Proceedings of the Subcommittee on Population Health
Issue 1 - Evidence, February 28, 2007
OTTAWA, Wednesday, February 28, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:12 p.m. to examine and report on the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chairman) in the chair.
[English]
The Chairman: Gentlemen, we deeply appreciate your coming here, particularly this week, before we break. The guidance and information that you will give us with your tremendous expertise will be enormously valuable to us as we continue working while the break is in progress.
I do not want to waste any of your valuable time. We will begin with Dr. Millar.
Dr. John Millar, Executive Director, Population Health Surveillance and Disease Control, Provincial Health Services Authority, British Columbia: Let me start by thanking you for this opportunity. It is wonderful that the Senate is undertaking this initiative. I am exceptionally pleased to be able to participate today.
I will start by showing you some population health data that we have run recently. I am from British Columbia. As you may know, I am the Executive Director for Population Health Surveillance and Disease Control in British Columbia with the Provincial Health Services Authority.
The Chairman: Dr. Millar, allow me to interrupt you for just a second. I want the senators to know that Dr. Millar has a tremendous background in this area and was with the Canadian Institute of Health Information, or CIHI, as it was set up. He was one of the moving forces there. That will influence your questions probably as you go forth.
Please continue, Dr. Millar.
Dr. Millar: It was a welcomed intervention. These data were compiled by some of my statisticians and epidemiologists. The Premier of British Columbia has said that he wants B.C. to be the healthiest jurisdiction ever to hold the Olympics. We ran these data that show Canada and B.C. along with the leading developed countries in the world that have the best health status.
There are some worrying trends happening with Canada. On the slide where the cursor is, the blue line is the trajectory for life expectancy in Canada compared to other countries. You can see that a number of countries are improving faster than Canada. The relative ranking of Canada is slipping for men. In this projection, which are well-validated projections, by 2010 Canada will rank behind Switzerland, Australia, Sweden and Italy for men. Coincidentally, I will note that British Columbia, thought of as a jurisdiction compared to these, will lead the world. B.C. already leads Japan, which is an unusual finding.
This next slide shows even more worrying data, particularly for women's health. Here you see, with the blue line, the Canadian trajectory for life expectancy for women. You can see that Canadian women are sliding, and they are sliding behind many countries. These countries that have been selected have a population of at least 1 million people. By 2010, when the Olympics are held, Canada will have dropped in rankings and will be behind Switzerland, Japan, France, Italy, Australia, Spain and Sweden. These are worrying trends.
Why is this happening? To some extent, it is driven by cancer data and by heart disease. Of course, those in turn are driven by risk factors such as obesity, and you are well aware of what has been happening with increasing rates of obesity.
However, I want to make the point to you, and you will hear it from others, that these behavioural risk factors, in turn, are determined by the social conditions that we have in our society. Obesity, in many people's view, is driven by the obesogenic environment in which we live and is often considered a failure of the market-driven phenomenon of junk food and so forth. What is happening is reasonably well understood. The question is: What are we to do about it?
I also want to focus your deliberations on the health care system. There are some interesting and important implications of population health for the health care system. There are rising life expectancies. If you look here, you will see that women are living longer than men still, although improving less quickly for women in Canada. It is a good news story overall that health is improving. It also means we are living longer, and as Dr. Keon well knows from other studies, the fact that we are living longer means that there is an increased incidence of heart disease and an increased demand for cardiac surgery, for stents, for hips, for corneal transplants, for lens surgery, et cetera, as the population ages. However, as these behavioural risk factors increase — worse levels of physical activity and nutrition and worse obesity — the prevalence of diseases is increasing. Also, through effective health care around major disease entities such as cardiac disease and cancer, we are converting many diseases that formerly killed people to chronic conditions. These combined forces mean that we have a huge increase in the prevalence of chronic disease coming down upon us.
This image shows B.C.'s data regarding new cases of cancer projected forward to 2017. If you add prevalent cases of cancer to these, and if you add on to this the number of cancers that increase because of poor physical activity and poor nutrition, this curve becomes even steeper.
This projection for cancer is duplicated for many chronic conditions. We see exactly the same sort of thing for heart disease, diabetes, hypertension, depression and musculoskeletal diseases. All of the chronic conditions are increasing in this way, leading to a huge demand on health care services. The point is that there is a connection between population health and the sustainability of the health care system that we need to think about.
This slide is now a famous one that Carole Taylor, Minister of Finance in British Columbia, has been using for some time now to show that, as a percentage of the total budget in British Columbia, health care now is consuming about 42 per cent and, by 2017 at current rates of increase, is projected to reach 71 per cent, leaving only 27 percent for education and nothing for the other 18 ministries that occupy government in British Columbia. It has the attention of all of the ministers, deputy ministers and the premier in British Columbia, as to what they can do about this.
What can be done? We know a lot about what can be done. Population interventions around population health are the first thing we need to think about. The early detection and prevention of the progression of chronic disease is the second major thing. I will speak about both of those.
These projections have been done by the Ministry of Health in British Columbia. The black line shows the number of women every year having an acute myocardial infarction, and you can see that it is projected to go from 50,000 in 1971 — these are actual data up to about here — and then it continues to rise to 80,000 by 2016, if things continue without any change. Underneath that here, this shows how these curves can be turned downwards again if we implemented what we currently know on the best available evidence about what we can do about diet, smoking, exercise, reducing obesity and moderating alcohol. We know that these curves could be turned down so that we can begin to address the sustainability issue of the health care system.
Similarly, this slide for diabetes shows that if we reduce obesity, and so forth, we can turn the costs related to diabetes downwards. It makes the point that we know enough to begin reducing this huge burden of chronic disease that is coming down upon us.
I am advocating to you that we need, as I have already said, to take a population health approach to preventing these chronic conditions before they arise. That will require changing societal conditions so that the healthy lifestyle choices around tobacco, nutrition, physical activity, obesity, alcohol use, drug use, and so forth, become the easy choices. It will require reforms of the health care system as well to provide better chronic disease management and reduce adverse events in care, which I will come back to.
Here are the major messages that I want to leave with you, and most of these, one way or another, address the questions you provided as a guideline. The first is that the field of population health is hugely complex; it is not simple. There are many determinants and they all interact one with the other, and we do not totally understand all of these interactions.
The second point is the one that you need to be aware of, namely, that Canada, through its academic institutions, particularly the Canadian Institute for Advanced Research, has led the world in understanding the causal links between these determinants and the health and well-being of the population. We now know that there is causality here. For example, people living in poverty and the fact that they have ill health is a causal relationship, not just a statistical association. As a recent paper from Harvard said, social inequality kills. We know now that this is a causal relationship.
It also goes the other way, of course, that people with poor health often have limited ability to make a living, so they may drift down into low income as well. The predominant causal relationship in this country is between low income and poor health.
Having said that, the third point here is critical, and you will hear this repeatedly: Gradients are an important contribution that Canada has made to understanding these links between the social determinants and health. It is not just low income people who have the worst health; it is also that the middle income group has worse health compared to high income. Therefore, there is a gradient along income, education, the type of work people have, and so on. There are gradients by geography, for that matter. Canada has led the world in understanding, but Canada has been exceptionally slow in implementing this knowledge. Many countries have gone ahead, and I will mention those shortly.
Having said that, we do not know all there is to be said about the determinants, but we know how to provide a basis for action. These are the major areas for population health intervention that I will propose to you, and you will hear it from other witnesses as well.
The first and foremost one is doing something about family and child poverty in this country. We are way behind many countries. I believe we rank fifteenth in the world for poverty. It is astounding to me, as a public health professional, that we continue to accept that when we know it is creating poor health in this country. We also know what we can do about this through minimum wages, increasing income assistance, child benefits, universal child care, making more social housing available, et cetera. There are a great number of things we know we could do.
For example, we could make high quality early childhood development and education universally available and address issues around school health. We know that children are not getting physical activity or nutrition at schools.
