Proceedings of the Subcommittee on Population Health
Issue 2 - Evidence, March 21, 2007
OTTAWA, Wednesday, March 21, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:15 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: First, let me thank everyone who has appeared today from the department and the Public Health Agency of Canada to help us and advise us at the very early stage of our hearings, which will occur over about two years with respect to our work on population health.
We are privileged to have with us today Dr. Sylvie Stachenko, who has a tremendous background and experience in this field. Please proceed with your presentation, Dr. Stachenko.
Dr. Sylvie Stachenko, Deputy Chief Public Officer, Health Promotion and Chronic Disease Prevention, Public Health Agency of Canada: I will begin by thanking you for this great opportunity to present to you today. The reason I have colleagues with me is that they are two pillars in the agency around determinants of health and social determinants.
To my right is Mr. Jim Ball, who is very much involved with the WHO Commission on Social Determinants of Health work and very much involved in the work that looks at models of intersectorial action working with other countries.
My other colleague, Dr. Maura Ricketts, will be coordinating work around the first public health report that will be presented to Parliament by the Chief Public Health Officer. That will happen in September 2008. The theme of that report will be reducing health inequalities and addressing social determinants.
Obviously, there is a lot of work happening in the agency. I thought it would be useful for you to meet Mr. Ball and Dr. Ricketts, in the event that in future you want to be able to connect with them.
I have a fairly long presentation, which I will shorten in length. To provide you a sense of what I want to do, I will be structuring my comments around four major themes. The first theme will involve what we know. I will not dwell too much on that because I think you have heard much from other experts. The second, third and fourth themes will involve what we are learning, what we have done in Canada and elsewhere, as well as where we see opportunities ahead.
In terms of what we know, basically we have fairly good and robust knowledge in certain areas. Basically, we know that the most robust body of evidence is around linking income, education, status and employment to health — and that is across a number of different health outcome indicators. That is where we have a fairly robust body of knowledge.
In terms of following policy approaches, we are looking at what we know with respect to the types of approaches and the models that are emerging to address those broader determinants. I would say that body of knowledge is emerging. It is starting to be documented, which is important.
The third piece, the most challenging piece, involves how to measure the impacts on health of the various sectorial policies. That is a bit of the lens I wanted to provide. Basically, the ``what'' is easy to define, where the ``how'' is more difficult.
We have known this for a long time, but this slide illustrates the case that, basically, health is largely determined by factors outside of the health care system and the health care domain. The Lalonde report was the first in Canada to determine that the health field was broader than just the health care domain. The slide indicates a number of countries aligned on the horizontal axis, and you are seeing the expenditures expressed by per capita spending on the line. You will see that countries that spend a lot do not necessarily have better life expectancy. This slide is illustrating that case.
What are the factors beyond the health care domain that we know affect health? This slide is drawn from research conducted in Canada that is well-known worldwide, from the Canadian Institute for Advanced Research. It has listed a number of determinants, and they had a fair body of research to be able to identify those. You will see here that they have identified 10 of these determinants, but we have recently added globalization. I think you heard from Ron Labonte. The global trends and influences now interface with these other determinants. Basically, however, this is the list of determinants. In terms of the classification of this, we always see emerging common threads. We have had a number of WHO reports that also looked at the list of determinants. In Europe, there were the solid facts. Basically, it is always the same.
You have asked about the relative importance of determinants of health. This is very difficult because, basically, all of these determinants interact with each other. The context as exists among different countries is also extremely important in terms of that relative importance. Basically, if you want to know what the relative importance is, it seems that the cluster of income, education, employment and social status has a profound influence on people's health. As well, early childhood development is also critical, but it is not only critical in terms of the patterns during a child's lifetime. It also has a strong importance in terms of what I would say are intergenerational effects — the next generation. That is very important in terms of that determinant.
I am showing this slide, which I am sure you have seen often. It simply emphasizes what I have just stated, that all of these determinants interconnect. What you see here is something that has been utilized by the WHO Commission on Social Determinants of Health. They look at layers and zones of influence, starting from the outside, which are the broader socio-economic, cultural and environmental conditions that obviously interface with living and working conditions through social and community networks affecting individual lifestyles. Basically, they are all interconnected. Up to a decade or two ago, we defined most of our problems in terms of health around the first layers. Therefore, the solution to that problem is defined in terms of individual approaches. The more broadly you define your issue and your domains, the solution, as you can see, will be more complex and will involve other sectors. That is the challenge, both in terms of policy responses as well as, more predominantly now, in terms of evaluation. How does one evaluate these complex approaches?
The next slide illustrates something I am sure you have heard about — and it comes from the work of Michael Marmot — that is, that health status improves in a step-wise manner for each increment in the following: income and social status, education, and employment. We need to not only think that if we address social determinants we will affect the less well-off in society; basically, as a result of this gradient, we will affect the entire population. Therefore, we will also affect those that are better off. It is a layered type of effect, which is important to be aware of.
The next slide is to provide you with an example that just came out. This is a recent report from the Health Council of Canada on diabetes. On the left, we see the prevalence of diabetes in the population with the lowest income and on the right the prevalence of diabetes in the population with the higher income. Again, we see a gradient approach. We see a three-fold difference. There are pretty major differences in health outcomes, according to this slide.
What are the specific vulnerable subpopulation groups that have a relatively disproportionate burden of disease? This slide represents work that was undertaken by a FPT task group on health disparities, which was established for the conference of deputy ministers in 2005. They have identified actions needs to identify three subcategories: First, individuals in lower socioeconomic status groups. We know that leads to reduced life expectancy, higher infant mortality and a higher prevalence of chronic diseases. The second category involves Aboriginal identity. We know that Aboriginal peoples have higher death rates, particularly from chronic diseases. The third category is gender, which we know obviously interacts with other determinants. Although women live longer, they experience more years in an unhealthy state.
Finally, on geographic location, the people who are living in remote communities have the worst disability-free life expectancy and the lowest life expectancy in the country. That is just a categorization that was identified and reported for the conference of deputy ministers. It is the result of a fair amount of research requested for this work.
What are we learning? We are now talking about one aspect — how economic development and social policies could affect health. However, because we want to think about the messaging in social sectors, we need to look at the relationship of health as a key contributor to the economic development of a country. We need to learn more about that equation if we want to have any ``buy-in'' from other sectors. How does health become an asset for society and a key contributor to the economy?
