Proceedings of the Subcommittee on Population Health
Issue 4 - Evidence, April 2, 2008
OTTAWA, Wednesday, April 2, 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 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 (Chair) in the chair.
[English]
The Chair: We are delighted to have with us this afternoon, Dr. Salim Yusuf, whom I have known for a very long time. He is a professor in the Department of Medicine and Director of the Population Health Research Institute at McMaster University. He holds a Heart and Stroke Foundation and Ontario Research Chair. He has been a senior scientist of the Canadian Institutes of Health Research and has received huge grant funding from Canadian granting bodies and from the National Institutes of Health in America. Before he moved to America, he was an outstanding scientist and scholar in England at Oxford University. He has a wonderful reputation, is a global authority and, in fact, is rather unique because in all the cardiovascular epidemiological studies, he has become the anchorman on a global basis. His publications have become a kind of bible in the field because they are referenced and cited regularly.
If I may say, he has been a dear friend of mine for a very long time, and I am delighted that he is here today. Dr. Yusuf, please proceed.
Dr. Salim Yusuf, Professor, Department of Medicine, McMaster University: Mr. Chair and respected senators, thank you for inviting me to come and share my thoughts with you. I will start with a little story. Last May, I was in Nairobi, Africa, with my wife, participating at the African congress of cardiology. While we were travelling by car from the airport to the hotel, I was taking photographs of people standing by the bus stop. My wife asked, ``Why are you taking pictures of people at the bus stop?'' I said, ``Look, no obesity.'' We went into the meeting and found that the obesity in Africa was among the cardiologists. This is how chronic disease starts.
These diseases are first diseases of affluence. However, when I was in Washington, D.C., at a similar meeting at the National Institutes of Health, I took the red subway line from the Shady Grove stop in an affluent suburb of Montgomery County, Maryland, and did not see very much obesity. However, as the train left the affluent area and moved into Washington, D.C., I was able to plot the people becoming heavier. As it moved out of D.C. and back into Prince George's County, Maryland, on its way to Glenmont, I saw enormously fat people.
Do not tell me that the genes of the people who live in Prince George's County are different from the genes of the people who live in Montgomery County and that the train brings those seeds of obesity as it moves from one county to another. Most impressive was that it was not lone individuals who were obese but rather masses of people.
Obesity is rare in individuals in societies that have, on average, lower weights and is common in societies that are heavier. Canada did not have much obesity in the 1950s and 1960s, even after accounting for the immigrant pool. The gene pool has not changed that much to be able to say that obesity in Canada is due to a changing gene pool. This brings me to an important point.
Most of the diseases of chronic illnesses of middle age and old age — lifestyle diseases — are diseases of populations and not diseases of individuals. This was well-described in the 1950s. We do not have unhealthy people living in a healthy population, but we do have people who are unhealthy because they live in unhealthy environments and the population as a whole has shifted.
We can study populations in rural India where the rate of obesity is under 1 per cent and the rate of diabetes is under .5 per cent. When that same population moves to the cities, it becomes obese. Their rates of diabetes rise to 30 per cent. This is important because the Canadian health care system is not a health care system. It is a disease management system; and we have misunderstood the two. The disease management system is important. We have a fine disease management system. Having worked in four countries, I can say that I am proud of it. I roundly defend our system against that of the Americans. It is a bit harder against the British, but I would still defend it.
Take another condition such as high blood pressure. We have many treatments, at least five drugs that can lower blood pressure. We know that lowering blood pressure will prevent strokes, heart attacks, heart failure and will make people live longer; yet, in Canada, only 20 per cent of people with hypertension have their blood pressures controlled. That is miserable.
The first response is to get more doctors out with blood pressure cuffs and prescription pads to check everyone and get them on medication. That will work, but it will be enormously expensive. Such treatment of hypertension would bust our national budget. The approach would have to be to try to prevent hypertension. If we do one or two simple things that affect the population as a whole, not only will it reduce the rates of hypertension by half, two thirds or even three quarters in middle age, it will also do so even in children. In societies where the adults are obese, we know that the children are obese. Where adults have hypertension, children, on average, have higher blood pressures.