With respect to workplace health, there is an abundance of evidence that we can reduce absenteeism, reduce turnover and increase productivity by addressing workplace health. It is poorly implemented in this country.
We can also look at housing and the built environment, how we construct housing, make social housing available and design communities to encourage physical activity, nutrition, a cleaner environment, increase security, reduce crime and injuries, et cetera.
The health care system itself is another point that I will return to shortly. I have made this point before. The risk behaviours are largely determined by marketing policies and societal conditions. We know enough to change these things to reduce smoking, improve physical activity, improve nutrition, reduce obesity, reduce drug and alcohol use, and so on.
Another point is around infrastructure. To move this agenda that I have outlined, we need better information systems and technology, data, analysis and information. We do need more research. I would like to point out to you a new initiative called the Population Health Intervention Research Initiative of Canada, which I urge you to support.
Turning to the health system, I want to urge upon you not to forget the health care system as a determinant of health. The health care system is a positive determinant; there is no question that it saves a lot of lives. However, you need to bear in mind that the health care system is causing a lots of preventable deaths. Estimated on the bases of Canadian data on this slide, there are 10,000 deaths per year in hospitals; another 18,000 through non-error related deaths in hospital related to infections and drugs, and probably another 20,000 in the community. These are Canadian figures. You add those up and you have 48,000 deaths per year. That would put the health care system as the second leading cause of death. That is preventable and it is because we do not focus adequately on quality. We have the Canadian Patient Safety Institute. They are doing a good job but not fast enough, in my view. This is a huge problem. Nobody has sorted out where is the benefit ratio with the health care system. We know it is saving a lot of lives but it is killing many people, too, and I want you to bear that in mind.
The other point to mention about the health care system is the theme I mentioned earlier around better chronic disease management. I know that is not your mandate in this committee but you need to be aware of the need for reform in primary health care where most chronic disease is treated. It is the combinations of cardiac, renal, diabetes, depression and various other conditions that are driving the system into the ground. We cannot adequately handle that with the system as it is.
I will close now by providing specific examples of where things are moving forward. Sweden is a leading example to which I would point you. They have formal policies right across all the determinants of health. They have reduced poverty and almost eliminated it, but not quite. The result is that they have much better child health reflected in the infant mortality rate, and there is no gradient. They have eliminated the gradient that characterizes Canadian, American and most other countries.
In British Columbia, we have the ACT NOW program, which you will hear more about. It is right across government. The approach here to population health in terms of implementation requires coordinated action across all of government. This is what Sweden is doing.
In British Columbia, the premier has told every one of his cabinet members that he would like them all to figure out what they can do about improving physical activity, nutrition, reducing tobacco and reducing alcohol use during pregnancy. A committee of assistant deputy ministers meets every month to drive that agenda. That is a good model. It is looking at risk factors. If you flip that over to look at the risk conditions and determinants, that would be even better.
The British Columbia Progress Board, which is composed of prominent businessmen appointed by the premier, have said that if they want to improve the quality of life in British Columbia, they must address poverty. There is a province-wide agenda around school health in Nova Scotia, and there are many other examples which I will not get into now. I will end there and turn it over to my colleague.
The Chairman: That was wonderful, Dr. Millar. Our next witness is Mr. Dennis Raphael, who is a professor of public health. He is from the School of Health Policy and Management at York University and has written some wonderful material which we have already reviewed. We want to hear the pearls today.
Dennis Raphael, Professor, School of Health Policy and Management, York University: This will be an overview of everything and almost anything of what social determinants of health are, and what we know about how they shape health. I suggest that we know an awful lot about mechanisms and pathways. I will outline some of the known information about the effects of social determinants and then put it within a public policy context. I will then identify some barriers, and there are some real barriers to having this addressed. I will then suggest some ways to move into the future.
What are social determinants of health? They are economic and social conditions. For the most part, these conditions are beyond the control of individuals. These are about the organization of society and about the quantity and quality of the resources that a society makes available to its members.
The interesting thing to keep in mind about population health, for example, is that it is about improving the health of the population, as are social determinants of health, but it is also about inequalities. Sometimes it may be that we lose the message that profound differences exist among Canadians as we try to improve population health.
The main message, first, is that this stuff is not new at all. In fact, we can go back to the 1840s and look at Rudolph Virchow and Frederick Engels, who talked about how living conditions shape health.
To bring it back to the present, in 1986 the Honourable Jake Epp pointed out that the numerous policies that influence health need to be coordinated. In a sense, by 1986 we had a nice list of what some social determinants of health might be. They included things such as income security, employment, education, housing, business, agriculture, transportation, et cetera. Similarly, as another example of a shopping list, the Ottawa Charter's prerequisites of health include peace, shelter, education, food, income, a stable ecosystem, social justice, equity and sustainable resources, and have been replicated by the World Health Organization.
More recently, in 2004, we reviewed the literature and put together our list of determinants of health explicitly placed within a public policy context. The assumption was that when we look at these, of course things can be done at the individual level. We can read to our kids at night. However, if we are serious about early childhood, for example, we would probably want to make sure that kids do not have to go to food banks or that they can afford to have access to books and have a decent education.
I think one of the traps we must watch out for is, to use a strong word, the hijacking of a public policy approach to an individualized approach, where we look at these things and see them as individual problems. I suggest that these are not individual issues.
In terms of what we know, the British have been doing a great deal of research. Their conclusion in 1995 was that it is one of the greatest contemporary social injustices that the people who are most disadvantaged to begin with are the ones who experience more disease, illness and shorter lives.
How do they shape health? As a kind of baseline, very simply. Social determinants of health, whether they are working conditions or income or quality of housing, provide the basic prerequisites for health. When I first entered this field in the 1980s, I thought this stuff about shelter and hunger was kind of quaint. With the growth of food banks and homelessness, it was not so quaint anymore. Clearly, we have many Canadians who are not experiencing the prerequisites for health.
We also know about stress and anxiety. Clearly, as Mel Hurtig immortalized, this issue is about "pay the rent or feed the kids." These are clearly things that wear down health. Even if we want people not to smoke, eat and sit around watching television, these are very difficult lifestyle changes even for upper middle class people to undertake, much less for people who are living stressed-out and marginalized lives.
There are models. This is from the other social determinants of health textbook, Bruner and Marmot's chapter. When I see the model that begins at the top left with social structure and then works itself down to work and social environment, with a clear link between social structure and disease and illness, the most interesting thing to me is that health behaviours is just one link on the way down there. However, if you look at public policy in Canada and the hundreds of millions of dollars that are being spent, all of it seems to be focussed on health behaviours to the absolute neglect of all of these, I would argue, more important issues.
What are mechanisms and pathways? Again, this is only part one on a long journey for all of us. The materialist approach says very simply that the reason social determinants of health influence people is that people experience different living conditions. As an example provided by John Lynch, by the time somebody shows up on the cardiac ward for a bypass, they are bringing with them the accumulation of an entire lifetime of experiences. Similarly, numerous models have been outlined. Again, this is a British model that very clearly outlines the steps by which adverse living conditions lead to poor health.
We also know about stress. One of the advantages of having been a psychologist in a previous life is that I know a great deal about the stress reaction and about the brain. The mechanisms of how adverse living conditions get under the skin to cause disease and illness have been long worked out.
The neo-materialist approach is interesting because it argues that people get sick not only because of the adverse living conditions that they might experience but that there seem to be entire countries, nations and jurisdictions where governments buffer these effects, or they do not allow these effects to occur in the first place. For example, Sweden is an example of a country where there are very few people with low income. There is, however, significant investment in all aspects of people's lives, whether it is early childhood education, job training when you are laid off or little or no tuition when you go to university. The neo-materialist approach says that we must take into account not only how income affects individuals at the bottom of the social hierarchy, which is poverty, but the amount of community infrastructure which governments invest that we also know supports individual and population health.
John Lynch is one of the people who have just moved up to Canada. He is at McGill University.