In that context, there has been a fair amount of work done by the OECD, the WHO, the World Bank and, more recently, the European Union on that equation, which results from the fact that increased health obviously increases productivity, labour supply, educational achievement and human capital development. There is a new body of evidence around health and the economy, besides the traditional health and wealth. That is highly important as we move forward in the messaging, so I wanted to mention it before the committee today.
What are we learning from other countries and from within Canada in terms of addressing the determinants and the social determinants? I would suggest that many interesting efforts and initiatives are taking place in Europe, at the European Union level and at the national level. The European Union, through article 152 of the Amsterdam Treaty, is legally bound to consider health in all its policies. Change takes time, but they are beginning with a legislative base in looking at ways to integrate health considerations in all of their social policy decisions. They have developed an observatory and are looking at how they can accomplish that.
During its presidency of the European Union, Finland developed an important report, entitled ``Health in all Policies,'' published in 2006, I believe. That report provides a strong basis for examining the experiences to determine what is known and not known to help them move forward. That document is important in terms of capturing many of the European experiences that could shape and help us to develop.
The United Kingdom has been in the lead in terms of the conceptual and analytical part in respect of poverty and health, with its Black report, the Whitehall report and the Acheson report. Interestingly, the U.K. has moved to action; in 2003, an analysis of cross-governmental programs and spending review took place to estimate the contributions made in terms of reducing health inequalities. In that review, targets were established for reducing health inequalities, in terms of both increasing life expectancy and reducing infant mortality. Interestingly, public service agreements are required from all sectors on how they intend to contribute to those two targets. Again, they have established mechanisms to get the contribution, all of this being led by the treasury, which is a powerful method. They moved from the conceptual analytical development to a treasury-led effort cross-governmental that asks departments how they are spending and contributing to this target set for all of government.
Everyone talks about Sweden as a country that has led the way in terms of having a whole-government approach. Sweden established 11 societal public health goals that resulted from a consensus. To develop those goals, they brought together the seven political parties and met with experts from labour, unions, academia and the health sector. Those goals represent a societal consensus. The result was the public health goals and a public health institute in Sweden. The mandate of that institute is to monitor progress toward these goals. As well, it is the technical backup to the implementation of these goals.
Those are some of the experiences outside Canada, but we have had some very interesting ones right here in Canada. The Quebec public health law determines what Quebec can do in terms of whole-government thinking. The legislation gives the Minister of Health and Social Services the authority to mandate a health impact assessment of any government policy that is expected to have a significant impact on the health of the population. The Institut national de santé publique du Québec is the technical backup that supports such work. They are beginning to develop tools around health impact assessments and we need to have those tools if we want to know what the impact is. The INSPQ is the collaborating centre for the public health agency around public policy, which is looking at the issues of governance, mechanisms and tools. We are building on these Canadian centres of excellence to help other provinces and other regions of the country to learn from that experiment.
What did we learn? We were able to identify a few common elements in terms of learning. The first one is that there needs to be a strong centre of government leadership. The second one, which is extremely important, is that it requires lead agencies, and in Finland, the U.K., Sweden and Quebec those agencies are the national or provincial public health institutes that are exerting technical leadership and providing support to a number of health impact assessments, economic modelling and determining the basis of the approaches.
That is one thing. The second thing is that legislative instruments could also be very useful in terms of moving forward. Finally, the development of policy frameworks such as goals is important if we want to measure progress. Out of that, there are some beginnings in terms of some directions that countries are taking.
What have we done in Canada? The WHO Commission on Social Determinants of Health is saying to us that before we effectively base our policy decisions on social determinants, we have a few prerequisites, which are that we need to have in place certain kinds of social supports and basically some kind of social orientation. We have in Canada a fair amount of foundations on which to move forward.
Our success story in Canada is in how policies could influence key determinants. It is the fact that the poverty rates of seniors have diminished. When you compare us to other countries, we are doing very well. The seniors are the least disadvantaged of the Canadian poor. That came out of very specific policies.
What do we do in the health sector? Given that we are talking about determinants that are outside of our purview, what have we learned in Canada in terms of health sector action? If you look at certain milestones, we, in terms of conceptual and analytical development, have been the lead in the world, but in terms of concrete action and holistic approaches, while we are starting to move there, we have mainly had a lot of developments around the more conceptual and analytical part of the determinants kind of debate.
I will not give you all the milestones, because I am running out of time, but I do want to talk about some of the assets that we have out of this development.
Canada has the strongest knowledge infrastructure to move forward on determinants. We have the Canadian Population Health Initiative. The job of that initiative is really to do the knowledge translation around the determinants of health. We have a key institution whose main orientation it is to do the synthesis or the dissemination on determinants of health. We have key research institutions. The Canadian Population Health Institute, the Institute of Gender and Health and the Institute for Aboriginal Health are supporting a lot of research funding to understand but also to learn more about effective approaches to address these determinants. In fact, we have supported over years a number of centres of excellence, and those are knowledge networks or networks of knowledge networks, to put it that way.
I want to point out the centres of excellence for children, because that is really a very important asset again in terms of synthesis of information. We have a knowledge hub on early childhood development in Montreal — the Centre of Excellence for Early Childhood Development — that is connected to the work with Clyde Hertzman that is connected to the social determinants of health. You are starting to see my gist.
We already have existing, concrete knowledge networks around certain themes that are very important. Again, those are assets we need to build on. We also have these collaborating centres. With the establishment of the Public Health Agency of Canada, we established the six knowledge translation platforms, and half of them are relevant to the whole determinants agenda. We have the healthy public policy one, which is basically the one I mentioned in Quebec, the determinants of health, which is in St. Francis Xavier in Nova Scotia, and the Institute for Aboriginal Health, which is in British Columbia. Those things exist and work is happening.
What are some of the challenges? We still have huge challenges in terms of coordinating this massive mountain of evidence and bringing it together and making a story out of it. That is what is missing. In terms of the knowledge, we have data banks all over the place. There are interesting data banks that come from perhaps other ministries, such as the transportation ministries. We have data banks around the health area. We need to develop more integrated information systems that can tell the story in terms of those determinants and the health outcomes, but to do that will require more capacity to bring all this together. Basically, it is not that they do not exist. As I said, Canada is very well positioned in terms of having all these institutions. We need now to we bring it together.
Most of the intersectoral action in this country has been at the community level. That is where we have experimented with those approaches. We have been funding a number of programs, the most known of which is around children — the community action program for children, the prenatal nutrition program, the Aboriginal Head Start. Those are examples of actions at the community level basically looking at the determinants and identifying vulnerable families and children as the main target groups.