I am trying to point out two things: Most chronic diseases, such as diabetes, obesity, heart disease and strokes, are diseases of populations, with the origins in childhood; and the causes of the determinants of these are societal. There are fundamentally three causes; the first is tobacco. We are doing a lot in this country to control tobacco concerning heart attacks and strokes, but we should do more. Most of us think that we know enough about tobacco to control it, and then it will take care of itself. That is not the case. In the last century, 100 million people died from tobacco-related causes. In this century, 1 billion people will die from tobacco-related causes unless we do something much more aggressive about it. Canada is enlightened in that it has one of the most advanced mechanisms of tobacco control, which we need to continue to work on. In 20 to 30 years, tobacco control in Canada will be a model around the world.
We need to control obesity and salt. Obesity is not because individuals decide to do the wrong things. It is because individuals decide to do the right thing. If I put food in front of most of you and you eat, that is a normal response. However, if I put lots of tasty food before you and tell you not to eat, that is an abnormal response. The way we try to deal with obesity in this country is to put this sea of plenty before people and tell them, do not eat. We are trying to take normal human behaviour and change it because our environment is abnormal. The right thing to do is to change the environment so that the normal responses come into play. Challenge people with less of the wrong kinds of food, and then people cannot eat the wrong kinds of food. If the schools were to serve the right kinds of foods, then the kids could not eat the wrong kinds of foods.
If I leave 15 minutes late for work in the morning, I get stuck behind a certain school bus. There are parents outside each home for about two kilometres along bringing their children out and putting them on the bus. It is a wonderful sight, but it makes you wonder why the children do not walk 100 yards and gather together to get on the school bus.
Our cities are structured to be obeseogenic and our systems have been structured to be obeseogenic. I am sure this building has staircases but they are called fire exits. They are unattractive and are put away in a corner. The designs of buildings promote inactivity. We are building a new research facility, and I said that it has to be an anti-obesity building. It will be only six floors high and the central piece is a beautiful staircase. We have elevators but they will be tucked away in the corner. We will put up a sign at the staircases that says: This is good for your health — free gym. At the elevators, the sign will say: If you are healthy, this is injurious to your health. We will see whether it will work.
In some sense, I might be joking, but I am serious. We cannot have a healthy society if our policies are not health- conscious and health-oriented. The Government of Canada has a bigger opportunity to do something here than all the doctors together in this country. As someone said, health is too important to leave it to doctors. Despite being a doctor in health research and in practice for 30 years, reluctantly, I tend to agree with that comment.
A few years back, the Soviet Bloc had a tremendous revolution that led to the fall of communism. In the midst of that, Poland was an interesting case study. When the communist government fell, they had very little money. There was chaos but, in the midst of it, they removed the subsidies on animal products on farms. As a result, people were growing vegetables in their backyards because that is all they could afford. Over a two-year period, there was a 20 per cent reduction in heart attack deaths and strokes in the entire country. This is like saying that, in all of Canada, we will control high blood pressure. It is as big an effect as that.
Why did that happen? It happened because the dairy consumption declined by 50 per cent and the vegetable and fruit consumption increased by 80 per cent. It was all a matter of affordability. Therefore, if a country such as Poland could do it inadvertently, Canada could do it. With the right policies and considerable resources, both in money and human brain power, we could do it if the will was there and improve the health of the nation.
I want to leave you with a final thought. I have not given you specifics; I just want you to have a feel for the issue. The problem of chronic disease will only get worse in Canada.
The best way to improve survival after a heart attack is not to have a heart attack. The best way to reduce disability after a stroke is not to have a stroke. The best way to avoid people being frail and cognitively impaired in old age is to avoid the progression of conditions that lead to it.
