Proceedings of the Subcommittee on Population Health
Issue 4 - Evidence, May 30, 2007
OTTAWA, Wednesday, May 30, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:20 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: Honourable senators, we have three excellent witnesses this afternoon. We look forward to hearing what you all have to say.
We are grateful to you for giving us your time because we are getting excited about the way our report is unfolding. It seems like a wonderful time in Canada because, with developments over the last 10 years, we now have a great science and health platform to deal from. We have the resources needed to get the information and systems that can change things to the ground.
We will start with Hillel Goelman. He is Director of The CHILD Project — Consortium of Health, Intervention, Learning and Development — and Associate Director, Human Early Learning Partnership, HELP. He has a great reputation from the University of British Columbia.
Hillel Goelman, Director, The CHILD Project, and Associate Director, Human Early Learning Partnership (HELP), Council for Early Child Development: I appreciate the opportunity to meet with you today to discuss the health, welfare and development of Canada's children. I applaud the committee's commitment to explore ways that the people and the Government of Canada can contribute to the lives of children. In addition to what you have on my CV, I am also speaking as someone who has taught young children and the teachers of young children. I speak as a father of two young men who have been raised to adulthood by my wife and me. I have been living the life of early childhood both professionally and personally for a long time.
I want to use a broad definition of child health. The three of us probably would agree that it is not just the absence of illness, the absence of disease, but that we are all concerned with looking for ways to support children's growth, development and welfare in all possible domains.
I will use a PowerPoint presentation to summarize some of the points that I think are most important my few minutes here.
I am speaking as the associate director of the Human Early Learning Partnership, HELP. Our motto is to create, promote and apply new knowledge through interdisciplinary research to help children thrive. One of the major questions we ask in our work is what makes a difference in early child development. One of my colleagues who works in the area of early intervention with young infants at risk says that I got it wrong. The real question should be: What differences can we make to make a difference? In other words, we do not want to just study for the sake of study what is happening with young children, but what is it we can do? Mr. Chairman, using your phrase, what can we do on the ground to make things happen, is what our research is about. I want to share with you some of the findings. We know about what can make a difference and what differences we can make in the lives of young children.
There are many different programs that work with young children. We know from our work and work in the United States and other countries that, when parents are involved, when children attend programs that are frequent, with a long duration, where there is intensity with staff training, these are good programs for children. We have much good information about what does make a difference. We know, for example, that high quality preschool early learning and care environments definitely make a difference. I will summarize three of those.
One, by Stephen Barnett, an economist at Rutgers University, studied the impact of preschool, pre-kindergarten programs in five states in the United States. He found that the programs made statistically significant and meaningful impacts on children's early language, literacy and mathematical development. He found that children who attended state-funded preschools had an increase in their vocabulary scores and also scored higher in mathematics.
State-funded preschools had a strong effect on children's understanding of print concepts, which is a key part of literacy. A common element across all of these programs is that all, or nearly all, teachers in these programs had a four- year college degree with an early childhood specialization.
There is a fantastic study out of New Zealand that follows children from the preschool years to now age 14, which was able to find direct impacts of the preschool environment on children's development. Which is exciting for me as an old kindergarten teacher is that it is not just the fact they went to preschool, but what happened in the preschools made a difference, such as when the staff were responsive to children, when they guided children in specific ways, when they asked certain kinds of open-ended questions that stimulated curiosity and joined children in their play. Children were given certain choices in high quality programs and, if I were to underline two words in my presentation, it would be ``high quality.'' We have to make sure that we do not just provide middle-of-the-road or moderate or mild. Children deserve the highest quality in programs.
In New Zealand, when those programs are implemented, they find it helps to achieve goals of readiness for school.
This particular slide is from the cost, quality and outcomes of a major study in the United States involving hundreds of daycare centres. Again, early child care programs do have a positive impact on the development of young children.
For too long this has been a picture from me about policy in Canada — periodically, governments that have come and gone have certain champions at different times who champion certain ideas or ideals, but I would impress upon the committee the importance of continuity, having a strategic plan that lasts over years so we do not have to depend on individual champions at specific times. I am thinking of countries such as New Zealand, which has a 10-year strategic plan that was signed on to by all political parties. The children there are no longer political pawns; they are not part of negotiations as to whether their government stands or falls. In New Zealand, there is this commitment of all parties to support young children.
The elephant in the room as I speak is that most of what I just referred to in the United States and New Zealand does not operate here in Canada. There is only room for about 12 per cent to 15 per cent of all preschool-aged children in Canada in licensed preschool facilities. This particular slide is about British Columbia, but the same percentages go for the country as a whole.
We are not providing enough good quality preschool experiences for children, neither in child care nor in pre- kindergarten programs. We are only catering to a small minority. I am embarrassed when I go to international conferences. I go to countries that are also industrialized, advanced countries in the OECD, Organization for Economic Cooperation and Development, whose reports have shown this as well. Canada only spends 0.2 per cent of our GDP, gross domestic product, on young children. Countries such as Italy, Norway and Sweden are up around 2 per cent. We are a wealthy country but we spend a small proportion of it on our young children.
One suggestion I made to the British Columbia government was to change this just by using whiteout in its School Act. The School Act currently reads that the government has to provide programs for children starting from the age of five years old. I said, let us change that. Let us start by extending free universal programs, which we have in kindergarten, down a grade to four-year-olds. Ontario has junior kindergarten. To a large extent, Quebec has preschool programs, daycare, and Alberta has had early childhood services, but across the country those are really the exceptions rather than the rule.
We need to start developing a strategic plan in Canada that works here in terms of the diversity of this country, its multicultural aspects and its history. You cannot read the details here but I tried to stress with the Ministry of Education in British Columbia that we cannot do it all at once, but let us start. Let us chart a blueprint, a road map, as if we were doing MapQuest. How do we get to a universal program of high quality early childhood programs for all children? What can we do the next year or the year after? How can we start ramping up to create the programs that our children need?
I will close with this graphic from my colleague Clyde Hertzman, the director of the Human Early Learning Partnership. Often we get stuck arguing between false dichotomies. Many people say that we should start with the targeted, the most unfortunate children. Others say we should start with the universal and what all children need. I agree with both camps. We have to have some programs that are universal, such as child care and universal preschool education, but we cannot ignore the fact that there are children who face specific challenges.
In Canada, we have Aboriginal Head Start. I just finished analyzing some data on the 14 Aboriginal Head Start programs in B.C. There are significant differences. Those children are now much more ready for school after the three- year-old and four-year-old Aboriginal Head Start programs.
Clinical programs for children with specific needs also have to be addressed. I would argue that we can and should aim for providing our children with the very best kinds of programs that will make a difference.
