I can use the term — bureaucracies of society that need to work together to provide a solution. It is not just the school system and it is just not this or not just that. In many issues we have to have large parts of our society working together to bring about solution, but within individual sectors such as health care we are hearing the silo issue a great deal. Yet we are hearing today and in previous sessions about clear examples of how groups can work together.

Dr. Birtwhistle outlined a family practice unit with real success and we have seen a number of these examples in the popular press. What we do not seem to be seeing is the identification of situations that work in a particular area and then their promulgation across the system. To use a simpler example, discovery is of no value to society until it is implemented and becomes an innovation that is spread across some sector of society.

Is it possible that one of the issues the new accord should deal with is clearly identifying a way to take innovative practices that develop somewhere and find a way to apply them more broadly? Then as we dig down further into the individual areas — in this case I will stick with health care — I will come back to Dr. Birtwhistle.

In one of your slides you outlined the need for credible appropriate, easily accessible guidelines that will improve preventive care in Canada. We have some of those. If we take the anti-smoking campaign, for example, it has had a profound effect. A number of issues have gone into that, as you have outlined. We have heard at this table in the study that there are a number of areas that could have a profound impact on health, such as simply brushing your teeth, children and dental care, impacts at that level.

We have heard in the case of those with diabetes, which are not an insignificant portion of the population, the simple situation of clipping your toenails could avoid a later amputation. We have heard today here, in terms of health, about the school breakfast issue which a number of us have heard in other sectors. I mention these things and I am coming back now to one that crosses into different areas of social responsibility.

I would appeal to you to look at these after you leave here in order to see if you have some recommendations for us of specific examples that you think we could reflect on as we make recommendations forward.

The method-of-payment issue comes up kind of carefully in a lot of our meetings. It seems to me that that may be almost a catalyst in keeping silos as silos or, to put it differently, could be a powerful catalyst in moving away from silos if we could find ways of dealing with method of payment. The example of patients going to their family physician and being limited to one or two questions that day, that occurs widely and that is a payment issue we hear. Then there is the issue of how do groups of expertise come together in a situation like yours, Dr. Birtwhistle. Again, it is sometimes implied that method of payment is a barrier to developing those kinds of situations.

Finally, we have deliberately attempted to deal with the issue of mental health in this round, even though specific aspects of health are not our mandate as such. It is incorporated into the larger issue of preventive health and the development of health for Canadians.

In winding this up, if you could reflect on the questions that my colleagues have put to you today in these areas and try to identify the specific best practices, or even examples that you know have worked in given areas, to illustrate the kinds of recommendations you have made to us to move forward in the next accord, it would be extremely helpful to us.

Lastly, I would repeat that we would like you to bring to us, following this meeting, any issue that occurs to you that on reflection you think we should be aware of.

With that, I want to thank my colleagues and you very much for a remarkable session.

(The committee adjourned.)