A whole new concept is emerging. I see that the future of people in cardiology is not in doing what we currently do, but in preventing cognitive decline by improving the health of people so that they are less frail and more independent. Healthy aging is dependent on healthy populations. Populations that are healthier on average have less disability.
There is a concept called compression of morbidity. Fifty years ago, four out of five people in Britain would die before the age of 70. Today, we have the theoretical promise that four out of five people will live beyond the age of 70. I believe that is true in Canada. However, 20 years from now, we have to be able to say that four out of five people will live healthily beyond the age of 80.
I believe it is possible with what we know if we have the right policies. You are doing a tremendously important thing in convening a committee on population health. The health of the population will improve the health of each of us. It will help improve our health not only when we get sick or when we are in our middle age but also in our children and our grandchildren from the day they are born.
Thank you for giving me the opportunity to share my thoughts with you. I would be happy to address any questions. Much of what I say may be alien, but I am known to be provocative.
The Chair: You raised a question in your anecdote that you did not address. You mentioned that as you sat on the train and went through different communities, you saw differing incidence of obesity. It is a tremendous population health problem.
As our hearings unfold, it appears that if we are to be helpful to government, we must find a way of making recommendations to help provide resources at the top. Examples are the prevention of tobacco use and control of hypertension. However, when we try to affect the determinants of health, such as poverty, poor sanitation, contaminated water and poor housing, I have the impression they cannot be addressed at 30,000 feet — at the top level.
We are lacking, in Canada, an organization that can pull together the resources to deal with the determinants of health at the community level. We have many examples such as native people or the city core.
We visited Cuba to look at the polyclinics that fundamentally do that. They service a given population of about 20,000 people usually. They provide primary health care, public health, prevention programs and are integrated with the early education programs and so forth. It is amazing that the indices of good health in Cuba are as good as in Canada without the resources to deal with the illness management system that you mentioned.
Would you comment on the need for organization at the community level that gives people a decent place to live, decent food to eat, et cetera, through the dozen or so determinants of health?
Dr. Yusuf: Undoubtedly in Western societies, poverty is associated with most common diseases. It is curious. About 100 years ago, poverty was associated with less heart disease. Then it flipped with what is called the post-Victorian gradient. In these societies, richer people — more educated, more affluent — know how to deal with the problems, and then they reverse the epidemic.
My story of Africa had a message. It is a continent on the rise; the rich people now have heart disease. The contrast with Washington, D.C. was deliberate; now it is the poor people who have heart disease. Think of Africa and Washington, D.C. as telescoping what has happened in 100 years in our country. That is what I hoped to get across. You can see poverty playing a major role.
Having said that, it may be too much to say that we will further redistribute wealth. Some individuals, depending on political leanings, have said that. I do not know whether it is desirable or not. I will not comment on that.
The point is we could do things at three levels. The first level is national policy so that it is easier to live a good life and does not cost anyone any money; for example make changes to tobacco laws, health education of children in schools and redesign school curricula to ensure physical activity is common in day-to-day life. Redesign the curriculum so that there is more physical education not only in schools but even in universities. When I consider my son and his friends, they were as thin as weeds when they finished school; yet, in the first four years of university, they all put on weight.
Redesign what happens in the workplace. Redesign buildings; perhaps provide free gym memberships or bonuses for maintaining a healthy life. Incentives can be incorporated. This may not cost individuals anything. It will, of course, cost society something, but these are policy-level decisions to increase physical activity. In the long term, redesign our cities to be health-conscious not automobile-friendly so that we walk more. In a cold city, passages can be underground or in covered parks, for example.
The other side is food policies. The one food policy that will not cost Canada much but will have a big impact on hypertension is reducing salt. Most of us do not realize that the majority of salt we eat is already in the food, and we cannot do anything about it. It is not the salt that we add either in cooking or at the dinner table. That is only 20 per cent of salt intake.
We need to reduce the salt in processed food. Even meats are injected with saline to increase their taste. Where I shop, that is what is done.