I am happy to respond to any questions or comments you may have.
Stuart Shankar, Professor, President, Council for Early Child Development: As the president of this council, let me say that I adore everything Mr. Goelman just said. I do not know if you are aware of this. Dr. Fraser Mustard retired in September and asked me to take over. This is at the heart of Fraser's dream for Canada.
We are in the midst of the most incredible revolution in our understanding of the origins of both mental and physical health. I agree with the chair's comments; I believe Canada is uniquely positioned for us to capitalize on this explosion of scientific knowledge.
I will start with this graphic for a reason. Approximately 10 years ago, this equipment was invented. We have had a real problem in developmental neuroscience. That problem is that we cannot look at the brain of a little baby unless it is a life-threatening situation. An American, Don Tucker, invented this system. It is essentially a souped-up version of an EEG but it is so powerful that, with the appropriate uses of computer models, we can see fairly deep into the brain. Not only can we now do this in a non-invasive way on any child from newborn up, but we can do it simultaneously on a caregiver interacting with her baby.
We have an opportunity now to see how a brain is actually developing. This is extraordinary for us because one thing we work on in our institute is kids who are suffering from some sort of developmental, psychological or behavioural disorder. We wanted to know, with all this intervention we are giving little kids, are we just tapping into some part of the brain that was fine or are we actually helping the brain to heal? Are we helping the kid to form these connections that were not there so the child can be returned to a healthy, neuro-developmental trajectory?
We are learning two things. First, we can do it. We can get kids back on to a healthy developmental trajectory. We do not know yet how our numbers will pan out, but it will be somewhere around 50 per cent. I do not want to be overly optimistic.
The second thing we are learning is that the earlier we can get to a child, the more effective our interventions are. Dr. Michael Kramer and I were just talking about this while we were waiting to get started. Dr. Kramer was making the point that there does seem to be a sort of window. It is not that it closes but that it gets increasingly difficult for us to have an effective intervention with these little babies. Right now our research suggests it is around the age of between three and five.
It is exciting that Canada has become one of the leaders in the world in the development of protocols that identify babies reliably with problems at 12 months. I know the guys who are doing this and they will push this down to six months. All I can say is that, in working with a baby between six and 12 months, it requires considerably less effort to get that brain back on to a healthy trajectory, to get these connections to form.
What scientists are looking at as we try to chart out population health for the 21st century is our focus is increasingly on prevention. We want to know whether we spot these problems early on and then take effective measures, which are relatively cost-effective, to prevent this becoming a serious problem. The problems I am talking about range from autism and ADHD to conduct disorder and depression, and to a whole range of physical disorders such as obesity and anti-immune disorders.
All of this range of developmental, psychological, behavioural and physical health will be shifting into this mode of identifying early signs of challenges or risks and then taking the appropriate corrective actions.
There is a second major element of this revolution that you should know about. When I was a student, we were taught that everything that happens to a child or a family is a result of their genes; if a family ends up with heart problems, depression, bipolar disorder, low income or low intelligence, it is because of the genes passed on from generation to generation. That crude model called genetic determinism has been overturned.
Canadians have played a leading role in this. Michael Meaney has played one of the world's leading roles in explaining how, yes, it is true that we do see genetic predispositions running through families but it takes specific kinds of environments to trigger or prevent these genetic problems. That is the first point.
The second important point is that these genetic factors relate to very low levels of our biology. It is not that there is a gene that determines intelligence or a gene that determines depression. The influence of the genes is on a very low level of biology which, together with certain kinds of experiences, leads to the problems in health that we are seeing.
That is the whole point in the slides I gave you — nature, nurture. What we are seeing now is that a child is not predestined to be unhealthy, depressed or whatever it is. We can significantly alter the child's trajectory if we can get at these things.
These are the kinds of things that are genetically driven. These are the kinds of challenges that can result in the various mental or physical health disorders we see today. These are low level things. I will give one example.
Everyone in this room has their own sensory likes and dislikes. For example, for me this is a wonderful room because you have natural light. I am a little bit under-sensitive to light so I cannot stand fluorescent lights and need lots of windows. I am a little hypersensitive to sounds so I could never go to a rock concert. Each of you has the same kinds of likes and dislikes but, throughout the course of your life, you have learned how to manage your sensory profile. Today, we are seeing a striking increase in the number of young infants with sensory problems that go outside this range of normalcy. They are so sensitive to vision or sounds that it is averse for them.
I will not talk about that today. We have various hypotheses about why this is happening. However, we think this is one reason for the numbers we are seeing in the various mental and physical disorders that we are diagnosing. This is a problematic area. If you have questions about it, we could return to it later.
The basic point here is that there are two models competing today on the scientific scene. The old model was a medical one where it was thought that everything was gene-driven. The new one is a pathway model that says the child comes into life with these various sensory or information processing proclivities or weaknesses, and the nature of the experiences the child is exposed to are what, together, will result in such-and-such a health problem. We want to look at young babies and infants to see whether or not they are demonstrating these kinds of biological compromises and then take appropriate interventions to help the child strengthen whatever system is weak, while at the same time working with the systems that are strong to get interactions cooking.
The basic foundation of healthy brain development is caregiver-infant interactions. That is what drives the development of the brain. It is as simple as that. If something biological is compromising those interactions between caregiver and infant, we will see problems down the road. We are trying today to target these problems as soon as we see them and help build up the child's biology to get the interactions cooking again.
If you think this through, you will see that I am telling you — and this was in Mr. Goelman's talk — that parents have to be the primary focus of all this health prevention. Any successful program has to be one that builds on the parents' role and provides them with the tools they need to deal with the sorts of challenges, not just in terms of biology but also in terms of the changing stresses and patterns of 21st century society.
We are talking at the council side about creating the kinds of resources Mr. Goelman was describing in the preschool environment that will give parents the tools they need to be, in essence, effective vehicles for the healthy development of their kids. I do not know if I have made that clear, but that is the basic principle.
My partner, Dr. Stanley Greenspan, and I did a study for the CDC, Centers for Disease Control and Prevention, in Atlanta. We wanted to know how serious the problem is today. We found that about 17 per cent of the population in urban America is demonstrating a clinical disorder of one sort or another. That fits with our data in Canada. The more surprising thing was that about 20 per cent of these children had what we call a functional challenge or a biological problem that could have been addressed if we had gotten to the kid early. That 20 per cent, when they get into school, are the kids who will never form friends and never understand what the teacher is trying to say. The problem is not that he is a bad or lazy kid, but he may not be processing this information. He may not understand what the teacher is trying to get him to pay attention to.
