Proceedings of the Subcommittee on Population Health
Issue 3 - Evidence, February 13, 2008
OTTAWA, Wednesday, February 13, 2008
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:06 p.m. to examine and report upon 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 (Chair) in the chair.
[English]
[Editor's Note: Technical difficulties resulted in portions of the proceedings being inaudible.]
The Chair: Honourable senators, unfortunately Senator Pépin is bed with the flu, so she will not be here this evening. However, we will proceed because the time is limited and we have very busy people in front of us. We appreciate their collective time and we want to make the most of it.
We will begin with Glenda Yeates, President and Chief Executive Officer of the Canadian Institute for Health Information, and Keith Denny, Acting Manager with CIHI. We also have with us this afternoon Professor Noralou Roos from the Faculty of Medicine at the University of Manitoba.
Without further ado, Ms. Yeates, please proceed.
Glenda Yeates, President and Chief Executive Officer, Canadian Institute for Health Information (CIHI): On behalf of the Canadian Institute for Health Information, I would like to thank you for your interest in our work and for having us here today.
I would also like to introduce my colleague, Keith Denny, Acting Manager of the Canadian Population Health Initiative. CPHI is a part CIHI and works specifically on population health. Its mission is to foster a better understanding of the factors that affect the health of individuals and communities, and to contribute to the development of policies that reduce inequities and improve the health and well-being of Canadians.
[Translation]
My presentation today will focus on two areas. First, I will review some recent findings gleaned from a number of CIHI reports on population health. Second, at the committee's request, I will present CIHI's view on the role of the federal government in improving population health.
When looking at population health, we are reminded that health and illness are closely linked to lifestyle, work, education and leisure activities. Canadians are among of the healthiest people in the world, although significant gaps have been noted among different groups in society.
These gaps can be attributed to numerous complex social and economic factors, in particular income and education, as we all know.
[English]
Studies have also shown that where you live matters to your health. Recent CPHI research illustrates that neighbourhoods within cities differ in terms of health outcomes. You asked us to concentrate on some of our recent health findings. In the material we gave you, we included information on the city of Halifax. We can see that residents of neighbourhoods with lower-than-average median incomes but with a higher-than-average proportion of post- secondary graduates were more likely than those living in other neighbourhoods to rate their health as excellent or good.
I would like to touch briefly on another example of recent CPHI findings. In a recent report, we looked at the relationship between homelessness and mental health. This study showed that the top reason for homeless people to visit emergency departments differs significantly from the population as a whole, particularly because of mental and behavioural disorders. The study also contained a synthesis of the literature which concluded that programs that provide housing as a first measure, when twinned with appropriate and flexible mental health services, appear to be effective at helping those who are homeless to stabilize their mental health problems.
[Translation]
At the committee's request, I would now like to present CIHI's view on the role of the federal government in improving population health.
[English]
We looked at three potential roles when we examined the question you asked us regarding what the federal government could do in the area of population health. We approached this question from our position as a provider of information and population health research and analysis.
The first potential role for the federal government is to provide continued support for the data that informs population health analyses. While we know a fair bit about population health, there is also a great deal we do not know at this time but need to know.
The Canadian Population Health Initiative of CIHI has worked directly with and heard from key stakeholders. They are keen to understand and use the evidence available. However, local data is often critical to make changes based on that data. Therefore, ongoing federal support for organizations such as CIHI and Statistics Canada is of critical importance as we strive to make population health data more readily available at a regional or even neighbourhood level.
The second potential role we would suggest in answer to your question about the federal government is to support what we call ``intervention research'' on population health. If we look again at our recent CIHI consultations, our stakeholders have said they would like more practical, evidence-based information on what works and what does not work in terms of policy and program interventions at a population level. This is often called intervention research. For example, is it is clear from recent studies that obesity is a problem in Canada, but what can be done to make a difference? We need more evaluations to understand what does and does not work, in what context and under which circumstances. The federal government, as a major funder of health research in Canada, could include among its priorities intervention research into population health interventions.