This, from the Ontario Health Survey, illustrates a key point. When you ask people if their health is fair or poor, you find that, while no regular exercise gives you twice the risk of reporting poor health, and being a smoker gives you a 38 per cent greater chance, the factor that is found repeatedly over and over again to have the strongest effect on health is an individual having a low income. The risk of reporting having poor or fair health is four times greater for individuals who are in the lower one-third of income than people in the top one-third of income.
Similarly, if we want to look at a really hard health index, something that is real — and the health utility index asked you about pain, the ability to go up a flight of stairs, a whole range of factors — the first tip for better health is: Do not get old, because that is the greatest risk factor for poor health. Failing that, and we cannot do anything about that, the next tip is: Do not be poor. An individual experiencing low income in a multi-variant statistical model is by far the best predictor of health than no regular exercise, smoking, and so forth. Income is an incredibly important determinant.
Some examples include functional health, from the child's national longitudinal study. This is real stuff that even physicians can love and enjoy. Vision, hearing, speech, mobility and dexterity are real health. What you find is that poor children are at profoundly greater risk for experiencing these issues than are other Canadian children. While there is certainly a gradient in that, as we move down the income ladder, disease or difficulties increase, a common finding is that people at the bottom of the gradient have a significantly greater accumulation of disadvantage and disease.
Here is an example of heart attacks. You can see that not only are the people living in the bottom 20 per cent of neighbourhoods more likely to have almost three times the rate of heart attacks than people at the top but also than people who are in the next 20 per cent of lower income neighbourhoods.
A variety of studies have pointed out that when you take into account the fact that these people at the bottom may smoke, may drink, may be overweight, and you statistically adjust for all of those things — Michael Marmot showed this back in 1980 — the risks associated with class, occupation and income for the most part remains. Thus if everyone in the poorest neighbourhoods in Canada were suddenly skinny, never smoked and never drank alcohol, they would still be dying at rates that are profoundly greater than those for other Canadians.
This is data that we have used to receive a grant. When I showed up here in the mid-1970s, I said, boy, this is not New York City anymore. Part of it was the fact that no matter which neighbourhood you lived in, the mortality rate among people for diabetes was fairly similar, and conditions improved until about the mid-1980s. Now there has been an explosion of death from type 2 diabetes in low income neighbourhoods.
We are doing a study that is attempting to look at this factor. One of the questions is: Do we need to identify each individual social determinant? For the most part, this stuff clusters together. Very few people living in big homes go down to the food bank; very few rich people have really crummy jobs. It all clusters together, and it clusters together right across the gradient.
What is public policy? To use a Toronto example, in 1981, if you look at the top of the chart, the coloured-in areas were the neighbourhoods that experienced significant numbers of people living below the poverty line. What we can see is that from 1981 to 2001, there has been a profound deterioration in the income situation of people in the city of Toronto. This is also the case in numerous other cities as well. This is not a good omen. Again, I would argue that this stuff does not just happen; it is as a result of public policies.
In terms of income, the last ten years have been very good for some Canadians. For the top 20 per cent of Canadians, their income — this is total income — has increased from $119,000 to $142,000. For the Canadians who we know are most at risk and most likely for disease and illness, their income has virtually stagnated, going from $12,400 in constant dollars to $12,900. This comes from the Federation of Canadian Municipalities, and the lines going down show the gap between how much low-end rents cost in Canadian cities and how much money low-income people have. It is basically saying that in Winnipeg, low-income people's income has increased relative to the rises in low-end rents. You can see, in the city of Toronto and in the immediate area of York region and Peel, a 60 per cent gap. Thus tenants, who were already in a difficult situation in 1991, have basically seen their rents increase while their income has been unable to keep up with that.
What is the answer? In 1998 the British came up with the conclusion from their independent inquiry that without a shift of resources to the less well off, little would be accomplished in terms of a reduction in health and other inequalities by interventions that look at downstream influences. Again, from a public policy perspective, there is a remarkable similarity between the National Council on Welfare, the policy priorities of Canadian food banks and Campaign 2000, and that is: Make more resources available to the most vulnerable.
At the same time, these effects also carry over into the middle class. When you improve employment benefits for the least well off, it also assists all of the Canadians in the middle who currently are not eligible for employment benefits, as an example.
What are some barriers to action? One is risk factor epidemiology. This is from the New England journal of panic-inducing gobbledegook. The idea is that every day we get another result, and it is almost as if the results are completely random. On one day you want to sleep more than 8 hours, then on another day you want to sleep less. One day in The Toronto Star they reported both: On page 4, if you slept more than 8 hours a day, that was a risk factor; on page 14, they reported the other study that said that you want less than 8 hours. Thus the conclusion is that you want to sleep absolutely 8 hours a day. This has a lot to do with the way risk factor epidemiology is taking place.
We do not want people to be fat and we do not want people to drink. However, the Canadian public, as well as the American public, has no comprehension that living conditions are primary determinants of health. In this particular case, from The New Yorker, we have a 30-year-old man starting on the 25,000-pound oat bran muffin he must consume over 40 years in order to reduce significantly his risk of death from high cholesterol. The overemphasis on lifestyle completely removes these broader issues from the public policy agenda.
Do not forget politics. When I looked up the members of this committee, it said Liberals and Conservatives, and I remembered that you are only appointed to the Senate by the ruling Prime Minister. Do not forget politics. Here are six or so policy suggestions by Campaign 2000 on how to reduce child poverty. As of the last federal election, the Conservative Party of Canada had a position of being opposed to each of these, the NDP had a position of being in favour of them, the Bloc, for the most part, was in favour of them and, of course, the Liberals were in favour of some but not others. This stuff is political. It is absolutely political. Improving living conditions in the end is about political choices that governments make.
The Conference Board of Canada, in its recent report, has been ranking Canada among the top 12 countries on a variety of things such as health, health determinants, education and skill. They draw attention to the Scandinavian countries, the social democracies, which we would expect to do better on health determinants and on health, which for the most part they do, whose economies are now outperforming Canada's. When the Conference Board of Canada begins to raise alarms about issues such as poverty, job training, et cetera, then I think we know we have an issue. I have done my book. It has been very well-received. It is great that now we are to have the Government of Canada, in the form of the Senate, beginning to look at these issues.
Ronald Labonté, Canada Research Chair in Globalization and Health Equity, Institute of Population Health: Again, like my previous two colleagues, I would like to thank this committee for inviting me here, and I emphasize the importance of the work that you are doing. Mr. Raphael said that this area of concern is not a new one. I was speaking with Senator Eggleton just before things started and reminded him that when he was mayor of Toronto, I worked as a community health consultant with the Department of Public Health back in the 1980s when we were trying, in some respects, to offset some of the changes that Mr. Raphael so eloquently mapped with that series of increasing poverty within the city.
It is not new, but we must remind ourselves continuously of the importance of this because it is about the political choices that people as a nation or as a global community choose to make about what its future will be. Those choices invariably will not be win-win in the classic sense; they will be choices that deal with the necessity of redistributing or sharing the nature of the resources that we have. That is what 2000 years of evidence around the determinants of people's health and well-being tell us.
I feel a bit as though, first, you have already been given your dinner. You are dining out on a whole lot of stuff, and I am hoping it does not give you indigestion. You are about to dine out on a little bit more. Then I feel a bit like Monty Python. Now you are about to get something completely different, because I suspect you did not expect to be talking about globalization as a health determinant. I have been turning my attention to this aspect for the last 10 years. I decided that I needed a focus in my life so I do not do extraterrestrials, but that is about it.
This is also a follow-up to Madame Bégin because I have been involved with the Canadian reference for the WHO Commission on the Social Determinants of Health and I chair the Globalization Knowledge Network. In consultation, we decided that I should speak a little bit on globalization as a health determinant. The usual disclaimer, which you can read, is that I take all credit for what you agree with and I totally disabuse myself from anything that you find offensive or disagree with.