If we can have national legislation that reduces salt in the foods that we already receive, even if every Canadian adds a bit of salt at the table, hypertension levels will drop. If we drop weight by a small amount in the whole population — 2 or 3 kilograms — then that will have an added effect. Between these two, my estimate is that we will lower hypertension and diabetes rates by 50 per cent. This can be done without huge tinkering; minor tinkering without huge changes.
One can be more radical and suggest that there is a story in tobacco that will tell us what to do about foods. Perhaps we should gently change our agricultural policies. Maybe we are subsidizing the wrong types of agricultural products. Maybe it is time to shift it to the healthier foods. Yes, help our farmers; I believe in that. We need a healthy farming community. However, change how we do it so that there is greater value in promoting the growth of foods and produce that are healthy. That may be more controversial, but I am just throwing that out as a possibility.
The second suggestion is borrowed from Cuba. I was at the CIHR today where they are having a debate as to funding international programs. The concern about funding international programs is whether something done in another country can have relevance to Canada. My response was to tell them that the only way we can learn whether our system is good, bad or indifferent is by comparing our system with another system, which is what we have done.
Returning to the Cuba model, we need a model of community clinics, health care workers, who are not necessarily physicians but extended health care workers — in this country, we call them nurse practitioners, but it can be any model — who are trained to deal with 20 of our common issues. That will, in one stroke, deal with the so-called shortage of GPs; it will deal with, as you know, the inequities of the reward system right now in medicine and will focus it back on the simple things that many people are afflicted by.
Doctors are more interested in doing the high-tech stuff. I am a doctor too, so I know this to be fact. I headed a cardiology program. None of my trainees want to do the simple things because they are not intellectually satisfying, and they are not well remunerated. We need to think of a different model. Doctors need to be part of the model; you cannot alienate them. Politically, that would be a mistake. On a positive note, they can be helpful; for example, Andrew Pipe in Ottawa. He has been tremendous with what he has done on tobacco control. The right physicians working with, not on top of, extended health care workers can be that next level.
Last, our medical curriculum in this country needs to evolve. It has to evolve from a biology-based approach, which is what I studied — and which is good — to the added concepts of the social determinants of health. Public health needs to become a much more integral part of the core curriculum of medical students training in internal medicine. You would all be surprised if I told you that when an individual in Canada comes out as a cardiologist, he or she has had four years of medical school, four years of internal medicine training and three years of cardiology, a total of eleven years. Do you know how much time they spent learning how to assess diet? Zero. Do you know how much time they spent learning how to get people to stop smoking? Zero. However, these two are the biggest causes of heart disease. Therefore, changing the curriculum of health workers to incorporate prevention and population health is also important. Again, those are the types of things the nation as a whole can do.
Senator Brown: I am fascinated by what you had to say. We had a doctor here as a witness previously talking about almost exactly the same three issues — tobacco, salt and inactivity. I also agree with your suggestions to change the buildings to make them more physically challenging. I experienced that myself since I came down here. I walked for the first three months and lost about 10 pounds just going back and forth from my apartment — involuntarily on my part because I did not have a car. It has been snowing ever since, so I have probably got it all back now.
The tobacco issue really fascinates me, because I quit smoking about 40 years ago. It takes some people a lot of effort to quit. I was lucky; it was not that hard for me. I think about the program that Canada has already used on tobacco. I would say 40 years ago, the majority of Canadians smoked, and now it is around 20 per cent. If that is correct, then we have done it, not with massive changes in our medical system, just with advertising on tobacco packages and television about how bad tobacco is for you.
Dr. Yusuf: It has been much more than that, senator. I would say that it is an enlightened multi-tier approach. First, we have taxed tobacco, and there is a very clear relationship between taxation of tobacco and users, especially in teenagers. Second, obviously we have, as you mentioned, health and safety warnings. Third, we banned the use of tobacco. Now tobacco is socially unacceptable in most places. We made a sea of change, and tobacco is a wonderful example of population health strategies working.