Finally, a third potential role for the federal government is to provide leadership and support for the type of electronic health record — or EHR — development that generates standardized information that can be used for population health. EHRs not only have the potential to help individual patients in a very immediate way, but they can be used to collect health system data, as well as data about populations.
EHRs open up new possibilities for what data is collected, how it will be collected and what will be available to support and understand population health. EHRs are designed first and foremost to support individual patient care decisions. However, their full potential can be further enhanced if they are rolled out in such a way so as to include a vision that encompasses the ability to improve the health of the population as a whole.
The federal government has an important leadership role in helping to clarify how data, derived from electronic health records, can, in a privacy-sensitive manner, enable the development of population health indicators and analysis to improve the health of the population. There is a need for commitment to developing electronic health records in such a way that they will generate standardized, comparable data that can be appropriately used to guide our understanding and to focus our actions in the field of population health.
As an organization dedicated to improving Canada's health system and the health of Canadians, I thank you for your interest in our work and would be pleased to answer any questions you may have.
The Chair: Thank you very much, Ms. Yeates.
We are now privileged to hear from Ms. Roos, who has tremendous experience and an outstanding background. As a professor at the University of Manitoba, she was the Founding Director of the Manitoba Centre for Health Policy. She is an associate of the Canadian Institute for Advanced Research.
Please proceed.
Noralou Roos, Professor, Faculty of Medicine, University of Manitoba: I am also delighted to be here before a committee that has population health as its focus.
I was trying to figure out what I had to contribute to your discussions. I will focus on the questions you were asking around structural barriers to implementation and options for implementing population health policy. After having spoken to a few people who had already spoken with you, it occurred to me that I also will focus on encouraging you to support investments in what I see as Canada's strength: population health databases.
I will give you some examples. We have found that to get the support of the public, one needs a broader discussion of population health; that is, one must communicate. We have been working with the Business Council on this initiative. I will show you the way in which we have put data together to persuade them that population health issues are important for them to take on.
I have given you a whole series of overheads. I will talk from overhead No. 3, which is the one with the circles on it that shows the database we created in Manitoba. We brought together not just data on the health care system — every contact with physicians and hospitals — but also data from education. That includes how kids do on standardized tests and in school. We have brought together data on family services which identifies children in families who have been on income assistance; in other words, poverty. It also includes children who have been taken into care or where their families have been offered protection services because of issues within the family.
All of these data are held at the centre in a completely anonymous fashion but brought together for a specific research question that we address to them.
If you look at slide 11, I have pulled out what has persuaded the Business Council that investing in at-risk kids is the path to increased productivity and decreased social costs. The bars on the right show what schools typically see when they compare the performance of children in families that are poor to those in better socio-economic circumstances.
On the far left, about 76 per cent of kids whose families have had income assistance at some point passed their Grade 12 language arts test. On the far right, you see that for the kids in affluent, urban Winnipeg — the suburbs — 96 per cent of the kids passed the test. There is a difference. One would prefer that this difference did not exist, but it makes one feel like there is hope. It is not a disaster.
When we started analyzing those data, we realized there were a lot of kids who were not in school on the day of the test. It occurred us, with the health data — our ability to merge across these data sets — we could go back and look at all the kids born in Winnipeg 18 years previously who were still in the province and who should have been writing the test. We could find out if they were in school, where they were in school and what the real picture was when it came to achievement. That is the picture on the far right.
In fact, 76 per cent of the kids whose families had at one point received income assistance, who were in school writing the test passed it, but of all those kids in these families who should have been in school writing the test, only 11 per cent passed it. This is what has persuaded the Business Council. I have given you a one-pager that they are now using to work with the government and the public to start highlighting this as an issue.
Another thing that bringing together these different data sets does is to bring the different ministries together. You then have the potential to work across ministries.
If you go to slide 22, we ask: Where are the kids that I have been describing — the kids in care, the kids whose families are on income assistance, the kids whose families are being offered protection services from Family Services and the children of teen mothers? These kids essentially all do as badly as those kids we were showing on income assistance. Where do they live?
In some neighbourhoods in the inner core of Winnipeg, 80 per cent of the children have one of those characteristics. In the affluent areas, less than 10 per cent do. Ms. Yeates was talking about bringing the data home; these data come very close to home.