The last one was the scary one. A quarter of the kids we are seeing now are showing depression at a very young age. They are showing attachment disorders. These are problems that can, in fact, be significantly mitigated if you get to the kid before the age of three. By the time they get into school, it is pretty tough.
Around 62 per cent of the population in urban centres — this is a strictly urban study — are coming into school with a range of severity but with problems we could have prevented or significantly mitigated. That is what we are trying to do in our study.
The way forward is exactly what Mr. Goelman said. We want to see the kinds of centres he was describing. We want to see the preschool experiences. We also need to have training. He mentioned that he wanted to see the ECEs, or the early childhood educators, have a four-year training program. The best programs we looked at, New Zealand and Cuba, insist on a minimum of four years training with constant mentoring. It is interesting that the training includes developmental pediatrics, all the stuff I have talked about — developmental psychologist, a bit of developmental neuroscience and working with mom and dad because, for these health programs to be effective, we have to be thinking in terms of translating everything we know into terms that parents can assimilate and practice. It cannot be didactic. You cannot lecture parents. Instead, we need to have environments in which we can monitor kids closely so we can pick up problems the moment they appear and provide parents with the skills they need to address those constrictions, whatever they might be.
The Chairman: That was fascinating, Mr. Shankar. I have known Dr. Mustard for well over 40 years. Indeed, I was a scientific collaborator with him back in the days when he was a platelet guy.
Mr. Shankar: So I was told.
The Chairman: I must say he has made another shrewd move in bringing you into the wings as he stepped out of this area. I have some interesting questions for you later, but I do not want to hold my committee up.
Our next interesting presenter is Dr. Michael Kramer, scientific director of the Institute of Human Development, Child and Youth Health, from McGill University and associated, of course, with the Canadian Institutes of Health Research or CIHR.
Dr. Michael Kramer, Scientific Director, Institute of Human Development, Child and Youth Health, Canadian Institutes of Health Research: Thank you, senators, for the opportunity to address you today. In addition to my post at CIHR, Canadian Institutes of Health Research, where I have been for the last four years, I also spent about three decades as an active researcher in the area of maternal and child health. You will not be surprised at my focus being different from those of my two predecessors this afternoon. I will focus on research needs in the area of child and youth health, and particularly not on what we know but on what we do not know.
Much of what I say today I also said at the Child Health Summit that occurred about a month ago here in Ottawa. It was partnered by the Canadian Medical Association, the Canadian Paediatric Society and the College of Family Physicians of Canada. These comments are also summarized in this brochure of which I left a number of copies with the clerk, and it goes into more detail than I will have the time to deal with today.
Although I fully support the importance of brain and behaviour development that has been emphasized by my two colleagues, my comments will be a bit broader in terms of covering a wider variety or scope of health problems that affect children and youth. I will discuss those under four headings — the social environment, the physical environment, obesity and physical inactivity, and injury.
I mention the social environment first not only because it is central to your subcommittee's mandate, but also because I believe it is the most important factor affecting child and youth health in Canada and in other industrialized countries today. I will not surprise you by telling you that one out of six Canadian children live below Statistics Canada's poverty low-income threshold and that children who grow up in poverty are at higher risk for a variety of health problems, including some of the things mentioned by my two colleagues — hyperactivity, emotional distress and failing at school — but it also leads to unhealthy health behaviours such as poor diet, physical inactivity, insufficient stimulation, exposure to violence, the absence of good family and neighbourhood role models, and mediocre schools.
The situation in Aboriginal communities is even worse than in poor rural and urban areas in the rest of Canada. For example, smoking rates among Aboriginal teenagers living on reserves are about three or four times higher than among non-Aboriginal youth.
Those are the things we know, but there are many gaps in our knowledge. Primary among them are those related to the impact of daycare and other early childhood programs on brain development and behaviour. As pointed out by my colleagues, there has been a lot of research in this area using high intensity interventions in more of a research setting, but when translated into the way daycare, for example, is actually played out across the country, it is the largest uncontrolled experiment ever carried out on Canada's children.
We need to know more about its effects, both beneficial and adverse, and particularly, we need to know how things like the age at which children start daycare, the type of daycare structures and the features that characterize good and bad daycare contribute to those effects.
We also need to know more about family and community risk factors for child and youth mental health and addiction. Although a large number of public health programs have been developed with the best of intentions to improve children's development, we need to apply much higher scientific standards to evaluating those programs, so that we can implement or reinforce the ones that work and discontinue those shown to be ineffective or harmful. That is a theme I will be coming back to recurrently in the remainder of my comments.
Although I believe the social environment to be of primary importance, if you ask Canadian children, teenagers and their parents, they rank the physical environment as the highest of their health concerns. Whether that concern is justified or not, we need to do much more as a country to find out which of the many physical and chemical exposures to which Canadian fetuses, infants, children and youth are exposed, may harm their health and development in the short and long term.
What do we know already? We know the developing embryo, fetus and infant are particularly vulnerable to the potential adverse effects of environmental hazards. Moreover, the behaviours of infants and young children, like crawling and putting things in their mouths, bring them in close contact with potentially toxic substances and increase their exposure to them. We also know that any damage caused during these critical periods can be irreversible and create long-term problems. Aboriginal children and children living in poverty are at increased risk for exposure to environmental hazards.
We know there have been a large number of changes over the last several decades in the construction, insulation, heating and ventilation of Canadian homes, and that these changes have affected the quality of indoor air in homes in Canada. That is the place where infants and young children spend the vast majority of their time.
What do we need to find out in this area? Even if the likelihood of harm by any one physical or chemical agent is low, we need to learn much more about the effects of low-level exposures to a wide range of environmental toxicants on the developing embryo, fetus and infant, including the risks of birth defects and other adverse pregnancy outcomes and their possible impact on long-term brain development and behaviour. Once we fill these gaps, we can apply that new knowledge to regulate air, water, food and other consumer products to reduce those exposures shown to be harmful, while reassuring the public about the ones without adverse effects.
We need to know more about whether the recent changes I mentioned in indoor air quality are related to the current epidemic that we and other industrialized countries are seeing in allergies and asthma. If so, we can reduce exposure to chemicals, moulds and allergens that are shown to increase the risks of asthma and allergies by developing new housing construction, insulation and ventilation standards.
I am sure your subcommittee has heard much about the obesity epidemic facing Canadian society, including its children and youth. You may have also heard the prediction that, for the first time in recorded history, Canadian children today may live shorter lives than their parents. In my view, and that of many of my colleagues, the epidemic of obesity, physical inactivity and type 2 diabetes can be addressed only by social and community interventions, not by public education, and not by one-on-one clinical interventions delivered to children and/or their parents. We need to take the same kind of coordinated societal approaches that were successful with tobacco, automobile seat belts and bicycle helmets. We must find out more about the characteristics of neighbourhoods, communities and regions that are associated with risks of obesity and sedentary lifestyles, and we must develop and test home-, school- and community- based incentives and interventions to reduce energy intake and increase physical activity and fitness.