Senator Brown: That is exactly what I was trying to get to. We started with a very mild program against tobacco. We asked the tobacco companies, or told them, to put a warning on the packaging. Then we started with more belligerent advertising, for want of a better word, and we have escalated it until we closed buildings from smoking. We have closed almost every public place that you can imagine.
I am not suggesting that we close off people from food, but I am suggesting the same type of a program. You are advertising it yourself with your words and your thoughts, and we are listening carefully. Most of us will believe what you have to say, but we need your thoughts to reach the entire population in Canada and its future generations, the children, especially the young ones.
We have to use what you are suggesting, but we also have to go back to what was successful with tobacco. We start saying, ``Hey, you are eating food with too much salt. It is bad for you.'' We have already started that program with candies and pop, et cetera. I believe it started in schools. We have to accelerate all of them, and it is worthwhile. I just wanted to add to what you are suggesting, because I really feel that the medical people cannot do it by themselves.
Dr. Yusuf: Yes, that is true.
Senator Brown: It has to be the whole of society.
Dr. Yusuf: I completely agree.
Senator Callbeck: I am certainly interested in what you have to say. When you talk about the health care system being based on disease management as opposed to prevention and maintenance of health, I agree with you. Many Canadians look at our health care system as hospitals, doctors and nurses.
From reading your presentation, you suggest that we take a percentage of the health care budget and put it into population health and prevention strategies. That would be a great move. There are many advantages there because it brings down acute care costs, and people are more productive and healthier as well. Their quality of life is better.
You know that governments generally think in the short-term, and prevention measures in population health take a long time to show results. My question is about the general public. How do you get the general public to buy into thinking that it is good to take a percentage of the health care budget and put it into preventative measures, strategies and population health rather than into hospitals, doctors and nurses?
Health care costs are going up. There is such a demand there for the health dollar. To my way of thinking, you have to get the general public to buy into this, so they can then pressure their politicians to spend these dollars on population health. Otherwise, will it happen?
Dr. Yusuf: You have raised some important practical issues. Some aspects of population health, the public will welcome; others they will fight because nobody wants to change the way they live.
If I have a patient after a heart attack, they want to know which stent I will put into them. They do not want to hear about smoking cessation or losing weight. Here is a person who has just had a heart attack, a life-threatening situation. Similarly, I am not sure people willingly agreed to wear seat belts. It was legislated so people wore seat belts.
It will call for leadership from the government to persuade the nation what is good for them. That would be the difference between a reactive political system versus a proactive and visionary political system. I will leave it to the government to decide which one they want to be.
On a more practical level, I spent two hours with Minister Smitherman last week. We talked about the assumption that everything we do in the hospital system, or whatever system we have, is useful. What if there is considerable waste? Let me give you an example.
When I came to McMaster University, Hamilton, in 1992, we had two heart catheterization units. We always had a waiting list. Whenever I mention waiting list, we assume that any waiting list is bad and everybody on a waiting list ought to be on it. Who said so?
We studied the waiting list. We then had a third catheterization lab, then a fourth built. Our volumes went from 3,000 procedures a year to 8,500 now. The proportion of people who do not meet appropriateness criteria for catheterization tripled in that period. Where we can find our savings is to have quality assurances and appropriateness. That is one source; it may not be everything.
There needs to be re-education. More health care delivery does not mean better health. There is very good data showing that for certain types of high-tech procedures, after a certain point, we start to do it in less appropriate people, and we start to get complications. Although we are spending more money, we are actually hurting people.
Most of you will think that for somebody with a heart attack today admitted to a hospital, the chances of that person dying is from the amount of damage to their heart. That would be logical, and that is what I thought.
However, last year, we did a study in our hospital and found that the most common complication in the coronary care unit was not the complications of a heart attack but the complications from the treatments, which is bad bleeding. Therefore, we have now gone to the other side.
We are hitting a ceiling, not in all parts but in some parts of medicine, where more investment will not lead to better health. It may actually lead to worse health. That is a paradoxical statement. It is not intuitive to the public; it is not even intuitive to most doctors.