If you look on the next page, we show how the government's current child care policy provides licensed child care to the city of Winnipeg. Manitoba has one of the best licensed child care systems in Canada. Only Quebec offers more funding — more subsidized care and higher training, et cetera.
However, the way the system is set up, they do not offer child care to kids in those inner-city areas because child care is funded for working mothers. You do not have many working mothers in the families I have just described. This has provoked a lot of serious interest and action on the part of government, working across ministries.
My last point is another example of how these databases can be used. Someone wanted to know whether this was the right committee, because I had also wanted you to take a look at a proposal for real world evaluation of drugs. Drugs are almost never tested on children before drugs come to market. They are also not tested on many high-risk populations; or they are only tested on very high-risk populations and they are given to a lot of relatively healthy people.
Building on these databases, we are trying to set up is a way of tracking safety and effectiveness issues with drugs after they come to market. That is another area where I think, potentially, encouraging the support of these databases could be very powerful tools for improving population health.
The Chair: Ms. Yeates, you will forgive me for taking a bit of time to frame this question, but I have wanted to ask you this for a long time. I will be asking you again in a couple of months when we organize a round table to get at some methodologies.
We have seen great developments in Canada in the last decade or two. CIHI and CIHR are the two most relevant institutes. There are another 11 institutes, as well as the new Public Health Agency of Canada. There has been progress in the provinces with their public health agencies and organization that has allowed us to get programs down to the community level. My own thinking is that we must get to the community level where we can integrate the dozen or so major determinants of health if we are to elevate population health, particularly in the very low population health groups.
If we are to do all that, we must be able to measure what we are doing. If we are blessed by having collective governments, agencies and NGOs adopt the recommendations we make or the framework we suggest to them, the most important thing going in there is that we be able to measure, from day one, the impact analysis of what we are doing on the population group. At this point in time, can you see a way of doing that between your own organization, the organizations I mentioned and numerous other organizations? The resources we have across the country are amazing; it just seems that they are not integrated.
The committee just came back from Cuba. We wanted to look at the polyclinics down there that bring health, social services, education and science to the community level. I cannot prejudge our report, but I think it is inevitable that we will get to that point in Canada.
I apologize to the rest of the panel for going on, but this is really important. Do you think we have the machinery in place whereby we can institute a process of health impact analysis, or maybe there is better terminology?
Ms. Yeates: I absolutely agree that there are tremendous resources. We are much better served in the country in terms of having the data available than we were 10 or 20 years ago. There is much better data available now.
There are a couple of levels at which one can think of a health impact analysis. One is the broader level, namely, looking at how a neighbourhood is doing over time as we do interventions. There is a health indicator framework that CIHI and Statistics Canada have put out. We have population health indicators and the determinants of health indicators, along with some of the health indicators of health services, which might include primary health care and hospital indicators. Having an indicator framework that you measure over time in a standardized way allows you to see which communities are moving and where changes are happening in which indicators. The indicator framework in Canada is powerful. However, the indicators are not developed in all cases, so there is more work to be done. It takes time to develop those indicators and then to ensure we have the data to fill them. Increasingly we can do that.
Our indicators at provincial levels are useful in some policy contexts. When you bring it down to city or regional levels, they are helpful for others. If you are running a regional or municipal health authority, the city-level analyses might be helpful. Increasingly, as Ms. Roos mentioned as well, we find that the neighbourhood analyses are strong. For example, we are working with urban medical health officers across the country to give them a template. We use similar analyses from our data and they have some local sources so that we can put out reports city by city that look at some of the neighbourhood-by-neighbourhood factors. Locally, people have a much greater awareness of their policy environment and what they might do. Working on comparable data and getting it out to the local level makes a difference.
In terms of intervention research, you have to look at a particular research frame to know the impact of some policies and the causal links because many things will be going on in a neighbourhood. For example, you might want to know whether a program to fight obesity in Nova Scotia schools is working. Some programs designed to combat obesity in schools did not make a difference and some did make a difference. We were able then to question that difference given that both programs were well designed with good intentions. Sometimes we need that research at a specific level to determine what works because a broad indicator might not catch the impact of a specific intervention. There is need for, first, a strong indicator framework — and we are well on the way — made increasingly useful by drawing the data down to as local a level as possible; and, second, on specific interventions, the research that looks at a specific type of intervention, its impact and whether it made a difference.