The fourth and final area of Canadian child and youth health I wish to address is injury — both unintentional and intentional injury. As you probably know, injury is the leading cause of death and disability in Canadian children and youth. The major cause of unintentional injuries is motor vehicle collisions, although falls and other playground and sports injuries, drownings, fire-related injuries and poisonings are also important. Besides the high death toll, over 25,000 Canadian children under the age of 14 are hospitalized every year for serious injuries. Not all of these injuries are unintentional. Child maltreatment has become increasingly recognized in recent years, although we do not know if it has become more frequent in occurrence. We do know that physical and sexual abuse can have profound and long- lasting effects on mental health and well-being. Suicide, another major cause of intentional injury, is second only to fatal motor vehicle accidents as a cause of death in 15- to 24-year-old Canadians. Once again, the problem is even worse among Aboriginal Canadian youth, who are five to six times more likely to commit suicide than non-Aboriginal youth.
What do we need to know in this area? We need to develop and test improved child restraint devices and their proper use in automobiles, and to improve the design and testing of child playground and sports equipment. We must also learn more about modifiable risk factors for maltreatment and suicide among children and youth. Finally, many so-called injury or suicide ``prevention programs'' have been launched with the best of intentions, but without rigorous evaluation of their effects.
I will conclude by saying that Canada has the potential to be a world leader in child health, but we first need to fill the gaps — not only the gaps between what we know and what we do, but also in the gaps in what we know. In other words, we need to do more and better research. As a country, we need to invest more, and more wisely, than we have in the past. Canada spends a great deal of money on public health programs for children and youth in all four of the areas I have discussed, often with little evidence that those programs are having the desired effects. Such programs are difficult to discontinue once they have started. We thus miss the opportunity to find out what works and what does not, and to ensure that taxpayers' money is well spent.
Thank you for the opportunity to make these comments. I will be happy to address any questions or concerns you may have.
The Chairman: Thank you.
One thing Dr. Mustard had been emphasizing the last few times I talked to him was that we had to back up beyond birth and start thinking about the intrauterine developments that we are paying such a tremendous price for now. I was at an interesting medical meeting this past weekend. One thing unfolding now, for example, is something I spent my life in, which is cardiac disease, but in fact congenital heart disease is fundamentally an effect of bad nutrition in the mother. It is the fact that the heart cannot grow, that you get holes in the heart and defective valves and so forth, because the nutritional components are missing to make that possible. Of course, we heard earlier that this is the fact, particularly in mental health, but in all of these things, fetal alcohol syndrome and so forth.
I am raising this because I want to bring before the subcommittee some real experts in this area. There does not seem to be much happening in this area in Canada at the present time. Before you leave, would you come to me if any of you know of expertise any place in the world in this area and, with that, I will move on to the other senators.
Would you like to make a comment? Please feel free to do so.
Mr. Shankar: We can give you some names afterwards of scientists in Canada who are doing this kind of research.
The Chairman: If you wish to expand and comment on that field, please do so, but Senator Pépin has some questions.
Senator Pépin: Thank you for coming. I will try to speak in English; otherwise, I will have to switch to French.
The three presentations were wonderful and will help us in our recommendations. My first question is for Mr. Shankar.
You mentioned the possibility of being able to look at the brain of a child, starting at six to 12 months or maybe four to six months. How many medical centres or hospitals have the technology you are talking about?
We know that you probably need a referral for those children. Since the majority of parents do not know this technology exists, does it mean they go to you because they have a feeling one of their children is sick and they have a referral? Where does the technology exist? Is it paid by medicare? What kind of environment do we need to prevent this? What should we do to have that kind of technology across the country in every hospital?
Mr. Shankar: Those are all wonderful questions. Can I tell you the story about how Dr. Mustard talked me into taking over for him?
This is something Dr. Kramer put his finger on and is an important point. In my institute at York, we were given $5 million by a private foundation. I spend $60,000 per year on every child that comes into my clinic. Children need a minimum of two years to get the benefit, sometimes three to four, so this is anywhere from $120 to a $0.25 million for one child.
Dr. Mustard called me to his office and asked how many kids I can treat and how we can translate this into a population program for the country — because you cannot do what we are doing, right? Is there a way for us to take the science and translate it into a model that we could not rule out on a population program basis?
What we were talking about before the meeting started was that Dr. Mustard had been meeting in Cuba for several years. In 1961, Castro set up daycares and he did exactly what Dr. Kramer said needs to be done. He commissioned his scientists to say: Look, this is not just giving moms a chance to work. This is an experiment on kids, so you need to study every aspect of it.
The Cubans did this. I have been reading the material. They looked at it carefully and got incredibly good results.
In the mid-1980s, Castro said: Can you translate what you have achieved with these circulos infantiles or state nurseries — which only served about 20 per cent of the population — into a population program? He made this the great challenge of the late 1980s for all the developmental scientists and pediatricians. They started to work on how you might use parents as your front line for delivering the clinical knowledge and service we do in my institute.
Today, they have an entirely voluntary program that has a 99 per cent uptake. In other words, everyone in the country gets covered by this. They took their clinicians and ECEs and trained them in all the things I do, and then started asking whether they could boil this down, simplify it, and get it into materials and a format that anyone can understand. It turns out it is not that hard.
We use these sophisticated tests to look at our kids, and the clinicians say to the parents: Does your four-month-old or your six-month-old initiate interactions? That is brilliant. One of the things we know is that a child with problems may respond well if you are rich in affect, if you work with the child to get the child cooking, but the child does not initiate. At the end of the day, it is that failure to initiate which is a potent sign of a potential problem down the road.
Now, the ECE is working with mom and dad who say that the child is a happy guy, but they ask whether he initiates at home. Now mom and dad are looking for the thing that, as scientists, we are spending all this money on. The parents come back the next week and say that the child really does not initiate.
Now what do you do? We were spending a lot of money training clinicians, and the problem is that a clinician can never do as good a job as mom and dad. There are many reasons for this. You get a dose effect and intimacy with mom and dad. Also, each of us has idiosyncratic ways of communicating, like the way I am doing now. The child understands the non-verbal gestures of mom and dad but has trouble with similar gestures from others.
We were not thrilled with how well we were doing in our clinic, so we started to bring mom and dad in, and now our clinicians are really just coaches trying to instill this knowledge in parents. That is what Cuba did on a national basis and on a shoestring.