As I think Madame Bégin may have mentioned in her presentation, the commission's work right now is at the point where the knowledge networks are just completing their synthesis of knowledge. That will be, I think, an incredible repository of information for the work of this committee. In turn, the work of this committee is extremely important in terms of building a larger global momentum for the WHO to move forward with this project in a multilateral sense. There is a real kind of synergy that could exist, and I want to encourage you to exploit that as much as possible.
A number of different knowledge networks now exist. This is how the WHO decided to carve up the territory for which we needed more knowledge. I will speak to some of the issues in globalization. The take-home message from this rather complicated slide, which I will not brother running through, is simply: Why should Canadians care about globalization as a health determinant? There are a series of self-interested reasons: Threat of emergent and multiple drug-resistant diseases, the fact that as health and economies decline in some countries, it sparks regional conflicts with spillover effects. There are limits to growth in the sense of how we look at global economic growth and its impact, perhaps, on climate change.
Also, in a very real Canadian sense, there is our role in reducing what is sometimes referred to as this race to the bottom in terms of a decline in standards and wages, labour protection and security, and the declining share of labour as a proportion of income relative to capital, which is well-documented. That has an impact on a lot of Canadian workers. There are a few examples that we know of, and one is that for the residual manufacturing in high-income countries, the OECD countries of which Canada is a part, what we are finding is less job security, a higher pace and longer hours of work, less autonomy, and greater psycho-social stress, higher rates of part-time or flexible work, all in the name of creating more flexibilities in our labour market in order to be globally competitive. There is an abundance of literature that tells us that that might be good for our global economy or our GDP figures but it is very bad for the workers who are involved. It is creating a lot of health-damaging consequences. That is another reason Canadians should be concerned about globalization and how the process under the current rules of market integration create some risks or threats for Canadian health itself.
I would like to say more because we have a research network, of which actually Mr. Raphael is a part. We will be studying this subject in much greater detail in Canada over the next five years, over a series of questions mapping out how these globalization changes are affecting some of the conditions in those low-income neighbourhoods in Toronto and in a number of other metropolitan areas. Within about a year's time, we should have some preliminary literature synthesis so that, along with the work of the knowledge networks of the commission, you will have some emerging research that will be coming out of the Canadian context.
If we cannot make an argument for self-interest alone, we can make an argument based on political commitments and on legal obligations. In relation to political commitments, normatively Canada has committed to the Millennium Development Goals. If you are not familiar with those, I can easily send you material about them. That is our commitment to try to make the world better for everybody.
Through the G8, we have made various commitments about making globalization work for the poor. For a long time now, we have promised to reach the 0.7 per cent of gross national income, or GNI, in our development assistance and we have singularly failed to do that. However, we also have legal obligations under various human rights treaties and the rights to health. The U.N. special rapporteur on the right to health indicates that many of the global agreements to which Canada is party, or negotiates, actually runs the risk of violating our obligations under the right to health. There is both a normative reason and a legal reason to be concerned with globalization as a health determinant.
Just on that one instance of Canada's meeting the 0.7 per cent of GNI, this is some kind of assessment that we did back in 2005. I am not sure whether it really holds with more recent budgets, but it indicates that it would take comparatively little in terms of Canadian federal revenue to meet that target, compared to the value of the tax cuts that were announced in previous budgets.
Like many things related to the social determinants of health, the question is not about whether we have the resources but whether we have built the political mobilizations or will or desire to use those resources in a different way. That is the fundamental question that always comes up in dealing with the determinants of health.
Backing up to globalization, a basic definition of what it is, the process of various forms of integration and knowledge, consciousness and so on, and in approaching it through our knowledge network and the research that I have been doing, I want to emphasize that there are a lot of positive aspects in relationship to globalization around the diffusion of health technologies, gender rights, and so on. There are many things that are positive about globalization. There are many things, though, that are also quite harmful.
In respect of the dominant argument, this is one that, I suspect if you talk to the people responsible for negotiating international trade agreements for Canada, or talk to people in the finance ministries, you will probably find that they would accept this argument. As countries integrate into the global economy through liberalization, their growth increases. That improves their wealth. That decreases their poverty. That improves their health. That, in turn, improves their growth. It is referred to as the virtuous circle or the rising tide lifting all boats. The problem with that is that, although it is a very compelling argument, empirically it has been challenged. It has flaws through every single one of those relationships, and there are many reasons to be quite concerned about that dominant, particular argument.
I have mentioned the spread of resistant diseases. I believe Mr. Raphael and Dr. Millar both talked about the obesigenic culture, which is now being globally transmitted. When countries that are relatively poor lower their tariff barriers, they lose public revenue to invest — as has been well documented — in other forms of social spending. Some countries grow; others do not. Those that have grown by integrating into the global market economy in the past two decades did so precisely by not following the rules on the earlier slide. They did so by taking a different course. Poverty reduction is not automatic, and inequality is on the rise.
Mr. Raphael mentioned that income matters. I recall Nelson Rockefeller once being quoted as saying money is not everything. He said, "I know, because I have money and I have everything." That "everything" refers to wealth, which is often not captured by income, and it also refers to the status and privilege that comes with that particular social position. Income, in many ways, is necessary for material reasons but for psychological reasons it is also really the proxy for power, and the relationships of power that income represents.
Using a very flawed instrument to measure income, the World Bank $1-a-day level — I will not get into why it is flawed but it is seriously flawed, and grossly overstates the actual extent of poverty — we can see that there was a slight reduction during this period of economic integration since the 1980s at the $1-a-day level, although in sub-Saharan Africa it continued to rise. We also see that there were increases almost across the board of poverty at the $2-a-day level, which means that if we had a rising tide lifting people up, it did not lift them far. We have, as we know from other analyses, a rather skewed distribution of wealth around the planet that has occurred within the last 20 years. It is not just around the planet in other countries, but also in Canada. This is a study that looked at the changes — and it captures some of what Mr. Raphael was talking about earlier — in who benefited most during these decades of unprecedented wealth creation. It was not the average Canadian. It was not the average global citizen. Bob Evans likes to talk about it as the revenge of the rich in terms of how a kleptocracy, or small grouping of people globally have captured most of the gains economically over the last 20 years.
By the way, the Canadian Centre for Policy Alternatives tomorrow will be releasing an update of this study. I have heard from the authors of it that it will present some even more chilling information about what is happening with the economic equity issues within Canada. I urge you to watch for that.
Why do they matter? They matter for many reasons. Globally, as inequalities rise, we have the migration movements, both of people who are desperate as refugees and of people who are skilled, seeking more opportunities in wealthier countries and, in effect, draining their own countries of the human capital required to grow or develop domestically. Nationally, the more the inequality exists, the more growth is required to reduce the residual poverty. It is also associated with decreases in social cohesion and, more important, a decline in solidarity — what we in sociology would call cross-class solidarity, where we recognize we are all in it together; therefore, we will all contribute to some risk-pooling for the kinds of services we would like to have when we need them. That was the principle that underpinned medicare and many of our social programs that have noticeably eroded in Canada over the last 20 years.
I will pass on that slide. The take-home message from this one is that, even at a global scale, there is the notion that economic growth is the way to reduce poverty and make the world a better, healthier place. Growth is now increasingly inefficient in its ability to do that. You would have to have sustained global growth at the level of 20 per cent per year to achieve the same amount of poverty reduction as merely taxing 1 per cent of the wealth of the richest 20 per cent and redistributing it to the poorest 20 per cent. A very small amount of redistribution will do far more to reduce poverty than growth at a level of 20 per cent per year, and a growth in our carbon economy of 20 per cent per year will burn us all. We know that. It is really no longer empirically, or even ethically, an issue in terms what we have to confront, globally as well as domestically, how we deal with the questions of the allocation of the scarce resources that we have.