We have some experience at the lab in terms of how we do this, and that has been going on for the last 10 or 15 years. These efforts have been evaluated. We also have a population health fund that has been established since the mid-1990s when we talked about population health approach. Those funds were there to be able to support efforts and interventions that would take that population health approach and evaluate it. We have had, over the last 15 years, a fair amount of effort in the country, but at the community level, and the evaluation is more at the community level.
Again, the problem is how you evaluate those complex interventions. Solid health outcomes take time. Often, they might have impact in other aspects, which is maybe not immediately health. It could be around integration of children in school or other such things. The evaluation challenge, in terms of these kinds of complex interventions, is that it takes time to get to a hard outcome. We have intermediate outcomes that we need to track. In terms of evaluating these efforts, you need to identify incrementally what you will actually get out of this the process and outcomes before you get to the hard outcomes.
Beyond the community, Canada and the provinces are moving towards what I would call whole-government approaches, and we are seeing some beginnings. You might have heard about the centrally-led, cross-government effort around a health issue called ActNow BC. The driver for this is they want, by 2010, to have the people in British Columbia as the healthiest in the world, so it is pretty ambitious. There is a cross-governmental effort led by the Prime Minister around that. Quebec has a cross-governmental effort around obesity that was launched this fall. We are seeing more and more cross-governmental approaches in this country.
There are many challenges around that. I think the main problem here is we are starting to have capacity around measuring health impacts of social sector investments. We need to develop managerial structures for horizontal work, accountability and protocols. If we want to do this, it will be about collaboration and partnership, and that takes time and resource. You need to invest in collaborative structures.
The next slide illustrates that countries have different stages in getting to the more holistic approach that we heard from the U.K. and Sweden. I think in Canada — and you might have heard Monique Bégin say this — we have had a number of isolated initiatives where we have taken a determinants approach at the community level. She calls it a country of pilot projects. We are moving towards a more government and joint up action. You are seeing this occur in the provinces and there are also, I think, some new opportunities for us to move in that direction.
In terms of identifying the gaps and what we have learned both in Canada and internationally, we need to put energy towards the assessment, identification and communication of impacts of government policies on health and health inequalities. That is a whole area that still needs to be developed and strengthened in this country.
We need to look at what the mechanisms are to bring joint up action. As I have mentioned, we must have information systems that are more integrated and include determinants type of data sources.
In Canada, we are obviously at a very important juncture. First, there is a commission at the global level that will be terminating its work in 2009. Basically, it is creating momentum around this issue, particularly by looking at the determinants and policy options that countries can look into. That is important work.
We will be hosting the next commission meeting here in Canada to be held in June. I think that will obviously raise awareness of this issue. We will also be holding a major conference in Vancouver on health promotion. This again will raise visibility around this whole determinants agenda.
In terms of our involvement with the commission, I wanted to highlight three major areas. First, we are heavily involved with Sweden, the U.K., OECD, World Bank and WHO around looking at the economic analysis of upstream investments. That piece will help the argument.
Mr. Ball is very involved around the global review of intersectorial action, determining the models that exist all over the world, both in developed and developing countries. Canada is actually leading that effort. It is part of the country component of the WHO Commission on Social Determinants of Health.
We are working with New Zealand and Australia in developing a compendium of policy approaches to addressing the determinants of health of Aboriginal populations.
Out of this big global effort, Canada is leading and displaying a fair amount of interest in moving certain parts of the work of the commission so it benefits us.
This slide indicates another very important event for us. I mentioned it at the outset. The public health report to Parliament will deal with health disparities and social determinants. Obviously, that will be presented to Parliament. We found that when you look at many countries and our provinces, those public health reports could build awareness. It is important if we can communicate that. With respect to the public health report, some countries in Europe have a debate around some of these major themes with regard to the population. There is an opportunity here in terms of increasing awareness of this issue.
Again, in terms of looking at other countries that are struggling — I was talking to colleagues in South America just last week — as they are trying to move to address this agenda, going back to the role of the health sector, how does the health sector exert its leadership? What does it mean in practice? We are finding that, in many countries, they are so involved with the delivery of services at national levels that they do not have the space to deal with and work with other sectors and be a steward in terms of involving other sectors around determinants.
In Canada, because of its federated system, there is a space that at the federal level can be filled in terms of bringing together all of the main players in government and outside of government. However, I think the stewardship role of public health is a key aspect of moving that forward. You need a champion, but that champion cannot be stuck with all the other provision issues. I thought that was interesting.
The country that seemed to have done the best is Costa Rica. They decided that they will put all provision of services at the regional level, like Canada does, but they have taken this space and will be putting it around the broader policies that impact on health. It is interesting to see how countries are exerting leadership on the health sector.
I summarize the rest of my presentation. We are saying that despite a relatively strong economy, health inequalities exist and could worsen without intervention. Addressing determinants of health benefits everyone. We know we can make gains using various policy levers. We have the models to learn from and the foundation to build on. Where knowledge exists, we know where there are gaps and what is involved in filling them.
I think there is potential for Canada to take an important leadership role in this agenda. It is not like there is an absolute model to follow. We are paving the way, we have the foundations, we are learning from others, and the time to act is now. Thank you.
The Chairman: Thank you. That was a very long presentation. However, I knew it would be. We wanted to get an overview from you because you have a better grasp of this subject over anyone I know.
We deeply appreciate you coming here early on in our study and telling us what you think is out there and indeed suggesting which direction we might start to go. We have our own ideas about where we want to go, but we will need your help.
It is also important that we proceed in sync with the Public Health Agency of Canada because it is timely now, of course, with the WHO. I hope our report is out before theirs in 2009. We will be imposing on you along the way. Dr. Stachenko, I wanted to ask about your determinants, in which you did not list the health care system. Allow me to expand.
It was suggested to us that we look at it not only carefully but also at both the positive and negative components of the health care system on the determinants of health. The second leading cause of death in Canada is the health care system or accidents within. Only heart disease is a greater leading cause of death. You would agree with that — and it is in your material. Is that right?
Dr. Stachenko: Yes, it definitely is. I was thinking of mentioning that beyond health care we have to look at these others. Definitely, health care is a key determinant. As you know, the WHO commission has acknowledged the health care system as a determinant.
The Chairman: We will move to questions.
Senator Cochrane: I am overwhelmed by the work that has been done. I am glad to hear you say that we have compared with other countries and have developed solutions in conjunction with the WHO. We can only improve by doing that and it is wonderful.