What are the results? I will give you one. We are conducting a huge study on Cuba now. We have a 0.66 rate of autism in Canada. It may not be that high because there may be a lot of misdiagnosis going on. Whatever the case, the rate of autism is pretty high. One in 150 kids has autism. Cuba is reporting 0.042 per cent.
I have looked at Cuba's data. It looks pretty good. The only way we will know for sure is to come in and do it ourselves, and they have agreed to allow us to do that. It looks like, through parents, you can pick up problems at a very young age and either prevent the problem or significantly mitigate it to the point where the child can function in a normal school environment.
Does that answer your questions about the way we are thinking about doing it? However we do this, it has to be working with parents and teachers. It cannot be doing what I am doing at York; it is just too expensive.
Senator Pépin: Is there only one centre right now?
Mr. Shankar: There are about three centres in the country.
Senator Pépin: I realize that we have to educate the parent. We have been working on child care for so many years. I was in the House of Commons in the early 1980s and pushing for child care. Maybe we can educate the parents when the children go to child care, because where will we be able to reach them?
Mr. Shankar: I would like to follow up on what Dr. Kramer was saying, I loved what he said about daycare. It is a social experiment, but nobody saw it as one. The parents were cut out of the process, so there was no parental education as a core element of all of this.
When we look at the things Dr. Kramer was talking about — all these toxins that might be affecting the fetus, the embryo and the infant — the other thing we are starting to worry about is that we live in a society today where something like 83 per cent of our country is living in a city. This is a very different Canada from the Canada of 30 or 40 years ago.
I live in the country. I live on an island and have a five-year-old and a two-year-old. My kids are happy because they can go out the front door and there are no cars. I take my children to Toronto and they are overwhelmed and I can see them closing down. I worry about this as another element of what Dr. Kramer was describing, the assaults of an urban existence on a young, developing mind and brain, and also the demands that we are now making on our children. These demands are very different from the last generation.
The Chairman: Dr. Kramer, we would not want to miss the opportunity for expanding on Senator Pépin's intervention. What can we do in the future with the parents?
Senator Pépin: What would be the best way?
Dr. Kramer: I am not sure that we know. There are some general principles about involving the parents that seem pretty clear. There is much we do not know about what parents should be doing and what daycare and teachers and others should be doing, not only to optimize development but also other aspects of health in children. We have this curious scientific double standard where you cannot get a drug on the market, which I agree with, without rigorous randomized trials. That is to treat a few people who have the disease treatable by that drug, and yet we implement all these programs across the board because it is like what clinicians used to do. It sounds like we will do this and this because it seems like it should work. The scientific standard for a program that affects all children in a community or a country is not as high as the ones we insist on for drugs. That is a scientific standard which is difficult for me to defend.
I am skirting your question because I do not know the answer. I think these people probably have a better idea than I about what parents should or should not be doing. We are not doing a good enough job ensuring programs that get funded and are then very difficult to discontinue are actually having the desired effect. I am not talking about the kind of research being done in a research laboratory.
The Chairman: If the answers were there, we would not be doing this two-year project. We are justifying our existence.
Mr. Goelman: I realized in my presentation that I talked about the benefits for the child. If I had had another two to five minutes, I would have talked about the benefits to the parents and the family as well. Good child care is a family support program. It helps the children cognitively, socially and emotionally. We do have hard data for that. The United States has good longitudinal studies looking at daycare centres. It also has a positive impact on the family as well. It is a great vehicle for family education, information on immunizations for children, screening for early disabilities and all kinds of early warning signs go off that child care people can pick up on.
We are finding that there are some measurable outcomes in terms of child development but also in family networking in the community, with new families in the area, and identifying who is the public health nurse. I see the effects of child care as a ripple effect, starting with the child but going out from there. There is good data from the United States and Canada for that.
Senator Gustafson: I hope that my questions are straightforward enough that we are not just politically correct here.
We have a society today that is demanding parents to be out of the home. The emphasis is on daycare centres. You indicated the next generation will probably not live as long as the current generation. Can the mother and father in the home be replaced? I see you shaking your head.
Mr. Goelman: I do not think so, and I do not think any of us would advocate for that. We see child care not as replacing the parents but supporting parents. The front page of today's Globe and Mail shows the unemployment rate is the lowest it has been. Everyone is in the workforce and we are strapped with it. That will not change, but it is important to turn the question around and ask how can daycare support working parents? How can it give parents the support they need?
Dr. Kramer: I have two points. One is the prediction that has been made about children today not living as long as their parents may turn out to be untrue. You should not underestimate the power of medical and scientific breakthroughs to change that prediction. That has more to do with the obesity epidemic. Certainly children today are a lot fatter and less physically active than their parents were a generation ago. That, as we know, is a society-wide problem and unless we fix it, even if they live as long as their parents, they will be living with a lot more health problems. That situation is critical. That problem is not related to daycare, mothers going into the workforce or the change in family structure.
It seems unlikely to me that having women in the workforce soon after giving birth will be reversed in the near future by Canada or any other developed country, nor will women having children later on in their lives and developing careers first before having children be likely to change. Given those changes, there are some things we could do as a society to make things better. Sweden, France and other European countries have much more generous maternal leave legislation than we do in Canada. Whether it is daycare or stopping breastfeeding — a very important issue for child development as well as health — at three months because the parent has to go back to work or takes the choice of either going back to work or losing income, is something Canada could and should address. Many other countries have addressed this more successfully. We cannot reverse the general societal trends but we can make some improvements in our society that can help mitigate the adverse effects of those trends.
Senator Gustafson: I have one more question. It is pretty well answered. In Canada, we are cramming our population into four major cities. For one thing, it has become a political nightmare. That is where the votes are which is where the members focus and that is the trend.
A country like Canada should not be doing this. We have a country of open spaces and great opportunity. Do you think that impacts early child development and the lives of young people? I am a farmer. Try and get someone to work on the farm today. You cannot do it. I am careful to even say this because you might take it wrong, but you see a successful person and you ask how did he get there? He got there through the school of hard knocks. We had Senator Mahovlich in committee last night telling us about why the best hockey players seem to come out of rural Canada. The reason is the school of hard knocks. We were tough. He named Gordie Howe, Bobby Hull and some of the most successful athletes in the country.
How does that fit in or does it not?
Mr. Goelman: My colleague, Clyde Hertzman, would point out that we have been doing assessments in various areas of British Columbia. In many rural communities, the economics stats might indicate that the kids are not doing all that great but, in fact, they are doing great. When we look at those communities more carefully, we see they have a lot of things going for those kids, such as more social cohesion, people know each other, they trust each other, their fathers knew each other's grandfathers and uncles. They did not need daycare centres because they had informal networks. What you are saying is borne out by the research that I know. In successful parts of rural Canada, those communities are strong and we in large urban areas without those informal networks need to learn from what rural Canada can teach us. That is based more on an impression than on hard data, but I certainly agree with what you are saying.