For the sake of getting through to some of the key points, I will try to summarize this by saying that globally, up until the 1980s, what you saw was a convergence in health as well as in income. Around the world, incomes were getting more equal and health was getting more equal. By the 1980s that started to diverge, and by the 1990s that went into a tailspin and began to go in the opposite direction, where health was diverging across the planet, just as income was diverging across the planet and getting worse. One of the factors for that was the early era of globalization with the structural adjustment programs that came about in order to deal with the debt crisis to allow poorer governments — that is, governments that were indebted and poor — to be able to repay past debts. This is the beginning of the orthodoxy of the economic model that is now being questioned multilaterally.
I want to give one example of this in terms of a poor country, Zambia. In order to get a loan from the World Bank and the IMF to pay back the interest on previous loans, in the early 1990s Zambia had to open up its borders to textiles, including second-hand clothing, much of which started as donations in countries such as Canada. That swamped the market and, because it had no production costs, as a result, in eight years Zambia lost all of its infant industries in producing textiles. All of the workers lost their jobs. It swept through the entire manufacturing force. At the same time, previously employed workers moved to the informal and untaxed underground economy. They had to privatize state enterprises, put in user fees, cut health staff, and reduce the salaries of those who remained. They are all aspects of globalization and they all occurred right at the time that the AIDS pandemic in Zambia was beginning to race out of control.
On a broad scale, you see in Africa that all of these globally-imposed economic policies were put in place in these countries right at the time that HIV took off and the death rates and life expectancy began to decline. There is a fairly compelling evidence base for that. In Canada, we need to pay attention to that.
I will flip quickly through these slides. This slide is interesting only for the reason that we often think we are quite generous in our relations with the poorer countries. During the 1990s we saw an enormous shift. Before, developing countries got a bit more money from us than we got from them, but by 2005 we were getting $560 million a year more from them than they were getting from us. It is an enormous, not well understood and incredibly scandalous redistribution of wealth from the poor to the rich on a global scale. It mirrors the kind of image we saw about who gains and who does not in Canada over the last few years. That is the nub of the issue that this Senate committee will have to tackle: namely, what drives and what buffers those types of inequalities.
I will pass on these next slides and say that in our knowledge network we have a simple, analytical framework about how we are beginning to approach our understanding of globalization. We have a very complicated framework, which you have. I would be happy to come back and talk about our results when we have them, but in a simple framework of understanding globalization as well as other forms within Canada, the way the social determinants of health become health inequalities is to first stratify people. They stratify them economically, by class and by gender. In the Zambian example, globalization, by opening up the border, stratified those previously employed workers and made them informal street workers who were paid less money, so that they entered a different social stratification.
It also increases or changes the exposure. To go back to the Zambian case, all of a sudden you had families split apart, with men employed in rural textile mills moving to the city to sell cast-off donations. That increased their risk, essentially at that point, of beginning to engage in sex for money. That began to increase the spread of HIV.
There was differential vulnerability: women whose husbands were also absent or perhaps dead because of the early stages of the epidemic. There were no public services available any more. There were user charges; they had to pay to get their kids to school; prices were going up; they were vulnerable to having to move into the sex trade as a way of survival. Because they could no longer afford health services, the health outcomes were different. You can begin to map out how the determinants become health inequalities by following these different social processes.
This is a list of our papers. You can look at it at your leisure. In conclusion, I wanted to underscore that government policies still matter, not only in terms of what Canada can do around globalization but also what it can do domestically.
These are charts with which you might be familiar from the Canadian Population Health Initiative that show market income inequalities and post tax-transfer inequalities. Canada does not do well on this. It does better than some countries but a lot worse than others. Consider, say, seniors. We have done extremely well in our programs in Canada with changing market inequalities for seniors and reducing their poverty rates. However, as Dr. Millar pointed out, we have not done well with children. Sweden does extremely well with them because they subject every one of their policies to human rights-based analysis to see if they are fulfilling their rights obligations. Canada does not do that.
I will pass on the global implications for Canada because that is a whole different discussion, but I will raise these provocative questions, perhaps, as a spark to our discussion. Is globalization reducing the policy space and capacity of all countries to act to decrease inequities in the social determinants of health? We answered that already in some of our work for the network. Yes, there is evidence that that is occurring. We are constrained by the rules of the global market integration in our abilities to be able to manage inequities within our own borders. We need to change that.
Does commitment to both domestic and global health equity require a politics based on rights, redistribution and regulation? That is a slight echoing of Mr. Raphael's challenge. I believe that the work of this committee needs to rise above partisanship, but it cannot rise above ethics or politics.
The Chairman: I wish to thank all three of you for those presentations.
Professor Labonté, I was hoping you would put up a chart showing a health-wealth convergence up until 1980, and then divergence. Do you have such a chart in your possession?
Mr. Labonté: I do not have that with me now, but a chart like that could probably be constructed. This work has been done for us by Giovanni Cornia, who has done a lot of work for the UN, over the years. He has done an incredible multiple regression analysis that found that, in the last 20 years relative to the previous 20 — the counterfactual, as it is called in econometric modelling — our policies related to globalization have actually reduced life expectancy at birth, on average, for the world by about 1.2 years. That was offset by health gains in technology but only to the point that we have had an overall average gain of about 0.2 years relative to not having gone down the path that we took over the past 20 years. I can make some of this available over time, but we have been busily working with this material right now in our work for the WHO commission. By June, we will have quite a bit of stuff to share with this committee.
The Chairman: Thank you very much. We appreciate your sending it along at your convenience.
Does anyone have a direct comparator of Canada and Sweden on the health-wealth equation?
Mr. Raphael: It turns out that Andrew Jackson has what he calls the "social development Olympics." It turns out that the book I am publishing next month compares Canada with the other OECD countries on a whole range of indicators. Generally, what you find is that whatever happens to you, or whatever can happen to you, you are better off if you are in Sweden, whether it is being laid off, deciding to go to university, having children or coming down with a disease. It turns out that the OECD, in its report, Society at a Glance: 2005 put together a whole range of indicators. They also have Health at a Glance. There is tremendous OECD data available. They even make available Excel data files that you can play around with.
To give you one example, I put something together the other day. With respect to unionization rate versus child poverty rate, the United States poverty rate is 26 per cent, going through the roof. Thirteen per cent of their people have a collective agreement. For Canada, it is a 15 per cent poverty rate; we have 31 per cent unionization. Sweden has about a 4 per cent poverty rate, and 92 per cent of their people are unionized.
There is a lot of policy data out there that includes not only Sweden but also a range of other countries, and it turns out the Conference Board of Canada has produced a great deal of data.
The Chairman: Thank you. We would appreciate anything you have which is relatively simple along those lines.
Senator Trenholme Counsell: I am focusing much of my attention these days on child care and early childhood development. I was pleased to see the references to that and references that support my cause and that of many others.
My background is that of a medical doctor, and I need to ask about the quotation from Dr. Millar regarding "health systems quality iceberg" and that the health care system was the second leading cause of death. Perhaps I did not hear that correctly.
Dr. Millar: No, you heard it correctly. The number, 10,000 deaths in hospitals in Canada, is drawn from a major study being published in the CMAJ.
Senator Trenholme Counsell: Is that 10,000 per year?
Dr. Millar: Yes, 10,000 per year, preventable deaths in hospitals related to errors, and there is an additional 18,000 related to non-error adverse events and then an estimated 20,000 in communities. Those data are drawn from U.S. publications where a similar conclusion has been reached. In the usual way we do with Canada versus the United States, you just multiply all those numbers by 10 and you have the same estimates.
In the U.S., in the Journal of the American Medical Association there is an article outlining those numbers and suggesting that adverse events in the health care system are a major cause of death. They do not routinely show up because they are not ICD9 or and ICD10 coded cause of death. These are things that are coded with another cause of death when they go to the death certificate. These are studies that have been done doing chart reviews by physicians who have reviewed the cause of death and concluded that there was an error involved.
Senator Trenholme Counsell: Is that second to cardiovascular disease?
Dr. Millar: Yes.
Senator Trenholme Counsell: This is debatable, to a small extent. I do not want to carry on too long, though. If we are looking at 20,000, which is the largest number you have here, community non-error drug deaths, surely that is the whole area of drug abuse and addiction?
