Proceedings of the Subcommittee on Population Health
Issue 4 - Evidence, April 9, 2008
OTTAWA, Wednesday, April 9, 2008
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:15 p.m. to examine and report on the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chair) in the chair.
[English]
The Chair: We have a number of witnesses this afternoon. We do not want to waste any time because we have to vacate the room at six o'clock.
We are delighted to have Dr. Sonia Anand here. She is a wonderful scientist and has done excellent publications out of McMaster University.
Dr. Anand works closely with Dr. Salim Yusuf and is a real authority on women's health. She is the Eli Lilly Canada/May Cohen Chair in Women's Health research and has been awarded the CIHR, Canadian Institutes of Health Research, Clinician Scientist Phase 2 Award, among others.
Dr. Sonia Anand, Associate Professor, Department of Medicine, McMaster University: Thank you for inviting me here today.
For the past 10 years, I have been involved first, as a clinician seeing patients with heart disease, obesity and diabetes and, then as a researcher trying to understand why certain people get those conditions within Canada. Also, I have been closely involved in trying to understand why different ethnic groups in Canada — people who originate from India, China, as well as Aboriginal peoples — seem to have a higher rate of heart disease and Type 2 diabetes.
I begin with my first slide showing a quote from Sir Geoffrey Rose, the father of cardiovascular disease prevention. He said:
A radical approach aims to remove the underlying impediments to healthier behaviour . . . . the first or medical approach is important, but only the social and political approach confronts the root causes.
As a scientist, at first, this came to me as a surprise. I always assumed that the biology would explain the disease and, once we treated biology, the disease would go away. However, more and more as I work in the field, I understand that, while individual lifestyle changes are important, it is really the broader social determinants and social environment in which people live that have impacts on who will develop risk factors for heart disease, such as obesity and diabetes, and who will ultimately develop heart disease.
My colleague, Dr. Yusuf, must have spent time last week going over the global burden of heart disease. I show slide 2 to make the point that cardiovascular disease, which means heart attack and stroke, is still the leading cause of death in Canada and around the world. By the year 2020, we expect a global epidemic of heart disease and stroke, primarily due to the large increase in this condition within developing countries. These countries typically did not develop chronic diseases because people would not live that long. However, now, as life expectancy is increasing around the world, cardiovascular disease will continue to be a problem.
Within Canada, it will also remain a problem because the Canadian population, on one hand, is good — we are all living longer — but older people will tend to develop cardiovascular disease. The other threat to why our cardiovascular disease rates will not go down is that obesity rates are increasing in Canada. Obesity is a major cause of type 2 diabetes or adult-onset diabetes and that is a major risk factor for heart disease.
If you look on page 3 where I show what has happened in terms of the reduction in heart disease in Canada since the 1950s until the present, you can see we expect the curves for men and women to plateau, not to continue to decrease. We would like to see them continue to decrease. They will plateau, if not rise, because of the aging population and also because of the epidemic of obesity and diabetes that we will face and are facing now.
In slide 4, I show briefly the prevalence of risk factor — the burden of a particular risk factor in a population. You will see ``physical activity'' and ``overweight'' are present in almost half of the Canadian population. Again, this points to the fact that, although we have made great gains in reducing things such as tobacco exposure and smoking, we still currently face the problems of overweight, obesity and physical inactivity.
The fourth line shows the percentage of people who consume less than the recommended number of fruits and vegetables per day, affecting two-thirds of the population. The recommended number of servings per day is five fruits or vegetables, which is not easy to attain even for those who try actively.
These are important risk factors, not only for cardiovascular disease, which is my discipline, but also for cancer. Cardiovascular disease and cancer are the leading chronic diseases within Canada and, by the year 2020, it is likely that cancer will overtake cardiovascular disease as the leading cause of death.
The more we understand the common risk factors for both cardiovascular disease and cancer, the better we will be able to try to prevent this epidemic.