It has been suggested that one of the benefits of health promotion and population health efforts is that by making people healthier demands on the health care system will be reduced. This would save us money and make our health care system more sustainable over the long term. I understand you have agreed with that. Can you quantify the potential savings from health promotion?
Dr. Stachenko: The phrase ``health promotion'' encompasses a great deal.
Senator Cochrane: Yes.
Dr. Stachenko: The latest investing report on chronic disease looks at the savings in terms of investment in the prevention of chronic disease. That savings would include figures on health care costs and national foregone income. We are talking about huge amounts. I do not remember the exact numbers but that is the kind of language we need to use to position this entire agenda — the sustainability of the health care system not only within the demographic population and our aging population but also with the fact that basically our underlying risk factors are increasing. The health care system will go broke if we do not look further upstream. We have those numbers, although I do not have them with me, on certain areas of prevention and what the health care cost savings are and what would happen in terms of national income losses. We also have comparative numbers with other countries.
Senator Cochrane: What do you think of the counterargument that the effect of people living longer, which is what we are seeing, and in healthier lifestyles is to defer the inevitable costs of old age and, in the end, we will not save money.
Dr. Stachenko: We want people to live healthier lives and if we can do this compression of morbidity, meaning that people are living healthier, then that is where the costs are engendered. It is true that during the last two years of life, the greatest costs to the health care system occur. We are looking at trying to keep people healthy until they drop dead.
Senator Cochrane: It does not always happen that way.
Dr. Stachenko: We are talking about what is avoidable. Currently, we think of only the elderly, but we are seeing people going through amputations and renal dialysis as a result of diabetes. The health care costs of that are huge. There is a great deal of potential in terms of reducing those pressures on the health care system. We do not need to have amputations or renal dialysis — they are avoidable — and yet these are on the increase not only in the elderly but also in our younger population.
Senator Eggleton: Thank you for that comprehensive presentation. One of the challenges and frustrations that I have found in the federal government over the years is the horizontal linkages of programs and services. We are a silent system federally, as are some other levels of government. If we are to do these social determinants of health comprehensively, we have to look at those horizontal links. Your website says that, in a population health approach, the articulation of health goals and targets includes the clear delineation of strategies to be undertaken and parties responsible for achieving targets. Are you working on developing these strategies with measurable outcomes? How will you get the buy-in other departments? Will the Public Health Agency or Health Canada tell departments, such as Human Resource Development Canada and Environment Canada, that they must meet certain goals and targets? How will that be accomplished?
Dr. Stachenko: I was trying to refer to that. Some people would call that health imperialism, but that is not what we are talking about. Rather, we are talking about changing the language. It is not only about looking at how they can help us but also about that whole debate on how having healthy lands could help their respective agendas.
We need to have value added for both sides, and the way to that is not clear currently. We need to have targets like they have in Sweden, where they address all governments and departments, who contribute to the goals, and where there is an agreed-to monitoring system and a societal consensus. There is a centre-of-government kind of leadership in Sweden. Or, it could be a system like the one in the U.K. that is financed, whereby departments tell government what they are doing to contribute and are then financed.
I envision health as being in a kind of stewardship system and supporting arguments and technical backup in terms of health impact assessments. They will not do that; we need to help them to do that. We need to offer something. Transport policies are developed for purposes other than health. We need to figure out how we can have policy cohesiveness where it is a win-win for both in terms of showing the contribution. A great deal of technical work needs to be developed, and there are many arguments about it. I spoke to the lessons learned — the need for centred government, targets and technical backup so that it is evidence based at the end of the day.
Senator Eggleton: Your website also refers to a population health fund. Where does that stand?
Dr. Stachenko: That is a funding mechanism within the PHA that carries a few conditions. These are interventions that have to involve the target population and a few sectors and take a comprehensive approach. That is a mechanism we have to stimulate action on determinants. Much of this has been to support a fair amount of community effort in this regard.
Senator Eggleton: Has there been take-up on the fund by the community?
Dr. Stachenko: Yes. It is very well known. The problem is, again, they are mainly isolated community efforts. I tend to agree with Monique Bégin that we have learned a lot, but now we need to bring it together and institutionalize the learning into practice. The demand for that fund is huge.
Senator Callbeck: Thank you for being here today. You have given us a lot of information. When was the Public Health Agency of Canada established?
Dr. Stachenko: It will be two and a half years in September.
Senator Callbeck: That was under Mr. Bennett?
Dr. Stachenko: The Public Health Minister at the time was Mr. Bennett, correct.
Senator Callbeck: This report that you are talking about and that will be presented to Parliament will be the first report of this agency?
Dr. Stachenko: It will be the first report under the leadership of David Butler-Jones, who is the first Chief Public Health Officer in Canada.
Senator Callbeck: This is the first report of the Public Health Agency of Canada to be presented to the public. What will it cover?
Maura Ricketts, Acting Director General, Office of Public Health Practice, Public Health Practice and Regional Operations Branch, Public Health Agency of Canada: Basically, Bill C-42, our enabling legislation, requires that the Chief Public Health Officer produce an annual report on the state of the public health. It actually says that.
During this first year of producing the report, because we are given about three years to get ourselves on our feet, and it is a highly complex task, Dr. Butler-Jones selected the topic of health disparities to be viewed through a life course. The idea is to start at childhood through being a young adult and, as you age and become elderly and eventually die, what are the impacts of the variety of health disparities? How can we intervene effectively? What is the role of public health in these areas, et cetera? That is basically what the report is about the first time.
There is no obligation to do exactly the same thing each and every year. We anticipate that, in the future, there may be a core component that is repeated, but we may shift the topic area to reflect a wide variety of other pressures or needs. This first time will take a long time to get us on our feet, but we will be developing the theme of the second report sometime this summer and will begin running these reports out annually with about a two-year prep time.
Senator Callbeck: With those reports, will we be able to measure in any way from one report to the next how we are doing in certain areas?
Ms. Ricketts: We can use those reports to look at those measurements, but, without getting into the boring part of things, although it is the kind of thing I love to talk about, coming up with a good indicator for the health of the population is not so easy. One big underlying effort we are involved in at the agency is working with other organizations, like Statistics Canada, to determine what kinds of indicators we could report on. It is important to understand that it will not change quickly. You can perhaps see people becoming thinner fairly quickly, but would you be able to see an impact on diabetes rates? It would be delayed over time, just as we saw with the behaviour of teenage girls smoking, the impact on lung cancer will arrive some years down the way.
I have to confess we are building the plane while flying it on this report, and we are learning from our various partners about the best direction to go in this. It is certainly something we are considering.