I am not saying that this is the case in every part of our system. What could we do? I told Minister Smitherman that you can have a 1 per cent solution by putting 1 per cent of the Ontario budget to create processes for quality control. Challenge the hospitals to put up 1 per cent of their own budget, and you will add 1 per cent. The hospitals will find savings, but allow them to re-invest them into better means. We do not have national quality assurance programs in the country, appropriateness programs.
When you institute it, at least in some areas, costs will be reduced. Not in all; some we will find we are underutilizing it. However, some of that savings can go in.
As you have seen, every year it is an X per cent increase in budget. For the health care budget, maybe part of that should be toward population health. It is politically and practically difficult to pull back money, but you can start to divert money. You can direct where the increases go. Over a short period of five years, you can get to the 10 per cent solution that I am suggesting here.
What you said about population health having a slow impact may be true in some areas. Actually, population health has a quicker impact than pumping money to create more MRI machines or something else.
All you need to have is one person with a cancer who could not get their MRI and it is on the front page of the newspaper. If you prevent 100,000 deaths in Canada, those 100,000 people are silent. Prevention is silent; the other is vocal. It is not that the impact on health is slow; rather the visible consciousness is slow.
I hope I have got my point across.
Senator Eggleton: Thank you for being here today. Your comments are very valuable to us.
I wanted to pursue this matter of salt. You say that a one-third reduction in salt in most foods would have a very substantial benefit. It sounds simple, so my first thought is why have we not done it?
I suppose there is pushback from some people out there. Who would be the people pushing back, and why would they push back against this type of reduction in salt, which you say comes in the food processing and packaging?
Dr. Yusuf: First, let me tell you that I am not an expert on salt. Should you care, please invite Norman Campbell from Calgary some time. He is the nation's expert. Let me give you my simple answer.
There are certain processes ingrained in the food manufacturing system. To change that takes capital investment, discovering new methods of packaging and preserving these foods. Salt is a preservative. It is doable; but in the short term, there needs to be an investment.
There will also be a slight change in the taste of food. People are concerned about how one product will stack up against a competitor. However, there is a move, and there are discussions to achieve that one-third goal in 10 years that are ongoing right now between public health experts and the food industry.
What I am suggesting is not farfetched. There is a lot of discussion. I would plead further ignorance; however, I would request that you talk to Norman Campbell or other people in the salt coalition.
Senator Eggleton: Is there any investment by Health Canada or in industry to find alternative solutions?
Dr. Yusuf: I do not really know. I do not want to comment on what I do not know.
Senator Cochrane: While you were speaking, you had me very conscious of eating my cookie. I was about to suggest to the chair that maybe we should have carrots and celery and so on.
Will you be here very long? I would like to be on the waiting list to see you. I have some concerns of my own, and you seem to have such a great knowledge base that I believe you could deal with any problems that anyone would have. I have some health problems as well, and I am sure all of us do.
More specifically, what sorts of strategies would you suggest for the prevention of Alzheimer's disease? We see a lot of that today.
Dr. Yusuf: There are many forms of dementia, and Alzheimer's disease is one specific form. We are trying to learn much more about Alzheimer's disease. Right now, we do not know enough to answer your question meaningfully.
We are beginning to believe that Alzheimer's is often misdiagnosed and people have what we call vascular dementia, which are micro-strokes in the brain. Nobody has lost movement of an arm or leg, but if we do an MRI scanning with one of the more sophisticated techniques, we see tiny white matter infarcts.
In our present research, we take the standard methods of preventing a heart attack or a stroke, for example, by cholesterol lowering and aggressive blood pressure lowering then study whether these micro-infarcts in the brain would be prevented and whether that correlates with decrease in cognitive function.
I have not answered your Alzheimer's question because we do not know enough about it to implement a strategy. However, as individuals, we are interested in cognitive decline in dementia, and there are enough hints that controlling the risk factors for hardening of the arteries — what is called atherosclerosis — will make a difference, but it is not proof beyond reasonable doubt yet. Give me three to five years, and I may have an answer then.