On page 4, you will see in the graphic a breakdown of the prevalence or the burden of heart disease and stroke by ethnic group. About 10 years ago, we were funded by the Canadian Institutes of Health Research to conduct a random population-based study in which we recruited people of south Asian origin from India, of Chinese origin, European Canadians and then I worked with the Six Nations people on their reserve near Hamilton and conducted the identical study there. We observed that there are large differences in the burden of risk factors as well as heart disease and stroke between ethnic communities. Clearly, people originating from India will be the leading non-white immigrant group within Canada, as well as Aboriginal people who have between two and four times the burden of heart disease compared to the other groups.
While we can take comfort in the fact that the rates of heart disease have dropped in some groups, they are high and climbing in others. Any population-based strategy that we come forth with must include some of the culturally sensitive population-based approaches because we aim to be inclusive in terms of our prevention strategies. On page 5, you will see that one of the biggest differences we have observed between the ethnic groups was the prevalence of obesity. We are learning that it is not so much what one's body weight is as opposed to where the body fat may be distributed. I call it the Canadian tire, the ring of fat around the middle. Anybody who has a Canadian tire should see that as a sign that they are at risk of developing diabetes and heart disease. While people of Chinese or south Asian origin might look small to you by body size, if they have abdominal obesity, which they do have in a high percentage, they are at risk of heart disease. Our south Asian population and our Aboriginal people have between 25 per cent and 50 per cent of people with abdominal obesity. One of our major targets here must be to try to prevent that over the next 10 to 20 years.
In my work with the Aboriginal community, I went in as a scientist trying to understand whether it is diabetes or smoking in terms of the main causes. When I put all the factors together in my statistical models, the single most important factor that emerged in terms of the predictor of who would develop heart disease was having a low household income. Those people on the reserve who received less than $20,000 annual income had the highest potential to develop heart disease. Although you might say that poor people tend to have more risk factors, even after taking into account the disproportional number of risk factors they have, people who lived in poverty still had higher rates of disease. Although we may target individual risk factors, unless we address the broader context of certain groups and the communities in which they live, we will not make much progress in terms of prevention of disease. For people in communities such as the Six Nations and other Aboriginal communities, as long as they continue to live in poverty, the rates of chronic diseases will remain high.
Often people ask whether diet can explain differences in groups. We found that the group with the best diet were of Chinese origin. They tend to eat fruits and lightly cooked vegetables — not stewed but steamed vegetables in frequency. They ate fats, but unsaturated fats, and they tended to eat more protein than carbohydrates, whereas south Asians tended to eat more carbohydrates and not as much protein. Aboriginal people had a very high intake of saturated and trans fats, such as lard, desserts, sweets, pizza and other fast foods.
While that information leads some to say that Aboriginal people should eat better or we should educate south Asian people, this business of what people eat has to move beyond blaming the individual or expecting an individual to make changes. I went on to the Six Nations reserve again with a CIHR-funded study and randomized different households to have a health counsellor of Aboriginal origin visit them once a week and tell them what they should eat and how they should exercise, compared to simply giving them Canada's Food Guide thinking it would make a difference. At the end of the study, there was no impact despite raising the level of knowledge about what people should eat.
I could tell a family to start eating more fruits and vegetables, but they would tell me: ``I have to drive off reserve to get them; they are the most expensive things to buy; they go bad quickly; and I am better off buying lots and lots of Kraft Dinner because I can afford it and it is easy to store.'' It is the same thing for physical activity on the reserve: ``There is no sidewalk and there are threats of wild dogs and crime.'' People cannot exercise and they cannot eat properly if their community or environment constrains them.
As we move forward to try to develop a population strategy to prevent obesity, we have to move beyond telling individuals how they should behave. We have to design communities in such a way that it makes it easy for people to walk and to go to the grocery store without driving to buy healthy foods at a low price. Currently, it is the other way — you can buy fast food and feel full for $3 to $4 and that is what people do as the default. Thinking of a broad strategy, community engineering will have a greater impact in obesity prevention than will asking individuals to make lifestyle changes.
When I reflected on the ideal population health strategy, the three risk factors that come to mind are: prevention of obesity; changing dietary intake by changing food availability, taxation, et cetera; and maintaining our stringent policy against tobacco use. We can learn a lot from the successes that have occurred from the prevention of tobacco use in Canada. We are proud to go around the world and show off our policy on tobacco control and how successful we have been. We made high-level policy changes that led to reductions in cigarette smoking and that was taxation. We can learn from that in terms of obesity prevention.