The Chair: Ms. Roos, I have a question for you but perhaps you would like to comment on Ms. Yeates remarks first.
Ms. Roos: I would reinforce what Ms. Yeates is saying. We are working with the Healthy Child Committee of Cabinet in Manitoba, which works across different ministries focused on children. They are trying to buy into a proposal to do a randomized trial of children coming into a summer program based in inner city schools so these children do not lose what they have learned the previous year by having nothing to do all summer.
We met with school principals and suggested that they cannot provide this program to everyone, and they agreed. They had a way of trying to identify the program participants, but they were perfectly happy to have us randomize and send out invitations. They were going to be transparent, and sell it. Combined with that, we then have the databases to track how the kids did who were not there, how many injuries they had, et cetera. That combination is powerful.
Incidentally, CIHI supported the powerful research that I described earlier. A combination of support and powerfully designed intervention research in the various provinces is important.
The Chair: We would like to get at the relationship between health and productivity in a meaningful way. Everyone has been talking about population health since former Minister of Health Marc Lalonde brought the issue forward many years ago, but the subject tends to put people to sleep. However, when you talk about health disparities, you get more traction and people begin to listen and to understand what you are talking about. If you really want to get someone's attention, you talk about health and productivity.
The problem is finding the hard data relating to health and productivity. Many times I have gone out on a limb and said that there is an undeniable relationship between health and productivity, but we need hard data to support that comment. Can you enlighten us in that regard?
Ms. Roos: That is an interesting challenge. We know that the same factors that are related to health are related to education. Socio-economic status is strongly related to educational achievement, and no one has any problem understanding the importance of education. If you cannot get kids to the point where they graduate from high school, they will certainly not move forward in the economy of the 21st century.
In area of southeastern Manitoba, the Rotary Club has been working with the rural health organizations. They have literacy days. Dr. Fraser Mustard has been out there and convinced them that to get the population health message out to people, you have to do a broad scope. That would be my focus.
The Chair: I would like to discuss this more, but I will move to senators' questions. First is Senator Eggleton, former Mayor of the City of Toronto. Senator Eggleton is Chair of the Social Committee, which is doing a concurrent study on cities.
Senator Eggleton: Ms. Yeates, you were specific in outlining three factors to a federal role, but I think you let the federal government off a little too lightly. There are three very good areas: data collection to strengthen the database; intervention research; and electronic records, which is long overdue. These strike me as proposals relevant to the traditional health sector that would likely fit in well with Health Canada. Of course, when we talk about population health, we are talking as well about social determinants of health, such as poverty, housing, education, early childhood learning, environment, et cetera, not all of which are part of the traditional role of the federal government and the Minister of Health. How do you see that being covered here? I am thinking in particular about the intervention research. You suggest that getting into that area will involve dealing with these other areas that I mentioned. However, that does not fit into the silo system of the federal government and its whole-of-government approach, which is very tough. They have tried in other countries, the U.K. for example, where they have high-level cabinet participation. How will this fit in with the recommendations you have made so that these other areas of population health are covered, not just the traditional health sector.
Ms. Yeates: In my previous role, I was a provincial deputy minister, so I bring that provincial history with me to a certain extent. My experience was in Saskatchewan and Ms. Roos mentioned some of the attempts in Manitoba. As people try to work across ministries, at any government level, one of the things that pulls them together is data and information. The structures do not particularly support it, but when you can show those kinds of things that pull people out of their silos effectively, I think that is very helpful.
One of the challenges in making the case to various ministries is that there can be no data. I have been in social services and health at a provincial level, as well as the Department of Finance, and my observation would be that the case can be made much more strongly in areas where you have strong data. Where you lack that data, you are working on theories and suppositions. It is not nearly as effective in getting your colleagues to rally to a common cause.