At the risk of yammering on and on, we were inspired by the Chief Public Health Officer's report in the U.K. where the Chief Public Health Officer made statements and said, ``This is a problem area. This is exactly what it looks like now, and next year I will come back and talk to you about what we did.'' It has to be recognized that the Chief Public Health Officer in the U.K. actually controls the health system in that country, as opposed to our federated system where we do not have that level of control.
Senator Callbeck: Many of these initiatives will be provincial. You mentioned British Columbia. Will there be reference in this report to those provincial initiatives?
Ms. Ricketts: Certainly, yes. A few weeks ago, we presented on this report to the Public Health Network Council of Canada, which is ADMs and Chief Public Health Officers of Health. We discussed it with them, because our best examples come from provincial initiatives.
The Chairman: We have this beautiful example of population health right now. With cervical cancer in women, we used to spend all this money on radiation and surgery, and the complications were terrible. Now we have a vaccine to cure it. To me, that is the mindset that people have to come up with for population health.
Dr. Stachenko: Exactly.
The Chairman: The savings there are enormous, and women will be saved enormous pain and suffering.
Senator Fairbairn: It is very interesting to hear you on this. We have just concluded another study, and will be working away on that tomorrow, and that is on literacy. I have noticed through your material the issue of education and learning and early childhood development. We often talk about literacy as a foundation issue. Looking at your work, the education and learning capacity here is also a foundation issue.
I was wondering, as you go along your very interesting and difficult trek, certainly Statistics Canada has had some quite outstanding people who have worked on this particular subject, but have you had any discussions with any of the organizations or national groups or even local programs on this issue? That would be people who are actually working in the field and facing this every day. I was wondering if you had been able to have any useful guidance or material on the part that it plays in the whole larger issue of health.
Dr. Stachenko: Yes, definitely health literacy is a key part.
In terms of what we have done more practically, a fair amount of work has been done around that in our regions through some of the community programs, and I know there are some findings in that. In terms of a national systemized effort, I am not sure. We definitely have a lot in terms of work growing at the grassroots level. Tools and methods are out there. It is part of our funding programs that we want to learn about how to do this. It is a key component of our children's program. As part of that, there are a number of tools, resources and approaches that we are learning from.
Jim Ball, Director, Development and Partnerships Division, Strategic Policy Directorate, Strategic Policy, Communications and Corporate Services Branch, Public Health Agency of Canada: I think your question is important and relevant in terms of the link between education and health, and obviously literacy is a component of that broader education domain. Within that, we have what we call health literacy.
In addition to these community investments, we have more recently created the national collaborating centre on the determinants of health that Dr. Stachenko mentioned. A big part of the work they are completing is to look at the link between health and learning, health and education in general, as well as health literacy. We want to determine how we best go about supporting Canadians in learning more about health, thereby taking control of their own health, not only through individual behaviours but by trying to influence the conditions within which they are living and working with that knowledge behind them.
Senator Fairbairn: This is particularly relevant when you get into the area of seniors and how important it is to retain as best they can their own well-being when they are not able themselves to read or communicate much. That is a key effort.
The Chairman: I am afraid we are being unfair to our other witnesses, so if you will forgive me, we will move on.
Michael Wolfson, Assistant Chief Statistician, Analysis and Development, Statistics Canada: I appreciate the time limits of the committee.
I appreciate the opportunity to help inform you in the important work you are undertaking. I will confine my remarks to a few examples of the evidence supporting the importance of the social determinants of health and the importance of a population health perspective when we think about the kind of health information Canada needs.
By way of background, my day job is at Statistics Canada and it includes responsibility for our health statistics program. I also spend a fair amount of my time as a population health researcher. I have four slides, but it will take me a while to walk you through them. I will try to keep myself to 10 minutes.
Let me begin with the most persuasive evidence in Canada that social determinants of health are indeed real and important. We have witnessed a major change from 15 years ago when I started the research that resulted in this graph. At that time, there was considerable scepticism that income was related to health at all. Now it is commonplace.
A few weeks ago, Ms. Bégin, in making the same point to your committee, referred to the Black report and the Whitehall study, both of which originate from the United Kingdom. In this Canadian analysis, we have gone on the hardest data possible.
The horizontal axis in this graph shows earnings as measured by Revenue Canada, while the vertical axis shows mortality from death certificates. They are connected fortuitously in this analysis in the data used to compute Canada and Quebec pension plan benefits and contribution.
In fact, and more subtly, we have on the horizontal axis average earnings over almost two decades before reaching the age of 65 and on the vertical axis mortality rates for the five years after reaching the age of 65.
In other words, underlying this graph, there is longitudinal data for each of over half a million men. The results, therefore, are strong and show more than a statistical association. They argue strongly for a causal link from income to health and not the other way around.
Moreover, the graph shows that this influence is not a threshold. This is not simply a story about poverty or low income. This is a gradient, as Dr. Stachenko mentioned previously. Every step up the earnings ladder confers a benefit in terms, in this case, of survival past the age of 65. This means that the social determinants are not only a factor at the bottom of the socio-economic hierarchy — I think you have likely heard this term used a few times — but they affect the lower and upper middle classes as well, indeed everyone.
There is a further point about the size of this gradient. I point out that the steps are not all equal sized. It is 20 per cent in the middle but 2, 3, 5 and 10 per cent at each end.
If the 80 per cent of men with the lowest earnings were somehow able to achieve the survival rates of the top fifth, their increase of life expectancy would be about one year. This turns out to be about the same as if we could magically eliminate cancer as a cause of death in this cohort.
The previous slide showed data only for men and then only at middle and older ages. It also focused only on mortality. For centuries, indeed up to the present, the most widely used measure of overall population health has been life expectancy, which is essentially a summary index of mortality rates across all ages.
More recently, paraphrasing the Quebec Rochon commission of some years ago, health policy quite correctly is concerned not only with adding years to life, but with adding life to years. This means that we need measures that combine length of life with the healthiness of those years of life. That question was responded to a few moments ago in terms of compression of morbidity, which is talking about the combination of years of life and the healthiness of those years.
As a result, Statistics Canada has developed measures of health-adjusted life expectancy, HALE. We have done this in parallel with other organizations, such as the WHO.
Information systems that can measure HALE provide the fundamental bottom line for population health. In terms of one of the committee's questions about the kinds of infrastructure we need, these measures should be an essential component of the government structures for generating, monitoring and assessing policies.