Mr. Shankar: I would try to reinforce something Dr. Kramer is saying. I think Dr. Kramer put his finger on what I regard as the most profound comment we could make today. He is talking about creating a science of population health — about looking at these questions on the basis of our scientific facts. He used the model of what we did with smoking. To this point, this debate has been very politicized, as was the smoking debate, until finally science got robust enough. I resonated with his subtle remark. I love living in the country. I cannot imagine anyone wanting to live in Toronto. I can imagine wanting to live in Ottawa today. I am optimistic about this city for tomorrow night. Our job is to look at this scientifically to try to see the country place these questions on a scientific basis. We have the tools to look at what Mr. Goelman just described. We have different kinds of tools, such as brain tools and tools for setting community development. The point is that we have not done it. Your question is interesting.
The reality of life today is that this is the reality. We have seen the collapse of the extended family. We see parents coming into our clinic who do not know how to breastfeed. We had to hire a breastfeeding coach, literally. That cost me $50,000 a year. You can try to influence the process whereby we treat these questions seriously, and recruit the scientific talent that exists across the country so that we can make informed answers, given whatever the reality is.
Senator Fairbairn: I, too, have been mesmerized in my life by Dr. Mustard because of work I stumbled upon many years ago to be involved in literacy. That is another issue we are discussing in this committee almost simultaneously with these other ones.
Talking about children, I recall Dr. Mustard saying early on many years ago in his first report that, if given the opportunity and the encouragement, a child, by the time it is 18 months old, will have all its connections connecting and they are ready to take in a great deal more. He said for both the parents and the children to use that experience to learn in every way they can, including early childhood reading, understanding and that kind of thing. It was not so long ago that he talked about this and it was innovative and helpful to the literacy community. Yet today, we are surrounded by technology and all of the corners it can turn in terms of learning and doing things no matter what age you are.
One of you spoke about children going into Grade 1 and the need to be connected and rolling along in a certain way. If not, it becomes increasingly more difficult for them as they go through their years at school.
What can we do when we know so much more about the science of health? What can we do to help parents because they are the first teachers, whether they like it they are? For many years in some provinces — Nova Scotia, Manitoba and Alberta — foundations have been put together, although not by government, to offer programs. For example, a hospital will not let the parent take the child home from hospital unless they have gone through a rigorous program and received the information package on how important this is and that, if they do not or cannot do it, their child is already in a deficit situation.
How does that figure in with the kinds of things you are doing? It should be simple but it is not simple. Now, despite our technology, it does not seem to be any more effective or any easier to do. Have you any comments on that?
Mr. Shankar: I will tell you a story about Baby Einstein. Do you know what that is? Baby Einstein is a video that was created by a psychologist. She said that the video is just a tool. She said at the beginning that it is for the parent to interact with their child and that it only works if they use it as a basis to initiate playful interactions back and forth. She was pretty good, and Disney bought it. I want to tie this in to what Dr. Kramer was saying. I worry about the toxic effects of our neighbour to the south because they do things that are not that great for kids.
Unfortunately, what Disney did with Baby Einstein is a lesson on what is happening to our technology. They did marketing surveys and found that 90 per cent of the parents who buy the video do so because it gives them 35 minutes to cook dinner or do other things. That is why they bought the video. They also found that these guys had a real problem in that babies tend to get bored with Baby Einstein and that screws up mom's hope for 35 minutes to get things done. They came up with the idea to just keep the images clicking over every couple of seconds. I was at a conference a couple of weeks ago in the United States with a bunch of neuroscientists. They said you can no longer use video for workups because, with Baby Einstein, these kids have been conditioned to have one-second attention span. We have to figure out new ways to do it because we have a population now that (a) is not reading to their kids and (b) is not holding the child. We have studies from 30 years ago that show the more you read to a kid the sooner and better the child can read. Now we have TV and videos.
Mr. Goelman: There are some great programs. One that is across the country now is called the Parent-Child Mother Goose program, where parents come together with their kids and learn chants, rhymes and finger plays. What it is really about is — as we know from neuropsychology — kids and moms are wired to look at each other and be responsive. We also know that, as children grow and change, children or the parents need to learn new dance steps; it is a dance of interaction. From that interaction, children learn about the importance of language, not just random noises. Language is meaningful, fun and something you interact with. Reading written language is an extension of that.
There is great data coming out of the University of Toronto which shows that things like length of utterance and size of vocabulary, and children using language in a meaningful way, comes out of programs like the Parent-Child Mother Goose program. We did an evaluation of it. We had all the numbers and talked to the parents and asked what they got out of it. Parents would say things like: I feel more confident with my baby now; I have a bigger tool kit; I feel more supported; I do not freak out when my baby cries because I know I have other tools.
The parents were reporting these other effects which were helping them in their interaction with their children. I mentioned the ripple effects before. There are things we can measure quantitatively, but also parents are reporting about programs like that.
Children like watching adults read. They learn a lot by observing. Yogi Berra said something like, ``You can observe a lot by watching.'' Children see their parents as readers; they read for meaning, they write shopping lists, they read those lists, they put notes on the fridge, and they talk about how they communicate in the family through literacy. It is not just sitting down and reading a dictionary, but literacy is meaningful in the context of life.
There is strong data that shows we can change children's attitudes as well as their skills around early literacy.
Dr. Kramer: Physical activity is another manifestation of the changes that have occurred with technology. It not only results in understimulation or less stimulation by the most important person, the mother, but it also leads to less physical activity and obesity and all the consequences of that. There are both developmental as well as physical consequences of that.
Senator Fairbairn: With all the great science, in some cases we have new difficulties as well.
Mr. Goelman: Some new technologies are having great difficulties. When I was growing up, my elementary school complained to my mother that I read too many comic books. My mother's response was, at least he is reading. I conquered that technology of comic books because my mother understood what it meant to me. I could figure out batting averages — that is how I got through mathematics and things like this.
This is a story about how I gave up earning millions of dollars. I was approached by a software company a couple of years ago. They wanted to write software for two-year-olds. Two-year-olds do not need software. They need finger paint, mud, sand; they need to get things under their fingernails, in their mouths and in their ears. That is learning. They went to someone else to design the software, and my wife has not forgiven me since.
Senator Gustafson: I saw a news item a couple of days ago where a child can actually learn two languages and then decipher which one is the most useful. How do you explain that?