When I think of intervention research, I think of the federal role as having a strong possibility for funding. There is a strong lead for federal funding capacity in CIHR and other bodies. I think of agencies like ours as having a responsibility to get some of that research into the hands of not only health departments; we specifically target other sectors.
When we finished our report on urban health, we sent it to all the mayors of the country and to education departments. We had planning departments phone us and want to engage in that.
We are very much trying to work beyond those silos. I agree with you; the solutions lie increasingly not within them.
In terms of where I think the federal government can help in that integration, I see them as having a strong role in research and data. Those are two key tools that they can use to help the integration locally, but there may well be others that you, as a committee, have studied.
Senator Eggleton: Given this wide range of areas that affect population health, in a government context, different ministries look after that. More significant than that is the fact that most of those other ministries are at the provincial level, or maybe delivery of service at the municipal level. What is the federal role in all of that? Do you see them pulling the provinces in together trying to develop a strategy? I think Ms. Roos used the phrase ``national strategy'' in her paper. What do you think?
Ms. Yeates: I do not know that I have an opinion as an information organization. As a former provincial person, I think it is helpful for governments to be clear about who does what best and who is well situated to do what best. Being clear about that and knowing what level of government can make the most difference is an important issue in this country, and sometimes we do that better than at other times.
There are certain things in a country of this size and diversity that the federal government does well and effectively, and there are other things that provinces and cities do well.
I was intrigued by the question because your committee has obviously been grappling with the question of what is the federal role. It is important to ensure that we think about how to move this population health agenda forward at each of those levels.
Senator Eggleton: Ms. Roos, right on the front page of your document it says ``Encourage National Strategy.'' How do you think the federal government should go about doing that?
Ms. Roos: I am seeing attempts in Alberta to bring together five ministries and all the data from those ministries. B.C. is trying to do this as well. People from three different ministries in Ontario visited us last week because they are also trying to bring together education data, family services data, et cetera. The same thing is happening in Halifax.
The federal role is often around funding, either through CIHI or CIHR. An initiative in this area would be hugely helpful, but also around setting standards and guidelines, bringing people together to ensure that if you are going to do it, you do it in a way to produce things that are similar; you can count things the same way.
Another helpful initiative would be the sort of thing we are doing now in Manitoba with the Business Council, trying to foster an understanding — somewhere outside of academia and outside of your committee and Fraser Mustard — as to why these issues are important for the productivity of Canadian society.
We need to put some traction on this issue. No one will deny that it is nice to talk about kids. I was on the health forum. Getting the public to understand population health is not easy. Business could take a very prominent role. Minneapolis and Hamilton have been proactive. The Business Council is bringing them to Winnipeg to talk to the business people there and the public, and I think that might be a very powerful role.
The Chair: Senator Segal is next. Senator Segal introduced a very interesting motion yesterday in the Senate and made a superb speech that we will integrate into our documents here.
Senator Segal: Thank you, chair.
I know it is not easy for the witnesses to step out of their formal roles [inaudible].
Slide 15, entitled ``Manitoba Kids at Risk,'' breaks up the 31 per cent of children who have at least one risk. The slide indicates that 14 per cent are in poverty, with the family receiving income assistance; 17 per cent have a teen mother; and another 17 per cent are in care or protection. With respect to the second and third categories, you are not suggesting that these are well-to-do people who happen to have a teen mother. These people will have a similar income, I assume.
Ms. Roos: Yes.
Senator Segal: If you only use poverty as a defining frame for the first 14 per cent, are you saying that in the second two categories poverty is not an issue?
Ms. Roos: No, I am not. Everyone assumed, before we put this together, that those were basically the same people. It turns out that many of them are, but certainly not all of them.
Senator Segal: They are defining characteristics.
If you were asked not about health determinants and not about population health, per se, but rather how you would spend $120 million to increase population health in the most radical and appropriate way, using the money most effectively, how would you respond?