Dr. Millar: No, this is related to prescribed pharmaceuticals in primary care.
Senator Trenholme Counsell: Community non-error drug tests?
Dr. Millar: It would be drug interactions, adverse drug reactions, that sort of thing.
Senator Trenholme Counsell: How many deaths are there from cancer a year here in Canada?
Dr. Millar: It is a number slightly smaller than that total of 48,000; I do not have the absolute number in my head, but it is easily obtained.
Senator Trenholme Counsell: I have to accept that. I was quite shocked. I do not know how Dr. Keon felt. That certainly woke me up.
Dr. Millar: The point I am trying to make is to not forget the health care system as a determinant of health, both positive and negative in its nature.
Senator Pépin: We never think about that. I was shocked to hear that health care is responsible for 48 per cent of deaths.
Dr. Millar: No, it is 48,000 deaths, not 48 per cent.
Senator Pépin: That is still quite a figure.
Senator Trenholme Counsell: Are those Canadian figures by extrapolation from American data?
Dr. Millar: The first figure of 10,000 is from a large Canadian study done across the country in urban communities.
Senator Trenholme Counsell: What year was it completed?
Dr. Millar: It was published in, probably, 2003 or 2004.
Senator Trenholme Counsell: With respect to the other two figures, are they extrapolated from American figures or are those data collected here in Canada?
Dr. Millar: No, they are extrapolated from the U.S.
Senator Trenholme Counsell: I can only hope we are doing a lot better than this data indicates.
Dr. Millar: Unfortunately, the evidence does not support that. These studies have been completed in Canada, the U.S., England, Australia and New Zealand. Everywhere they have been completed, the figures come out very similar. Canada does not look any better.
Senator Callbeck: Thank you for appearing here today. You have certainly provided us with a lot of information.
Dr. Millar, I want to ask a couple of questions on your presentation. In the revenue spending scenario, are those figures based on British Columbia?
Dr. Millar: That is correct.
Senator Callbeck: You are saying that 71.3 per cent of the budget will be taken up by health in 10 years. Are you just talking about the health care system, or are you talking about factors that affect health care such as housing?
Dr. Millar: No. I am talking about straight Ministry of Health expenditures on hospitals, physicians, pharmaceuticals and community care.
Senator Callbeck: Do you have figures that are based in other provinces?
Dr. Millar: The figure of 42 per cent in 2005, appearing on the left-hand side of that chart, is similar right across the country. Most provinces are currently running around 40 to 45 per cent of their budgets.
Senator Callbeck: Projecting 10 years down the road, do you know whether other provinces are talking about something like that?
Dr. Millar: I have not seen those projections from the other provinces, but I suspect they would be remarkably similar.
Mr. Labonté: Up until a few years ago, I was in Saskatchewan. At that time, there were similar types of projections undertaken in Saskatchewan. There were arguments that if we did not deal with fairly dramatic forms of health system reform, the ability or space to be able to invest in other determinants of health would start to be eroded. That is an important point around health care systems, namely the determinant of health.
There is another aspect that we have not looked at, and that is the financing of health care systems as a determinant of health. Around the world, out-of-pocket payment for health care is the leading cause of poverty. It is called medical poverty. More people are plunged into medical poverty around the world than are lifted out of poverty by economic growth. Canada has not yet been seriously afflicted by that, but the United States suffers from it tremendously.
The nature of financing of our public goods, be it health care, education or anything else, has a dramatic, indirect role as a determinant of health in terms of foregone expenditures and what it means. That is why income measures in themselves are extremely important but do not capture the full impact of public policies on people's capacities for health.
Senator Callbeck: I wish to ask another question with respect to the messages. You say that Canada has led the world in understanding the causal links between the determinants and health and well-being. Then you say Canada has been slow with attaining this knowledge. I would like to get your opinions on record as to why you feel we have been so slow.
Mr. Raphael: Let us look at the year 1986. The conclusion I have come to — and we can certainly get reaction from others — is that John Myles, who is a political economist at the University of Toronto and a very smart man, said that by the end of the 1970s, Canada had a welfare state that looked very similar to Sweden.
Clyde Hertzman, in an article that just came out in Social Science & Medicine, also argued that, compared to the U.S., Canada maintained its welfare state through the early 1980s.
What occurred was the debt crisis. The decision on how to deal with the debt crisis in Canada, for the most part, involved cutting social spending. In European countries, they have dealt with worse debts in very different ways. I hate to use jargon but it is real. There has been a greater preference for what people have called neoliberalism. That is, an emphasis on the marketplace and individuals as opposed to community.
I believe a Liberal senator wrote a book called Hard Turn Right. You may recognize the name. I do not remember it. What Canada had during the 1980s and 1990s is something we may call entrenchment or withdrawal. People in the area of public health now perceive, unless they happen to be in some specific regions — and we can name the good guys, such as Waterloo region, Peterborough interior region, Chinook region and Edmonton — they perceive that raising these issues as public health issues are very simply career threatening. It sounds overdramatic, but it is not.
When health units raise issues such as housing, poverty and food bank use, either there is a reality or a perception that they then get hit hard by provincial governments, and perhaps federal governments, that do not want to hear about it.
Political scientists have talked about how public policy has shifted over the last 15 years. That shift towards the marketplace and towards an individualized approach conflicts with the social determinants of health approach. It is not compatible. We have seen a retreat from the healthy cities movement in the 1970s and from healthy communities. People such as Perry Kendall in British Columbia and other medical officers are doing this at risk because it is not consistent with the increasingly dominant approach to governance.
Dr. Millar: The question is: What underlies that and what is behind it? As many of you are politicians, you know that politicians tend to follow where the public goes. The values of Canadians drive these decisions, to some degree. That, in turn, I am sure is a consequence of living next to the United States, which does have a very individualistic approach to things.
However, I think there is an enormous change happening right now. I mentioned in passing the BC Progress Board, which is a group of prominent business people that Premier Campbell has appointed, has come to question how to make progress in British Columbia. They have stated that they must reduce poverty. It is unheard of to have business people say this.
You have heard that the Conference Board is similarly drawing attention to this same problem. Last fall, the Chronic Disease Prevention Alliance of Canada, which consists of 600 public health people in Ottawa, came out with a public statement that the number one issue that we have to address to prevent chronic disease in Canada is to reduce family and child poverty. We are seeing a change in values here, so there is room for optimism.
Mr. Labonté: First, I will be totally unprovocative by stating that one of the reasons that Canada has been so good at producing analysis and policy pronouncement is as a result of the British North America Act and the division of powers between the provincial and federal government. That, essentially, means that the federal government has been an incubator in many instances of these ideas, as have local governments. Provinces run the show, and they get into federal-provincial wranglings that go on.
Hugh Stretton, an old colleague of mine from Australia, when I was doing international consulting in Australia, I remember that he was doing a forecast into the future. He talked about how, as a result of this strange division of powers in Canada, Canada creates these wonderful ideas but does not have the unicameral type of government that allows them to be easily implemented. By the year 2010, according to his projections, Canada became the leading exporter of international consultants. This happened when I was one of them in Australia, so it rang rather close to home. That is one issue.
I think we are all familiar with the concept that the pendulum swings in terms of major orthodoxies or ideas. We have lived through about 20 or 25 years where there was a major shift away from the post-war kind of evolution or the second golden age of capitalism, as it was referred to, with the creation of fairly strong national welfare states that took different forms in different countries, the least perfectly implemented being that of our southern neighbour with whom we are most economically integrated. This is one of our problems and why we do not act on the knowledge we create. We have a tyranny of geography in terms of where we happen to be positioned on the planet.