These graphs in particular show on the left life expectancy and HALE for males and females for the first two bars at birth and the second two bars at the age of 65. The red colour indicates those people who are assumed to survive to the age of 65. The total height of the bar is life expectancy, and the shaded portion is health-adjusted life expectancy.
On the right are two groups of three bars, one for males and one for females, which show how these look by income groups, in this case, thirds. The red-coloured braces show the differential between the bottom third and the top third of the income spectrum, first for men and then for women.
Again, to put these disparities in context, the gap between the bottom and top thirds is larger than that attributable to heart disease and lung cancer combined.
One fundamental challenge for a broad understanding and action on the social determinants of health is something so basic that we are generally unaware of it. These are the kinds of words or concepts we use in conversations about health. These conversations are dominated by a biomedical or clinical paradigm.
When I started in the health field at Statistics Canada, it was taken for granted that all our data should be defined and measured in terms of diseases and risk factors.
For example, the latest thinking about the major cause of or precursor for diabetes is labelled syndrome X. There are several definitions, but they all use some combination of cholesterol, blood pressure, blood glucose and adiposity measures. By labelling and describing the causes of diabetes in these terms, should we be surprised that the first line of attack in thinking about preventing disease is in terms of pharmaceutical interventions, for example, to lower cholesterol or hypertension, and counselling by your family doctor to improve diet and physical activity? However, if we had for the last 30 or 40 years a statistical system that described diabetes as an end point, but socio-economic status and sedentary lifestyle measures rather than the kinds of clinical markers that comprise syndrome X, we might instead have concluded, having done the same kinds of epidemiological studies, that diabetes is caused by ``low stat sed syndrome,'' my phrase for low socio-economic status, sedentary lifestyle syndrome. In turn, with these kinds of labels for the causes of the disease, we might have privileged a very different range of interventions. Instead of pharmaceuticals and counselling, we might have thought more about effort-reward balance in the workplace, different incentive structures and regulations for the food industry, whether our urban transportation options are obesogenic, and different priorities for raising children to inculcate lifelong attitudes towards ingrating physical activity into daily life.
Let me conclude my remarks with one more graph and this response to Senator Keon's question about whether the health care system is a determinant of health. This is a bit of a complicated graph, so I will take a second to describe it. Each dot in this graph represents a health region in Canada, indeed a large region with over 100,000 residents. For every resident within each of these health regions who arrived at hospital with a heart attack, two basic features of their medical history were extracted from the data. Were they treated with heart bypass or angioplasty, in other words, revascularized, within 30 days, and did they die within 30 days? The horizontal axis shows the percentages in each of these regions who were treated, while the vertical axis shows the percentages that died. By the way, these are age and sex standardized. The red dots show the situation in 1995-96, while the blue are eight years later.
There has clearly been a dramatic increase in the proportion of people who come with heart attacks who are treated, almost a tripling, from 14.5 to 39.5 per cent. We might therefore expect a similar improvement in outcomes, and we do see some improvement in survival, but, compared to the increase in treatments, the reduction in mortality is really quite modest, about a 15 per cent drop from 11.5 per cent to 9.7 per cent 30-day mortality. Moreover, the scatter of these dots shows a very wide variation among health regions. In 2003-04, a number of health regions had 30-day mortality rates around the eight per cent mark, if you look at the scatter horizontally just below the 10 line, yet treatment rates varied more than threefold, from under 20 to over 60 per cent.
To me, this signals a fundamental problem in the way we manage our health care system. There is lots of smoke, but I am not sure where the fire is. The slide also tells us about what we do not know. Obviously, there is much more to caring for heart attacks than revascularization, but we do not routinely collect the data to enable us to understand why some regions appear to be doing so much better than others — in a word, to learn what works in preventing heart attack mortality. Some of what we do not know relates to clinical medicine, for example, how quickly clot-busting drugs are administered after the heart attack and how often beta blockers are prescribed at discharge, but other missing pieces of this puzzle relate to lifestyle and risk factors. For example, are the heart attack patients in one region much more likely to be smokers or to be obese? Are there significant differences in what some call the clinical signature, the leadership and practice patterns of the physician group in one health region compared to another?
Most fundamentally, in my mind, this slide shows how important it is to bring together what have up until now and generally continue to be two solitudes — clinical medicine, on the one hand, and the broader social determinants of health on the other. In your work as a committee, I would commend you that these should be joined, both in our thinking and in that fundamental prerequisite for effective action, our health information system. The key question raised here, both for clinical medicine and for social determinants, to repeat, is figuring out what works, ensuring we have the evidence base both for monitoring and understanding what we are already doing, and to make the difficult choices regarding what new interventions, whether clinical or directed toward social determinants, merit investment.
I am happy to answer your questions.
The Chairman: Thank you very much. We are old friends. I do not know how many years it has been — probably more than either of us cares to admit.
We will go ahead with Mr. Glouberman's presentation, following which we will have questions for you both.
Sholom Glouberman, Associate Scientist, Kunin-Lunenfield Applied Research Centre: My sense is that you wanted a very quick beginning for discussion, and that is what I thought I would do. It took a long time to prepare because, in order to say what I have to say, it is very easy to say in four hours, but saying it in 10 minutes is really hard. It took me a while.
I made this chart, because it seems to me that the state you are in, the difficulty you have, is the fact we have gone through several very big ideas about health and health policy, and I thought I would try to lead you through the ideas about health policy that come from the public health folks and give you an overview of that and a sense of what the ideas are, what some of the policy consequences of the ideas were and what some of the outcomes were, and then some of what the odd outcomes were as well.
The earliest big public health idea came from a group called the sanitarians, who believed that filth caused disease and that filth was the cause of the epidemics that were the presenting problem at the time. That happened all the way from the 17th century through to the 19th century. In the early 19th century, they thought they would do something about it, and a guy by the name of Edwin Chadwick in England, who was I think probably the Michael Marmot of his day, began a process of working towards a public health law. It took him 50 years. He had this idea together with a fellow by the name of Jeremy Bentham, who was tremendously influential on public policy in England, and together they worked on this. The idea was to clean up the air, the water and the sewage system. That was the most massive effort of public health in the 19th century, which culminated at the end of the 19th century.
They promised that if they could improve the physical environment in these ways, this would reduce the requirement for medical care, it would make people healthier, it would result in much healthier population, and it would have the consequence of less sickness and less need for medical care. That was the promise at that time. At the end of the 19th century, that happened and people became healthier, but it did not reduce the demand for medical care. People did become healthier, and there was a huge increase in longevity and a huge decrease in mortality. Certainly, there was the beginning of the response to these major epidemics.