There are enough organizations like CIHI that do outstanding work from which we all benefit. Diagnostic tools are always getting better and people are working intensely on those. However, we are bereft of the instrument by which you take the diagnosis and make a real difference in people's lives before they die, before their kids are lost, before a community is bereft of options. What is the instrument? If you had to choose the most salient instrument that will produce the best results, would it be income security? As I look at some of your numbers, it seems to me that education is a somewhat better predictor than income, although who gets an education is, as you yourself said, determined by income and other issues. Please give us your best advice.
Ms. Roos: We need to invest in kids for the first 17 years with targeted universal programs in the highest risk communities. We need to do whatever it takes to provide them with nurturing early childhood experiences, for example making enriched child care available at very early ages.
We need to prevent teen pregnancies in young women who have grown up in poverty. When they have kids, it starts a vicious cycle. Investing in their kids produces better results. I would invest early and often throughout childhood.
Ms. Yeates: I support what Ms. Roos said. From my experience in social services, I believe that one of the best instruments is income security; supporting the kids, but also supporting the parents. Income support programs are important, and the source of the income support also matters. Income support and income from other sources are both helpful for children. The way we support families is important because intergenerational effects can make a difference.
We need to offer support through positive environments in those families. [inaudible]
Keith Denny, Acting Manager, Canadian Institute for Health Information (CIHI): I agree with the early childhood development. I would say that we have a lot of research [inaudible]. We also have a whole range of health outcomes.
We still have an underdeveloped sense of what works. We need to find out how those lenses work and what mechanisms link them to those outcomes. Even with all that money to spend, we still need research that helps us understand what those things look like so that we can then evaluate the impasses. I would go back to that. We still need to elaborate our understanding of cause and the mechanisms between the determinants of health.
Senator Cochrane: I had not heard about concentrating on mothers who are about to have a newborn baby. When a child is born, it is important to ensure that the mother has enough information whereby she can get the right vitamins, food and so on so that she has enough weight on her when the baby is born. [inaudible] Do you have any data on that?
Ms. Roos: In our CIHI study, this was one of the most ``aha!'' moments. We know that women who are in poverty do not eat well, as you just described. We know that they are more likely to have low birth weight babies — that is, babies who are not as healthy as others.
If you look at slide 13, we found that at birth all children are overwhelmingly similar, regardless of their background. Over 90 per cent of the children are indistinguishable, whether their parents have been on income assistance, a teen mother or whatever. [inaudible]
I am not denying that it is not important to deal with nutrition issues, et cetera, during pregnancy, because it is. The overwhelming issue is not what happens before birth; it is what happens during those first years. [inaudible]
Senator Callbeck: You talked about the present role and you gave three examples about what the federal government should be doing. What is the electronic health record? Will it provide standardized comparable data? We have been talking about this for years. Where are we now? Is every province doing its own thing?
Ms. Yeates: It is an enormous undertaking. Canada Health Infoway is working across the country to help support the projects that go to make this up. They have imposed certain standards on interoperability and what I think are the messaging standards.
We have learned from health and information science initiatives that have brought people from other countries to look at the question of whether to use this system in the first instance or with individualized health. For example, as an individual, my lab test would be with my specialist or my GP. I think we all understand the case for electronic health records.
Across the world, some countries have done better than others. This is called secondary use of data. It is not a phrase that offers a particularly good description as it implies a sense of unimportance. The ability to pull health information from these records, in privacy sensitive ways, that would allow us to understand population health trends and impacts is enormously powerful. To do that, however, we must standardize definitions. For example, you may ask whether we are experiencing more diabetes in Winnipeg than in Halifax or Vancouver, or whether the interventions in Halifax are more successful in treating diabetes; that is, are they having fewer eye or foot problems than elsewhere? To know those things on a population basis, we have to define a foot or eye problem or even diabetes in the same manner from place to place. To do that requires standardization. That is something on which we need to focus.
As we make this important and vast investment in electronic health records, it is important to note that it must not only be good for individuals but also serve to support population health impact analyses. If we have that vision, we will design the framework slightly differently, and I think that will be important.
Senator Callbeck: You say that pieces are being standardized. Have any been standardized?
Ms. Yeates: There have been tremendous efforts to build on the investment of one jurisdiction from another. For example, when a drug information issue occurs in certain provinces, there is a learning of impacts from one to another. I do not know all of those local pieces to say how standardized they are. I certainly know that some components are and some components may not need to be.