For all kinds of reasons that different political theorists and historians have gone through, that began to be eclipsed during the 1970's. It was actually started by the quadrupling of oil prices and the kind of global recession that that created. It shifted around at the time when more neo-conservative governments were also coming into power; we know about Reagan in the United States and Thatcher in the United Kingdom. It created a context in which a whole new series of ways of essentially gaining profit were developed with financial market liberalization, different derivatives, technology, that allowed for the creation of an enormous amount of wealth, but in ways that were no longer, either actively or in terms of the capacity of governments, being captured for public-good consequences through the kind of tax and transfer mechanisms that had been in place before. Then governments, in some respects and in varying degrees, tried to outdo or compete with each other on that trajectory. We witnessed that globally in the imposition of international financial institutions on poorer countries.
Now, there has been a shift in that discourse because empirically the benefits that were claimed would be derived from that particular approach have not materialized. Bob Evans liked to describe the gradient of the benefits of a hierarchy always looking better from the top. Unless you happen to be in that rather elite position, the claimed benefits of that particular model empirically have not been demonstrated, and many of its earlier advocates are now rescinding their support for it.
At a global level there is a shift now, in a way, back to some of these issues about the need for social protection, the need to have public insurance programs, the need to have improved taxation and transfer programs. That has not been firmly emplaced in many nations at this point in time, but that is part of the work that the commission is trying to engage with nations, to see how that agenda can be moved forward.
One final point is that we should not mistake the idea that countries that have fairly high levels of progressive taxation, fairly strong welfare kinds of systems that are not based on a residual model — we will just look after the poorest of the poor, in kind of a rather mean-spirited fashion — that these countries are somehow economically uncompetitive. Some of the northern European countries that have the highest levels of taxation, the lowest poverty rates and the best health outcomes also have the lowest unemployment rates and the highest economic output indicators. There is not a built-in contradiction between some of the goals we might want to see economically, with the type of policies that buffer what the market, by itself, cannot produce, the kind of equity issues that we are concerned about, and which are at the core of the social determinants of health.
The Chairman: Senator Pepin, by the way, is the vice-chair of this subcommittee. She is a great politician and she was a nurse before she entered her political career.
[Translation]
Senator Pépin: I must admit, I am quite distressed by everything you have told us. I noted a number of things: that the choices made by the government will determine the health of our population; that there seems to be a movement in certain countries to correct the situation; that globalization will obviously affect health, but not how I thought it would; and that our programs here in Canada are falling apart.
I knew that Canada was not ranked very high, but after listening to our three witnesses, I am quite distressed by everything I am learning. Above all, however, I realize the importance of this committee and our work.
Also, if I understood correctly, with respect to health and poverty, you said that the expertise of the various governments does not mesh entirely with today's reality; or rather, that we know what is going on, but we are not making the necessary links.
What is the most effective way for us to do something? We can write an excellent report, but practical action is needed. Where do we begin?
[English]
Mr. Raphael: One of the things that I suggest to people when I visit a health unit — first of all, keep in mind that you are not alone. There is a national coordinating centre for the determinants of health. That is part of the public health agency in St. Francis Xavier, and they are dealing with the same question.
Think about tobacco. First, we had to educate people. Then we had to do the analysis and the statistics, and basically we had to change people's understandings.
We did a wonderful survey where people were called up and asked off the top of their head their important determinants of health. Eighty-six per cent of Canadians said diet, exercise and weight. There was not a reportable mention of poverty, even when they went through the list asking the importance of "income" and "having a job" as a determinant of health. Credible, though. At the very minimum, the discourse has to be shifted a bit.
The next thing that I suggest is: find out where the good guys are. There are many good guys now. One of the questions you asked is: Who would be in favour of this approach? What I might suggest is that you look at my résumé, and to the groups to which I have been speaking: registered nurses associations, legal clinics, and Ontario municipal services. You are not alone; I am not alone.
The other thing is that it is distressing. Some of the most distressed people are people like me who moved up here to get away from all of that. Thus, it is education; it is policy analysis; it is looking to other examples and basically realizing that most people who care about each other are receptive to these ideas. They just do not hear it very much. They do not hear it. You know what they hear. It is not in the media. One reporter said to me, "I know there is a relationship between health and poverty. Try pitching that to my editor."
There are lots of forces but I think that, as has been suggested, the tide is turning. When I looked up the members of this committee, whom some of you were back when you were more influenced than you might be now, these ideas were commonplace. They just have to be brought back into currency again. One of the slides I have is Pierre Trudeau and the Just Society, from his memoirs, so I use that. It is there; it has just been pushed down a bit.
Dr. Millar: The question you ended with is: Where do we start? I would say, look for successful examples in other countries. Sweden is a wonderful example. Maybe you should go over there and talk to them. What have they done? They have set about 10 major goals. As you have just heard, they have already addressed poverty. They have virtually eliminated child and family poverty but they still, in their goals, emphasize the importance of children, the importance of early childhood development, and the importance of education. They look at the importance of work and employment conditions. They look at the importance of housing and communities. Then they also look at how they can further drive tobacco use down; how they can improve physical activity; how can they improve nutrition, and reduce alcohol and drug use. They have national goals set for every one of those things.
We were very close to that, but it seems to have fallen off the agenda. That would be one thing: Set some national goals that address the determinants and the risk factors. The other thing is to look at structures within government to actually pursue those goals across government. The British called it joined-up government so you get away from the silos.
This is happening in B.C. now. It is a good example. You can get Premier Campbell to come and talk to you about it because he has all of his ministers working together to try and improve health.
Sweden has that model. The U.K. has that model. Here in Canada we have those models. Therefore I believe there are lots of very practical things you could do to start with.
Mr. Labonté: Again, the trinity. I would say the first thing is to be upset. There is nothing as powerful as evidence-informed anger in terms of creating change. When I was trying to respond to that question about who would be interested in this subject-matter, I differ a little bit from Mr. Raphael around people in terms of understanding the determinants of health. If you asked people what it was in their life that was affecting their own health, they will give you the answer around the determinants of health. If you ask them in the abstract way about what makes people healthy, they will give you that cartoon with all of the little spinning wheels because that is the top of the mind abstract.
In terms of when you go out and work with communities as part of your undertaking, in hearing the personalized stories of what it is in people's own lives that is important for their health, you will probably get a richness of understanding about the determinants. People, I think, will galvanize around those issues when their own interests are at stake. Your own interests are at stake if you are a parent and you do not have access to adequate child care; if you are looking after an elderly parent and cannot get access to some sort of supportive housing for them; if you are trying to deal with education but cannot afford the cost of post-secondary education. Those are instances where people will begin to galvanize around that.
When we look at the equity distribution in Canada, as elsewhere, we find that it is the groups that have the least amount of resources and the least amount of power that will be most affected by the public policy choices that governments at all levels make about resource allocation. How are their voices heard? Their voices can be heard sometimes by compelling individuals who come forward, but usually it is through some formal organizational structure, some civil society organization, often supported by professional organizations, but the key is their own organized voice. One of the difficulties here is that, right now, Canadian laws are essentially clamping down on the ability of those organizations to undertake any form of advocacy. You cannot get funding from the government now if you have "advocacy" sitting anywhere in your organizational mandate. That is a simple way of silencing all but the people who do not need government funding to support their voices, which means everybody who can make it on their own in the market without having to deal with the government to sort of buffer the problems the market creates.
The committee might want to consider looking at what are the existing government policies that are aiding or impeding the ability of Canadians to express their concerns about policies affecting the determinants of health.
I will leave it at that, as a start.
Senator Fairbairn: Thank you for being here. You have asked a question: How is this sector of our society heard? How does it get attention? This is a very interesting day for me, after an interesting day yesterday. One of the ways in which they are heard, it seems, in this particular year is by the Senate of Canada. I have come here today, and I have been on this committee for quite some time, and there is something else I have been involved in for quite sometime. I am reading your things here and I see early life education and early childhood development, education. On this one, it is early childhood development and health systems.
I mention this only because the other part of what I do is about literacy. It is about learning from the very beginning. When you talk about Sweden and places such as that, they have a different system than we do, totally. I think that there might be four Swedes in all of the country who cannot read and the government is out trying to find them to get them going, whereas we have to fight every inch of the way here in Canada to have these programs put in place and accepted that will help people get through this difficult part of living.