That grew at the end the 19th century when you had the beginnings of scientific medicine. At the beginnings of scientific medicine, you began to see that you could actually conquer some diseases like smallpox. People began to understand how the diseases worked and to have the knowledge and understand what the interventions should be to cure or prevent those diseases. The second big idea came from this. At the end of the 19th century in England, there was the Boer War in 1899 to 1903. During the Boer War, the soldiers went and came back, the ones who were looked at by doctors, with what were discovered to be medically curable diseases. Medicine was become being more scientific and there were more medically treatable diseases, but people did not have the money to go to the doctor, so they said, ``Let us have a universally covered health care system.'' The idea for that started in about 1899. People began to fight for it. It took 50 years for that to happen in the U.K. In Canada, the idea came out after the First World War, and it took about 50 years for it to happen in Canada, to go from the idea to implementation of universally funded health care.
I think that was the second great public health idea, to provide health care to everyone. It is an idea that still has not come to fruition in the United States. If you listen to American public health people, they argue for universally funded and universal coverage in health care. They have not gone there yet.
When they argued for that idea, the people promised that if you had availability of doctors and hospitals for everyone in the population and you treated what was medically treatable, you would have a healthier population. The consequence of that would be that there would be less demand on the health care system.
Of course, we all know that did not quite happen. Although, in fact, longevity went up and the population is indeed healthier by many measures. Therefore, you have a healthier population but an increased demand on the health care system as a result of these kinds of interventions.
A third idea came up in the 1960s by a man named Thomas McEwan, who was a kind of epidemiologist but more a thinker about health and health care. He is very impressive because he recognized that there were more determinants of health than a clean environment and medical care. His argument was that there are more influences on health than these things. He argued for research, for the social determinants of health and for lifestyle. People could then take control of their own health and take control of what they did in terms of lifestyle.
He had a tremendous influence on a man by the name of Hubert Laframboise. I do not know if you know who he was. He was the man who wrote the Lalonde report. Historically, the Lalonde report was probably the most influential health policy document to ever come out of Canada. It sort of hit the world with a storm. If you have ambitions to do something important, what you want to do is something that has that kind of influence and that kind of impact on the world.
The Lalonde report made 52 recommendations. It was interesting that the recommendations in that report were recommendations into policy, and many of those policies were actually created and carried out. Things like ParticipACTION, the Canada Food Guide and mandatory seat belts all appeared in the Lalonde report.
What is very interesting about the Lalonde report is that, even though all of these policies came out, there have been very interesting consequences and interesting things have happened to the health of the population since. For example, we eat more white meat than red meat. We did a study of this. In the 1970s, milk was homogenized or skimmed. There was no intermediate kind of milk. People ate very few green vegetables and fruits as compared to now. We eat more green vegetables, more fruits, more white meat than red, we drink low fat milk, we eat more low fat foods, we follow all of these things, and yet we have an epidemic of obesity. That is very interesting. What is that all about?
A lot of things change in a period of time. What happens is that policies that fit one time have to fit into a complex environment. You have heard this from both of the people who spoke before, that we increasingly recognize the extent of the complexity of the environment. We increasingly recognize that the interventions we make may have odd outcomes, which is true for the many interventions we look at. We must look more carefully and more locally at what we do.
The second big idea that came after the introduction of universal health care was the idea of inequalities in health. Of course, the Black report came out in 1980, and a huge amount of work has been done on inequalities in health.
As the people from the Public Health Agency of Canada said, it is very clear that these determinants of health, though we now have a certain number that we espouse, the number of determinants has grown from four in the Lalonde report to 10 or 13, depending upon where you look in Health Canada, to 28 when people start to look over the field. When people look at indicators, they have now managed to see more than 5,000 of them.
Therefore, the idea of what a determinant is, how it interacts with other determinants and how policies interact with determinants is not a matter of doing more research. It is a matter of trying to get a much more fundamental understanding of the nature of that complexity. That is the stuff we are beginning to work on.
The new ideas arising start to recognize the complexity of the health and social environment and of the tremendous number of interactions. It is not only a question of being sensitive to health knowledge. It is a question of having education in general. Good kindergarten education likely helps make children healthier than not. That is the point. It is that these determinants are not necessarily health determinants but are social determinants and happen all over the park, in all the ministries.
One thing to think about is how you can start to provide a much broader picture of both the nature of health and the nature of the kinds of interventions that are relevant to health than we have had hitherto and of understanding the contributions of different things in a better way. Thinking and learning about that will take some time and effort. However, I think opening up people's minds is part of what must be done.
The reason I say this, over the last three years we have started a program at McGill University — the International Masters for Health Leadership. We have brought in health professionals from around the world. It is very interesting seeing how siloed people are, how hard it is for people to have a broad picture, how hard it is for people to see beyond their disciplines, beyond their immediate needs, beyond the needs of the people they serve and beyond their research directions. Therefore, getting these broad pictures is something that will allow them to see the complexity.
Also, I think there are measures that deal with complexity. The way in which you intervene in complex environments is not by having broad universal policies only but by thinking about the things that will release the efforts of individuals and small groups throughout a society.
A lot of policies do not release obstacles, they create them. The question is how to reduce the obstacles. We have some examples where we try to do that in some areas, and we are having a great deal of difficulty.
Many efforts of dealing with Aboriginal health in Canada over the recent years have been meant to release the obstacles for people starting to organize their own health system and understand it. However, that has been very difficult. Understanding what that means and understanding how to do it will take time.
There are examples in other countries where people are trying to do that. Others have mentioned the efforts in the U.K. The public health doctor of Scotland can target particular groups and start to work with those particular groups in order to release some of these obstacles and understand how they work. There are examples, and they are worth looking at.
However, I think it is very important to understand the fundamental ideas that stand behind the people who come to you so that you understand where they are coming from, what they are after and that the policies that must be engendered must go back to the people and have some kind of consequence for them. It is not a measure of validating or improving the measurement of the consequence; it is a matter of better understanding the kinds of policies we begin to create.
The Chairman: Unfortunately, we only have five minutes left because we must have a five-minute business meeting and be out of here by six o'clock.
I want to come back to you, Dr. Wolfson, and your chart, which I have been looking at for many years. Are you getting any closer to being able to sort out these discrepancies? Do you have the software to do it yet? Is that as far as you can go at this point?