Our sense is that more work can be done as a country to define what we actually want and expect from these population health data sources. There will be some components that should only be used for individual circumstances and we should leave those data elements there. There may be others that we think should be used at a population health level. Those would be the ones that we need to standardize.
Senator Callbeck: Do you feel that the federal government is playing a strong role in this endeavour?
Ms. Yeates: It is clear that the federal government has made a major investment in the electronic health record, which is critical. We cannot proceed without that kind of investment.
I think that individual jurisdictions have less of an interest in standardization across the country. This is an important potential federal role. In addition to the role that has been made, there is the potential to be clear about the expectations of electronic health records for the kind of population health uses that can, in a privacy sense, be done where appropriate.
Senator Callbeck: Ms. Roos, your presentation indicates that public support is needed for action on these broad issues. You then gave the example on the slide where you showed the real educational outcomes, and the Business Council saw this and made the connection. What role does the federal government have in trying to get the public to understand how population health affects productivity? How can the federal government make people aware of the fact that this contributes to good health? How do we make this connection?
Ms. Roos: I have spent the last 35 years in Manitoba with a few forays into federal issues, and I have some problem knowing factually how to answer that question because I do not know. My sense is that the federal government has powerful potential in partnership with national business organizations that have groups in every province. Let me describe what is happening in Manitoba and maybe you can translate it to the federal level.
The Business Council takes on initiatives. For example, immigration has been their big initiative to solve the labour shortage. They had an all-day session where they consulted with the public, business leaders and government. They had lunch with ministers and their deputies. They set a target that is being met, and they are very happy with this. That is the type of effort that they will now begin in relation to investing in the at-risk kids agenda. They are bringing in people from Minneapolis and Hamilton and will have an all-day session, again bringing in the ministers. Once the ministers see that the Business Council is interested in this, and if the public buys in, and, of course, the press is very interested in this, then the government, despite all of its competing interests, will think it is important.
Maybe we can get a few examples of at-risk kids who have done well. We have a program in the inner city schools that is working. The United Way, another organization, is starting a poverty council. They are interested in working with this in the United Ways across the country.
The federal government could initiate a series of conversations and consultations around using data that exists in British Columbia, data similar to that which I have presented for Manitoba children. They could do the same thing in Ontario and other provinces. It would be possible to bring together in each locality the potential to persuade the broad community to make a commitment.
Senator Callbeck: Something else I wanted to ask you about was drugs not being tested on our children before the drugs come to market. They are usually tested on healthy adults. This, I guess, is a proposal, is it?
Ms. Roos: Yes. The drug safety and effectiveness research network is a proposal that is now being considered by Health Canada and the provinces.
Senator Callbeck: And the provinces?
Ms. Roos: Across the country.
Senator Callbeck: Thank you.
The Chair: I wish to take you back to the comment you made in response to Senator Cochrane when you said ``aha!'' in regard to the similarities of infants at birth across socio-economic groups. As I mentioned to you, there is a huge emphasis on prenatal care. I am aware of programs in Canada for First Nations where there has been a heavy emphasis on the change of [inaudible]. I have not talked to [inaudible] about this, but I did talk to him about it last time. He still was convinced [inaudible]. Some of the early development scientists, neurologists and various kinds of research [inaudible] saying, the brain is developed to about one third when a child is born; the other two thirds [inaudible] and a lot of it [inaudible]. If that first third does not occur in the uterus, there is a huge problem. I got the impression that you had the data to back that up. Is that correct?
Ms. Roos: We looked at three different measures. One was birth weight. One was gestational age — small for gestational age and large for gestational age. The other was the one- and five-minute Apgar scores that cover the general functioning of a child.
Having looked at those data which suggest that only 11 per cent of kids in income assistance families are passing their grade 12 test on time, compared with 76 per cent, we find that almost 90 per cent of kids at birth are essentially undistinguishable on those measures. When I said it was an ``aha!'' moment for me, that is what I was describing.