Senator Cochrane: I see. Well, even that is helpful.
You spoke about restructuring our health system, and the doctors would be sort of on the outside looking in. Midwives delivering babies comes to mind. If we could give licences or something to people who have the interest and the skills to do something like that, that probably would be another cost-saving measure and well worth it. Would you not agree?
Dr. Yusuf: I would agree. I am not an obstetrician, so I am a little outside my realm, but I would agree.
The U.K. has a strong midwifery program and midwives. My oldest child was born in the U.K., and we had an excellent midwife in attendance. However, there was excellent backup should there be a problem. Unfortunately, we did have a problem, but it worked out because the health care system is all there as well. That is a good example of where we should not think of any population health strategy as being a replacement for a disease-related strategy. Both should go hand in hand.
That is why I like the idea of a 1 per cent solution that gradually grows to, say, a 10 per cent solution. However, midwives have to play an important role.
Moreover, the so-called shortage of doctors in Canada will not be solved by more doctors for several reasons. First, doctors are not interested in doing a number of things that keep people healthy. Second, our system of reimbursement does not attract people to do that, so we need a whole new cadre of people. Finally, for economic reasons, we will always have a gradient, and it would be from a less-wealthy province to a wealthier province, from the rural to the urban, from Canada to the U.S. We will always have that gradient, unless we put people in shackles. It will not happen. Therefore, to stabilize our system, it may be better to have non-doctor extended health care people in obstetrics, pediatrics, prevention, population health and so forth; we see them as having a complementary role to the existing system.
Senator Fairbairn: In listening to the very positive things that you have said, it occurred to me that in spite of all of the problems that come with the various issues that you have spoken about, there is also, in Canada, an effort through communication — not necessarily with the medical profession but in other areas — to have an effect on our younger people as they are growing up. They watch television, watch the good and the bad and hear important things that apply to them.
I mention this because there was quite a shock that went through my city. I am from Lethbridge, Alberta. A couple of years ago, a group of young students caused quite a stir in the community. They had a cafeteria in their public school that had food items that would not be on your list of perhaps the greatest items to have. This group of young activists on one occasion marched into the principal's office with other teachers and told them that they were, from that moment on, boycotting the cafeteria because they did not want all these foods that they found in the cafeteria that were salted, et cetera. They were very clever and aggressive.
It caused quite a buzz in the community because this was coming maybe from what they heard at home and maybe from television. However, at the same time, they were talking about it because they wanted to be athletes. They wanted to be engaged in everything available to them, and all of a sudden they were hearing that most of the food that they were used to eating would take them in a different direction.
How important is it, then, in your world, that there is a methodology of communication of this type of information and the consequences of doing or not doing the right thing? How much is being done in Canada in that respect? There are all sorts of other types of communication, but this is a different level. This is young people learning right smack in the middle where they are crossing the line, that there is a better way of doing it. How aggressively are we doing this in Canada? To what degree would you offer us a way to do it better?
Dr. Yusuf: First, I am delighted to hear what happened in Lethbridge. I hope that can be replicated across the country. That would be terrific. I would imagine that the starting point was that these young people educated themselves on what was important. It sunk into their consciousness, and then they were empowered.
We could do much more in our schools if we did four things. First, health education should become a much more integral part of the school curriculum. Second, we should remove the pop machines and so on from the schools. It is already beginning to happen. Many people see that as a conspiracy because these companies fund the school boards, et cetera, but let us not go there. Let us just say that all those arrangements were made at a time when people did not know it was not good. Now we have to roll it back. Third, more activity breaks are needed; and fourth, obviously, change the choice of foods in the cafeterias.
In Britain, there is a national program. Many years ago, 40 or 50 years back, they used to offer a glass of milk to all the children when under-nutrition was the concern. Today, they have stopped the milk and changed to free apples. They give free apples to all the children, and the children walk around munching apples. These are the types of little things that can be done. Remove the chips and the greasy food. It is the small changes across our society that add up to big changes. The analogy I use is that to climb to the top of this building — I do not know how many floors there are — it is one step at a time. It is all those little things that add up.