If that cannot be done, then when folks like yourself, and when all our doctors and our nurses are trying to do the best they can, we have a big problem because the people they are trying to help find it very difficult to understand and respond. At this point in time — and Senator Callbeck was with us — our Committee on Agriculture that is currently studying rural poverty has just started on the road. We have been having hearings like this for the better part of last year. We are starting on the road and we have visited Atlantic Canada. What is in your papers today we heard in a different way, but we heard it everywhere we went. The one thing that was not making it all rather depressing was the feeling of absolute pleasure and delight of the people who came to our hearings that somebody was at least listening, or trying. Whatever we could do, at least we were trying.
When it comes to this huge title of Subcommittee on Population Health, would you think it is fair to assume that one of the factors that will and must — and hopefully can be done, and it has to be done through some kind of government facility, but enabling our country and the people in it to be able to communicate and to read and to understand what it is we are talking about? Would you consider the foundation of literacy and education development as one of the major foundations of what you are building on and what you are doing and what we are trying to do here?
Mr. Raphael: The Institute for Research and Public Policy, which I always call Hugh Segal's group, have a policy challenge. They are having a conference in a couple of weeks and they have identified seven major challenges. They went to Clyde Hertzman and Bob Evans and they asked what were the three things that would improve health outcomes. Number one was the early childhood development program. Again, it all clusters together.
Any time you go to these OECD reports and look for government spending on education, Canada is a laggard. When you look at government spending on active labour policy, we are a laggard. We certainly heard recently about cutbacks to adult education. Yes, they cannot even get that foundation in there. We have some real issues. There is one little problem. If everybody reads well but we do not change the work structure — in other words, people still have very low-paying, insecure jobs — then literacy, by itself, will not improve things. One would like to think society would respond; that as literacy improves, work conditions will improve. Again, literacy is absolutely essential; it is a foundation. As it turns out, the countries that do very well in health also do very well on literacy. Carl Hertzman points out that if you are a high school dropout in Canada, your kid has crummy literacy skills. However, if you are a dropout in Sweden, your kid's literacy skills are probably similar to those of a university graduate's kids. They flatten that literacy gradient, and they flatten it by being reasonable. That is what is so maddening about this whole aspect. It is the most reasonable stuff in the world. You do not want three families living in an apartment in St. Jamestown. Yes, it is an absolute foundation.
Dr. Millar: To add to that, the answer to your question clearly is "yes." Literacy and early childhood development are key. However, you do not want to be thinking that there is a magic bullet approach to population health. What we have learned over the last 10 or 20 years in health promotion and in population health is that for complex problems, you need complicated solutions. You need to think of all of these things. The child who does get early childhood development done well but then hits the school system and comes from a poor family that cannot afford to feed him will not learn because he is hungry. That is related to housing, to work and to everything else. The point is that we do not want to just focus on any one area, but we know the major half dozen areas on which the government should be focusing. Then the challenge is how to get a coordinated effort across government and into other sectors of society in order to do something about those factors.
Mr. Labonté: I want to weigh in on that issue. The task of this committee will be extremely challenging because every time we talk about an important determinant and a possible domestic solution to it, my own work in the last ten years hits me over the head like a two-by-four and says "No, it is necessary but far from sufficient." The problem we face, and Mr. Raphael hinted a little bit about it, is that we know already that there is credential inflation. The work that people used to do with a high school diploma, now they need a bachelor's degree to do; for work done in the past with a bachelor's degree, now they need a master's; and for a master's, now they need a Ph.D. We now put people through not one, but two or three post-doctoral fellowships before we put them out into the labour market. We have insufficient labour demand. We have a huge, overwhelming surplus of labour on a global scale at every skill level, from the least skilled to the most skilled. In the European Union, highly skilled workers are taking huge concessions now in Germany because with the EU consolidation the companies are saying, "We will move to Hungary. They have many Ph.D. people already. They will be half the price." We will be facing that with China and India. Even in highly-skilled labour, if we are looking at it in terms of economic benefits or the benefits that accrue to education, in the past education was the ticket to a better job, better income, better determinants of health. In the future, it will not be that way, at least to the same extent it was in the past.
We need to rewrite the social contracts that we have seen eroded over the last 25 years. They will not look the same as they did before, but they have to have the same effect, which is essentially to mediate and buffer the inequalities that inherently arise from markets, which even market economists will say inevitably arise. Those are not just the social inequalities but the environmental externalities. We must rewrite our social contracts with those end points in mind. We cannot just do it within Canada. Canada has to do it globally. We could do the best thing here locally, but it is a bit like cities having great programs and the province simply undoing 20 years of progress in the cities; or the provinces doing many good things, only to have the federal government step in. I do not know; the BNA Act is a bit of a puzzle to me. However, globally we know that Canada could engage in relationships internationally to undermine its capacity domestically.
We need a new social contract domestically and globally. There is increasing recognition that that is what we need to survive. That is what we need to do. What it contains and how we get there, I am not sure. There is a lot of debate, but that is, to me, the most exciting part of the committee. When Monique and I first began talking about this committee and what we would see as an outcome of our engagement with the Commission on the Social Determinants of Health, what we agreed upon and what I quite unabashedly said is that if, at the end of the day, we have people in Canada talking seriously, passionately and honestly about the importance of equity in our country, without fear of being dismissed by right-wing tabloids as vaguely reminiscent of the 1960s, or some other moniker like that, if we can re-esteem that discourse around politics, where equity matters, we will have accomplished quite a bit. That is the doorway into the details of that particular social contract.
I want to make one other comment for you to keep in mind as you do your work. We have talked much about the Nordic countries. There is not just Sweden; there is Norway, Finland and the northern European countries. They always tend to do better, but they are under some considerable strain right now. One thing is different about the Nordic countries — and this goes back to why our social contract has to look different now. The original welfare state that we have now seen eroded over the last 25 years was really predicated on two phenomena. The first was cross-class solidarity, which meant at the time it was being created that the outrageously huge inequalities that we now see between the top 0.001 per cent of the population and everyone else did not exist. We did not have the small number of uber-rich controlling so much of the national wealth. There was less inequality and a greater sense of solidarity; that what happened to you could happen to me. There was also at that time a much larger cultural homogeneity, a sense of relatedness, that we were all more or less the same.
One of the reasons that has been put forward as to why the Scandinavian countries have been able to preserve their welfare system to the extent that they have is that they still have much more culturally homogeneous populations than the Anglo-American market liberal countries that, along with their market liberalism, also tended to have much more open doors to migrants from what are now low-income and middle-income countries. It does not mean that we cannot strive for a new social contract that has those same effects, but we must recognize that we are grappling with, in many ways, a more complex social environment than characterizes some of those model countries in northern Europe. We can take what we can use usefully, but also embrace the challenge that we have from such an open-door policy around migrants, which creates richness but also creates a greater challenge around achieving the notion of social solidarity.
The Chairman: Before we adjourn, I want to take you back, because you have talked a great deal about early childhood development, and this is a favourite of subject of Senator Trenholme Counsell. Fraser Mustard has been preaching this gospel for years out of the Canadian Institute of Advanced Research.
Dr. Millar, particularly to you because you have a link there, the last time I talked to Fraser Mustard, he said that we must back up well beyond that. In other words, we must back up well beyond early childhood development, because the child that is born from a poor mother has a tremendously increased risk of cancer, congenital anomalies, retardation, and the list goes on and on. The chances of that child getting a square shot at life are very poor. The intervention must start with the mother. Please comment on that.
Dr. Millar: I agree. That is absolutely right. If we do not deal with preconception, we will then have an intergenerational problem that keeps repeating itself. We will not solve it unless we take that approach.
The Chairman: Thank you all very much. We deeply appreciate your coming here on such short notice. It is tremendously important to us to have had this hearing today. It was absolutely terrific.
The committee adjourned.