Mr. Goelman: That is Janet Werker, a colleague of mine at UBC. She was on CBC's The National and in The Globe and Mail. She showed that babies could tell the difference between their first language and a second language. She was saying we are pretty much programmed early on with sensitivity to language. What I would take away from that is it fits in with neuropsychology and child health. Children learn from a young age. They are very receptive and aware about picking out signals in their environment. I would not say we must start teaching children in this way or that way because of this finding, but it affirms that young children are active learners from very early on.
They are making hypotheses. There is a great book called The Scientist in the Crib. It is about babies making hypotheses and they test things out. At six months of age, which is what Ms. Werker showed, children can differentiate between their own first language and a language they have never heard before.
Senator Pépin: Speaking of languages, children learn their parents' language and they learn the neighbourhood language. At four years old they can be bilingual. If the neighbourhood is English, they will speak English. It is really amazing, compared to us; it will take us a much longer time.
In 1996, the federal government and premiers had a meeting and said they wanted an action priority program regarding adolescents and children. I was wondering if the collaboration is still working. If it is a bit slow, what is the problem or how can we help to have better collaboration, to have better programs for children and adolescents? Listening to you, I think we do not have a choice. It must be a priority from early childhood on. I was wondering if you have any information, or what could we suggest and work on with the government?
Mr. Goelman: Could you clarify what you mean by the ``collaboration''?
Senator Pépin: The Prime Minister, the federal government, with the different premiers of the country. In 1996 they had a program saying children and adolescents should be a priority.
Mr. Goelman: The National Children's Agenda.
Senator Pépin: What stage is that at, and is there a way we could help to have it renewed and working with collaboration?
Mr. Goelman: You are asking our view of federal-provincial relations?
Senator Pépin: You have your two feet on the earth.
The Chairman: You are not running for election.
Mr. Goelman: Tomorrow I go to Victoria for a similar session with the British Columbia government.
Dr. Kramer: Just as I think we will not change general societal directions such as the age of child-bearing and careers for both men and women, again I may be naive but I do not see changing the federal-provincial political system near at hand either. My understanding is that most of the programs — be they for daycare, education, health, public health, early childhood stimulation — are planned and implemented by provincial, regional or local governments with budgets provided by the province.
One area where the federal government has the main role — this is not even disputed by the provinces — is in the area of research. It is the federal government's role to fund research, to find out what works and what does not. The provinces may have different ways of implementing the results of that research. The provinces are aware that some of these programs are actually occurring. Certainly, our institute is trying to work with provincial governments and decision makers to ensure their questions get answered by our research — the questions that they need to answer — for the programs they are implementing locally. Some of the provinces have their own research enterprises; Quebec, Alberta, B.C. to some extent, though the provinces tend to fund infrastructure rather than projects.
I am not saying it is the only role for the federal government, but research is clearly a mandate with little disagreement. We need to take it seriously.
Mr. Goelman: I would encourage your continued support. The Aboriginal Head Start Program is certainly one of them. The Canada Prenatal Nutrition Program and Community Action Program for Children are others. Those are federal programs for the early childhood years and we have strong data which supports those programs. The limiting step is a dollar issue. I would encourage the federal government to continue to support and expand those particular programs. They reach their mark. They work with very disadvantaged communities, Aboriginal and non-Aboriginal. Aboriginal Head Start has two versions, on-reserve and off-reserve. They are both successful and responsive to local communities. The one in Saskatoon looks different from the one in Yellowknife, or in Nunavut. In that regard, there are some clear divisions. There are some programs run by the federal government, and I will make a strong pitch for maintaining and expanding those. They make a difference.
Mr. Shankar: All three of us have the same sort of initial response. It would be easy for us to attack what is happening but, in fact, the country has accomplished quite a few important things over the last 10 years. These should be celebrated. Dr. Mustard and I brought out a new edition of the Early Years Study that Senator Fairbairn mentioned, in which we tried to draw attention to the successful programs. Let me put in my two cents for why Canadian Institutes for Health Research is important. I do not know if Dr. Kramer would agree. It is creating a sea of change in Canadian universities. Canadian academics were not very responsive to the needs of our society, and how does one change that? How does one get these professors who see their grants as a perk and not that they are being paid by our society and they have a responsibility to our society? I feel that CIHR is accomplishing two great things. One is the federal and provincial governments are rightly asking: How can we commit to programs without evidence? How can we commit without the research? Second, CIHR is changing and I can see it happening with young academics now where they are returning to the values we saw in Canada and Canadian academics in the 1960s. There is a belief that we are here to serve our society. I wish to celebrate the important advances that have been made. That could be a valuable thing this committee does.
Senator Gustafson: I have one comment on this very homemade experience. Our farm bought a new air seeder, which is advanced technology. My son was showing me how to run it. He said, ``Get the kids in here.'' They are doing this stuff on the computer all the time. They will pick it up just like that. Well, I finally got on to it and I was a pretty good operator. It is an example of what these kids had been doing — they were able to transmit that into something very useful in society. You could create a super race.
The Chairman: I want to get on to a subject that is very important before you go. We will finally wind up our hearings which is some time off, and get down to recommendations. I want to hear from the three of you. If we are really going to get to the ground with effective population health programs to change the health status of Canadians, we have to get to the ground with a combined approach through health and education. I was interested to see one of you suggest that we already ramp back educational programs and start at age four. I totally agree with that. Kids can learn a tremendous amount at age four, and we could have them out of high school much sooner because the university programs are getting longer. Educational programs have to embody healthy living. That has to be part of education. It has to be part of our lifestyle as they grow up.
Now, first, tell me if you agree with that and, second, address the simple task of telling us how it can be done so we can put it in our report.
Mr. Shankar: Yes, I agree. We have some advances in the country. It is interesting what has been done in Saskatchewan where they have merged the ministry of education with early childhood development. When we look at the Cuba example, what strikes us is that programs they are running are essentially zero to 17. It is not zero to three or six. This is the program Mr. Goelman described with well-trained specialists working with the zero to four population. The Cubans have done that now with primary school. The teacher stays with the cohort for four years with tremendous success. They say to the teacher: Are you in loco parentis? You must know your family. How can you teach a child if you do not know what is going on back home? Now they are embarking on another experiment. This was enormously successful. The Cubans want to know if they can do this in high school. Can we have our Grades 9 or 10 teachers stay with the cohort for four years? Yes, it is hard but the results are that the child-teacher relationship is transformed and becomes one of mutual knowledge and trust as well as education.
I agree wholeheartedly with everything we have talked about today. It has to be applied throughout the educational course.
The Chairman: It is interesting by serendipity that I happen to be meeting the Cuban ambassador and three Cuban doctors in my office tomorrow.
Mr. Shankar: I tried to bump a meeting, but it could not be bumped, so it must be with you.