The Chair: My old friend, you are making me very uncomfortable because the director of my operations — I always forget her appropriate title — the woman who runs everything in my office, walks the nine flights up to my office every day, and I cannot even walk down with her, let alone up.
Dr. Yusuf: Get her to train you.
Senator Fairbairn: Thank you very much for those comments. In this case, it was not that some great opportunity had been carefully thought out as a way to see what would happen. That was not the way it happened. The young people listened and watched beyond, perhaps, what the adults thought they would, and it came as a bit of a shock.
Dr. Yusuf: That is a nice story that needs to be replicated across the country. Stories are just as powerful as data.
Senator Callbeck: Dr. Yusuf, you said that much of what has been described is likely to apply to the prevention of other conditions, such as arthritis and breast cancer. To what are you referring?
Dr. Yusuf: Let us take one cancer that we can relate to easily. Smoking causes about 20 cancers, the most common of which is lung cancer. If you can reduce smoking, you will reduce heart disease, strokes, lung cancer and the 19 other cancers it causes. Fats in foods are related not only to heart disease and obesity but also to breast cancer and colon cancer. The evidence on that is moderate but reasonably powerful.
The breast cancer rates are going down in some countries. Arthritis is fairly obvious. Obese people have more weight on their joints and osteoarthritis is related to people's weight. You could start to see that what you do to improve healthy lifestyles does not affect only heart disease because it could also affect cancers, diabetes and the most common forms of arthritis.
Curiously, I found a paper last week that indicated that some genes that increase the risk of heart disease also increase the risk of diabetes. The surprise was that those genes also increase the risk of some cancers. At the population level, I told you that some determinants are the same, but if we start to find it at the genetic level, that brings more coherence to the story.
The Chair: We are a few minutes over time, but this is a rare opportunity to have such a witness before the committee. I will ask one more question, if I may.
One of the instruments that will have to be used to promote the concept that you advocate and that we believe in is population health assessments. You are an expert on data and likely the world expert on epidemiological data. You have done more sophisticated studies than anyone else in the world.
We have heard evidence from people who are involved in this work. Can you see, in the short term, the technological capability for ongoing population health assessments in Canada? I know you are aware of the Quebec initiative, but can you see it on a national basis?
Dr. Yusuf: Yes, I believe I can see that on a national basis. Some countries, such as China and India, do repeat samplings of random cross-sections of the population every year, although you do not have to do it every year. Let us imagine that we had simple assessments of 2 per cent of the Canadian population every three years. That will start to give you the trends that are needed with real numbers. We are not talking about 50 per cent or 100 per cent. Such assessments can be regionally sensitive, ethnically sensitive, include the underprivileged, socially disadvantaged people or Aboriginal peoples. With today's technology, it can work out quite well.
Repeat cross-sectional sampling would be a barometer that the nation could use to align its health care needs.
The Chair: Do you think that we can apply technology to monitor regional disparities?
Dr. Yusuf: The same process could happen. Understanding regional disparities will require drilling down and taking two or three of the extremes. As we know, Newfoundland has had the highest rates of obesity, and people in B.C. have the lowest rates. You can study contrasts. Knowing there is a difference in obesity is not good enough because you need to know whether their diets, activity levels, attitudes, et cetera are different. These surveys might have to include more than just weight or blood pressure. You will want a sampling of dietary habits and other factors.
The food industry and grocery stores have excellent statistics on what they sell and where they sell it. If they are willing to share the information in an anonymous fashion, we can find out what people in Halifax are eating from looking at what the stores are selling. There are ways that you can obtain indirect estimates on national and regional consumption. I am sure that if the government were to do it in such a way that no trade secrets were given out, people would cooperate.
The Chair: Again, thank you for giving us your time.
The committee continued in camera.