Fetal alcohol syndrome will not be picked up necessarily with those tests. That is something we are now working on. We have a registry regarding fetal alcohol syndrome, and we are trying to determine how much of what we see may be explained by that.
Even the biggest assumptions regarding FASD come nowhere near to explaining the long-term differences we are seeing. To me, the ``aha!'' is you keep kids in school and the differences in socioeconomic status, or SES, almost go away. Look at the Reading Recovery Program given to grade 1 kids. When you look at kids from those income assistance families and from very affluent families, their scores before and after the program are very similar; poor and rich kids recover. As far as we can tell from physiological studies, these income assistance children are not damaged kids; they have real potential. That is the kind of stuff that comes out of this data.
The Chair: That is truly fascinating information because we have not had a lot of information so far. The information we have received has been steering us in the direction of maternal health, prenatal health and early childhood development, and then move on from there. What you are saying shakes up that hypothesis. I must spend more time with you.
Ms. Roos: I would be delighted.
Senator Fairbairn: I could not let the day go by with people like yourself here without asking if you could expand on the fundamental importance of literacy. When does literacy become important? In your studies and in your work, you see the effort that is being made within the schools to reach the very kind of children that you are most concerned about in respect of their development. I am very aware of Manitoba and the terrific work that has been done on this issue over the years. Could you expand on that a bit for us?
Ms. Roos: We are very interested right now in working with the Ministry of Education to understand how well their programs are working. I mentioned the Reading Recovery Program and how well it reaches those at-risk kids. This is a universal program. Manitoba gives a certain amount of money, depending on how many grade 1 kids you have, to every school to reach those children who do not read well. The problem is that it is a per capita grant. The affluent communities get essentially as much per kid as do the inner city schools. The affluent kids are much more likely to recover than the kids at inner city schools because they cannot do one-on-one programs.
I do not want to underplay the importance of the mothers. When I mentioned that the regional health authority was working on literacy programs, this was to reach the mothers and fathers of these kids. We know that a child spends so much time with their family that it is incredibly important to try to raise their literacy levels also. There is no question that those kinds of programs are very important.
Senator Fairbairn: We were in a good position a while back when the various levels of government were working closely together on this issue, and it is not quite like that now. I am not pointing my finger at any particular level of government, but, as time goes by and other things arise in the world, sometimes these issues that look fairly mundane slide off the table. When you talk about these inner city issues, are they part of joint community efforts or efforts with one particular organization?
Ms. Roos: We have been trying to bring together as many organizations as possible. I was just in communication with the head of the Winnipeg Regional Health Authority who is bringing in the head of the Department of Pediatrics and the head of the Women's Hospital because they now have joint programs with the Ministry of Family Services. We know these are high-risk kids with a lot of issues, including accidents and injuries, that bring them to the hospital.
For example, a pediatrician I work with said that in their neonatal intensive care facility they now treat teen mothers the same way they treat mothers of very low birth- weight infants in terms of the probability that their child will be re- hospitalized. They connect them with services and tell them that they need to have frequent visits to a pediatrician. Trying to get the health responders to respond to social risk factors as they do for biological risk factors is another achievement.
Senator Fairbairn: A few years ago, the City of Winnipeg was active in a program that started in a small community in southwestern Alberta and then blossomed as people picked it up. It was called Books for Babies. The program started in a little town like Pincher Creek and went across Canada. It went into the hospitals and, sometimes, into institutions so that no one now walks out the door without knowing that literacy for themselves and for their babies is a critical issue. I would hope that in Manitoba they are still doing that.
Ms. Roos: They are. Again, I think involving the parents is so important. They were sending the family home with books. The father said, ``Why would you read to a baby who cannot read? What is the point?'' The explanation was that while you are holding them, they are learning lots of new words and their brain is starting to learn. The father said, ``Okay, I can do that.'' He clearly could do that, but it never occurred to him before he heard from the program.
Senator Fairbairn: That is the magic of the gentleman who will be here tomorrow. He has been an absolute icon.
The Chair: Honourable senators, if there are no more questions, allow me to thank our guests. We have had a lovely afternoon. We will be in touch with you. This is not over yet.
The committee continued in camera.