The Chairman: Are you in town tomorrow? Why do you not come to my office at 12 o'clock? It is two floors up, room 902.
Mr. Shankar: I would love to.
The Chairman: Are you going to lunch with them after?
Mr. Shankar: No, I am flying to Edmonton.
The Chairman: There is a luncheon. I do not think I can attend. Senator Pépin is vice-chairman of this committee and she will go with them.
Mr. Shankar: There is a book published two weeks ago called Cuba's Academic Advantage by Martin Carnoy. It is a wonderful book and directly addresses your question. We do not want to try to institute a Cuban system here, but one thing we can learn from what they have done was dealing with the money and how can we enhance an educational system that is suffering.
The Chairman: I have been looking at this situation for some time. I have had an interest in population health for some time. I spent my whole life operating on a disease that is 90 per cent preventable. I have an institute sucking $140 million a year out of the system to treat a disease that is totally preventable. That is what stimulated my interest in getting to this on a much broader basis.
I have been really interested in what has been accomplished in China and Cuba with population health. They are way ahead of us. They do not have great health systems but they have fantastic population health. In any case, I hope you will join us tomorrow at noon.
Senator Fairbairn wants to ask you something, but after she is finished, will you come back and tell us where the combined health and education programs in Canada are working? What are the prototypes that we can have a hard look at and incorporate?
Senator Fairbairn: Mine is a comment more than a question, and it follows on what the chairman is saying. Cuba has done incredible work. One of our former colleagues, Jacques Hébert, has been very engaged in a variety of ways with Cuba.
Mr. Shankar: Yes, his book is wonderful.
Senator Fairbairn: A couple of years ago, he was going down for a big meeting in Cuba on which the whole foundation was childhood learning. It was not a question there of whether you wanted to do it or not, but they had created this incredible process. It was there and you were going to do it; the parents would take those little ones in there and they were going to start. They were inviting people from other countries to come in, and apparently it was amazing to watch.
Mr. Shankar: I had a bunch of doors open for me in Cuba — and this will really make you laugh. They came to me finally and said the reason we want to work with you is we love Canadians, and they gave me Mr. Hébert's book.
Senator Fairbairn: When he came back, he said it was absolutely astounding. In what we regard as a poor country, they have taken that as their foundation issue. Those kids are going to be up and their parents will be in deep trouble if they do not get them going.
Mr. Shankar: Mr. Goelman said something at the beginning of his talk that I did not want to let slip. It directly addresses your concern. He made the point that, when we look at this, we are not simply looking at the prevention of disorders, whatever they are, we are also looking at enhancing the overall health of these kids. The thing that strikes me when I am in Cuba is I have not seen one obese child and they are all laughing and happy.
Senator Fairbairn: Learning is fun for them. You have a great job.
Mr. Shankar: It is fabulous.
The Chairman: Mr. Shankar, as happens about 20 times a day, I gave you misinformation. The meeting is at 9:30 a.m. in my office. Can you still make it?
Mr. Shankar: I could make it a bit later. I am meeting at 9:15 a.m. on Parliament Hill and that goes until 9:45 a.m. Could I come at ten o'clock?
The Chairman: Sure, you can come, but if you are just meeting with an M.P., that is not important.
Senator Pépin: In the early 1980s, I was in the House of Commons and we worked very hard to get child care. At that time, I had one member of Parliament who came to me and said, ``My wife is just like you.'' She stayed home and looked after her children instead of fighting for child care. I said you may be right, but when your daughter will be 20 or be married, she will ask you for child care. He said, that will be the day.
When I was appointed to the Senate a few years ago, he came back and said, Lucie, you were right. My daughter has two children and she wants child care. Listening to you, I think there is hope but, as you say, there is not enough. It is unbelievable the number of children who do not have the access to that.
Senator Fairbairn: That is the thing. Why not in Canada when they can do it in Cuba?
Mr. Goelman: That goes back to Senator Keon's question to us about where does it work? Where can it work? Where there is a political will for it to work. One place in Canada where it is working is the provincial government of Manitoba. They had a cabinet level committee called Healthy Child Manitoba. Where I come from in British Columbia, I have to go to one office for child care programming, another for training, another for subsidy, another for preschool, another for education and everybody says, ``We are not the answer, it is across the hall or down the block.''
Healthy Child Manitoba has brought together all the players, so instead of saying who will shirk the responsibility, they look around the table and they have the deputy minister of education, the deputy minister of health and the deputy minister of welfare. I do not know a lot about Cuba, but my sense is that they have more centralized planning. Maybe there are good and bad sides to that, but many of us get tired between the federal-provincial bashing — my provincial officials say the feds are not cutting our money and the federal people say we cannot trust the provincial people to put the money in the right place. I think there has to be some infrastructure changes.
We have a lot of bright people and a lot of good energy and information, but the systems are fragmented. It would be great if there is some way your report could encourage the integration. I mentioned Aboriginal Head Start before — great programs on-reserve and off-reserve, but they do not talk to each other, which is a shame because they are both doing excellent work. There is a savings involved, but also a building of capacity if they could work together. I do not mean to single them out, but that is just another example of how there is good work going on but there needs to be some political will to say let us make things work better.
The Chairman: We are meeting with them Friday morning. We will try to be here on Friday from 9 a.m. to 3 p.m. One objective is to try to get at this. The problems are so huge there, but this dichotomy is a particular problem.
Mr. Goelman: The gentleman I would refer you to in Manitoba, Rob Santos, is the head bureaucrat who runs that cabinet level committee. He is a national treasure.
Mr. Shankar: Yes, I would bring him here.
The Chairman: We will do that. Are there any other beacons out there you can think of across the country?
Mr. Shankar: We would suggest Tom Boyce from the University of British Columbia.
Mr. Goelman: He does developmental nutrition; we lured him from the U.S. to come to UBC. He is an outstanding scholar and does his research with both a sense of passion and compassion. He speaks eloquently and does high quality research. Also, on the maternal child side you mentioned before, Dr. Tim Oberlander is a developmental pediatrician who does a lot of work on maternal health during pregnancy and how that impacts on children.
The Chairman: We want to spend some real time on that.
Mr. Shankar: Can I give you one more? What Mr. Goelman was just talking about, we have developed in Canada models for how you get from chaos to coherence. These are pretty good models of the step-by-step processes communities have to go through to get all the services integrated. We have someone on our council named Jane Bertrand. She is extremely good on how you do get these conflicting parties to talk, to come down to the same table.
The Chairman: On that note, I really thank the three of you. You have been tremendously helpful and a real pleasure to talk with. You turn work into fun, so thank you very much.
Dr. Goelman: Thank you for your hard work in this area.
The committee adjourned.