Mr. Wolfson: The challenge is not the software. It is in having the underlying data that allows us to bring together more information ranging from the beta blockers and clot busting drugs, with which you are familiar I am sure, to the upstream social determinants factors.
We do have some capability by linking the Canadian Community Health Survey, for example, but then we are at risk of having small sample sizes.
In my view, if one is serious about attacking population health with social determinants, they must be thinking about the information systems that would support ongoing understanding and analysis. At the moment, we have a limited capacity, but we are pushing as hard as we can.
The Chairman: It is interesting that Canada Health Infoway just received a big shot in the arm of its budget. Although it is not as big as I would like, it is quite substantial. Have you talked to Richard Alvarez about giving you the appropriate programs?
Mr. Wolfson: There is more to it than the conversations that Statistics Canada and I have had with Infoway. A small group of people, including from CIHI and the provincial chief information officers, is talking about this. As you know, Infoway has been focussed on patient care — and the phrase ``secondary use'' or ``health system use.'' How do we ensure that that investment in vitally important new information systems serves not only patient care but also an understanding of what is going on in a chart like this one? It is a sensitive area because of privacy considerations and because, to be frank, I am not sure clinicians are happy with people analyzing their practice patterns statistically. It seems vitally important that that electronic health record initiative not only proceed but go ahead in a broader perspective that ultimately includes being able to provide information relevant to social determinants.
The Chairman: Do you see a possibility of a loop closing between you, CIHI and the Public Health Agency of Canada?
Mr. Wolfson: Certainly, we are talking. At my level, there is a consensus of view but I am not sure about the broader public level. For example, I do not know that politicians are focussed on these kinds of issues.
Senator Eggleton: Mr. Glouberman, I understand that you once wrote that making people healthier will help to reduce demands on health care services.
Mr. Glouberman: I never wrote that.
Senator Eggleton: Okay. I guess you do not subscribe to that.
Mr. Glouberman: I do not subscribe to that at all. The idea of compression of morbidity is a fantasy. Rather, it is a deferral of morbidity. I also think that we have an explosion of epidemics of chronic diseases and they are very different than the kinds of diseases that lend themselves to analysis in a straightforward way. Heart attacks are very different from the slow process of heart disease. They are the acute representation of a disease and the question about what happens over a long period of time so that we can slow down the progression of heart disease in many ways and still have heart disease. I believe that someone said that, with good management of chronic illness, we can avoid some of the worst complications, and that is correct. Good management of chronic diseases requires a great deal of input from the patients as well, and we are beginning to learn that. The notion of how disease is understood is interesting. Diseases that used to be thought of as acute are now thought of as chronic, like cancer.
Mr. Wolfson: In reference to the indicator that I showed on health-adjusted life expectancy, among other things it is designed precisely to enable us to understand whether there is a compression of morbidity or a deferral of it. We are assembling the best time-series data that we can do. Certainly, deferral occurs. However, the amount of time between health-adjusted life expectancy and life expectancy — the proportion of a lifetime that one can expect to feel unwell and cost the health care system money — is likely declining as a proportion, although we do not have the definitive data. It will defer health care costs only, and not eliminate them; we all die.
Senator Eggleton: You will have a better quality of life for a longer time, in your opinion.
Mr. Glouberman: That is the hope, and you can avoid some of the worst complications. If you think of that as compression of morbidity, then it is so. However, it is not the kind of situation where you live a full and healthy life and then keel over dead. That was the fantasy of the 1970s, but that is gone.
The Chairman: Available data show that the 100 year old who dies does not cost the system nearly as much in the last two years of life as the 50 year old costs in the last two years of life.
Mr. Glouberman: That is true.
The Chairman: If you can move the curve out, then you are saving money.
Mr. Glouberman: That is true. There are heroic interventions to save the 50 year old in the process of dying, but the cost of a 70 year old and 90 year old would not be that different.
Senator Cook: I should like to focus on the younger population and specifically on the future of those that are the ages of my grandchildren. In this complexity called living, which was so simple for me, how much can we find out about it, tell about it, and then who has the right to say that this is wrong? Where is the freedom of choice?
Mr. Glouberman: There should be a great deal more freedom of choice. I went to a conference on obesity in children. Because many people, especially those from the research community, are mired in an old way of thinking, which is reductive, in trying to reduce things to a series of formulating what is approved, you get into problems. The question of how people become fat is not only about eating fast foods and sitting before the TV but also about the nature of families and how much loving there is in the food, for example, which is very hard to measure. The question about understanding much more about the process of how people get along and how all of these things happen is not simply a matter of finding a series of variables but rather it is a matter of looking at the whole picture. People do make choices, and understanding what their choices are and including them and what they want to do in the mix is important in understanding how we move many of our policies forward.
Senator Cook: Like the policies of fast foods and transfats.
Mr. Glouberman: Yes.
Senator Cook: Until that came on the radar screen, it was a wonderful place to take your kids when you did not want to cook, perhaps on a Friday night. Now we have to re-educate children and reform their taste buds. How much can society or government inflict on the will of a person who wants to do as they please and to heck with the rest? We are victims of the marketplace.
Mr. Glouberman: Yes, we are such victims, but we can create other opportunities. Having opportunities for people to do things and to self-organize and decide what they will do ends up being very valuable in contributing to health and to how people operate and make choices in life. For example, I sat on a government commission for HIV/AIDS. I met a man who was sitting on that commission who was a gay Aboriginal. He said that he started smoking when he was 14 years old because he knew that he would be dead by the time he was 30. He knew that smoking was bad for him but decided that if he was going to die by the time he was 30, it made no sense not to smoke because it gave him pleasure. The choices that he made in the circumstances of his life were such. If we can create an environment where he knows he will not die when he is 30, then he will have to think about smoking in a different way.
The Chairman: I thank our witnesses for their testimony this evening.
Senators, I believe you have received a copy of this budget, which contains a change. I had initially asked for $70,000 for professional services, but I am now asking for $105,000 — because Mr. Chodos, who was to be my right arm, will move on to the mental health commission, as well he should. However, he is not readily replaceable. He has been with us for six years and has become a kind of appendage. Howard, we congratulate you.
Back to the budget, honourable senators. It will cost us a few bucks because we cannot replace him but instead will have to hire a few people with expertise. As well, an amount is included in the change for six from the committee to go to the Vancouver meeting, which is a must. This budget has to be presented at tomorrow's meeting of the Social Affairs Committee chaired by Senator Eggleton for approval, following which it will go before Internal Economy. Is it agreed, senators?
Hon. Senators: Agreed.
The committee adjourned.