What are the systemic strategies that I might recommend? The ideal public health strategy would be one that does not consider individual risk factors in isolation.
For example, in Canada, we have a diabetes surveillance and prevention strategy, an obesity prevention strategy and a tobacco strategy, but none of these groups talk to each other. When we think about how to prevent heart disease and the nine risk factors that cause it, we, as clinicians and researchers, must go to each one of the strategies and try either to get them to crosstalk, which is difficult, or to divide and conquer. At this level, if a recommendation could be made that we need to coordinate across disease and risk factor strategies to have one coordinated strategy against disease, it would do more good than what is currently happening.
On page 7 is a slide that shows how resources are currently divided between treatment and prevention. If we think of cardiovascular disease, heart attack and stroke, and if you look at all of the millions of dollars that are devoted towards taking care of people with cardiovascular disease, you can see that 95 per cent of our resources go to the treatment of people who have risk factors or who have already suffered the disease. That is important. We never turn away a patient with symptoms or a person with the disease, but you can see that only 5 per cent of our dollars go toward preventing the disease. Prevention of risk factors such as obesity, poor diet and smoking will do more good to prevent cardiovascular disease than all of the money that goes toward treatment.
I often hear in the news and from various governments that we are working on a prevention policy, but that has been lip service to date because it has been under-resourced. Even within Ontario, the Ministry of Health Promotion is relatively under-resourced compared to all the other ministries. They cannot actually do anything. Therefore, prevention is not happening in Canada. Again, we must look at the broad determinants of health and then create a strategy that leads to a coordinated prevention at a very high level for many cardiovascular risk factors to make gains in cardiovascular disease prevention.
There is some good news. There are some partnerships occurring across the country and Dr. Keon and I are involved in one of them. It is called the Canadian Heart Health Strategy, which is trying to coordinate across prevention strategies, detection strategies and treatment strategies to come up with a national policy or strategy to control cardiovascular disease. At the same time, there is the Canadian Partnership Against Cancer, which has recently given $40 million toward creating a large study across Canada to prevent cancer. Those two communities, namely cardiovascular disease and cancer, are now talking. We can therefore pool resources and come up with a large approach or infrastructure to understand the common causes of cardiovascular disease and cancer, which will then lead to some coordinated prevention approaches.
I will end with another quote from Geoffrey Rose who said that, ``Much can be done by individuals themselves to improve their own health prospects, but whether or not they will actually take such action depends substantially on economic and social structures for which governments are responsible.''
In conclusion, I believe anything you can do to influence, at a high level, community-level strategies that can make it easy for individuals to make the lifestyle changes they need to prevent obesity will be time and money well spent. I will stop there and am open to any questions you might have.
The Chair: Thank you, Dr. Anand. It is always delightful to hear you.
When I was actively practising medicine, sometimes the patients would post-operatively ask me about diet. I would jokingly say, ``Eat Chinese food and drink red wine.'' I would then send them to the dietician to get proper counselling.
That brings me to the question of where alcohol and, in particular red wine, fits in the agenda at this point in time. There is a mixed approach because of the problem of alcoholism and its recommendation as a form of therapy. I know where you stood about a year ago because I heard you speak then, but I have not heard you since. Where do you stand on that issue now?
Dr. Anand: As you know, in many studies the lack of alcohol intake is a risk factor for heart disease. To flip that around, moderate alcohol intake seems to protect against heart attack. It is a complex issue. As a physician, I never recommended to a non-drinker to begin drinking because it can become a slippery slope and result in social discord, injury, accidents, et cetera.
For people who were drinking moderately, I said that is probably a good thing. However, I must take that into consideration now, based on a report that came from the World Health Organization about six months ago about nutrition recommendations for chronic diseases. Although moderate alcohol intake protects against heart disease, it may be a risk factor for some cancers. Again, it is a slippery slope to recommend across the board that drinking alcohol is okay. It has been associated with both colon cancer and breast cancer. It is difficult. At the end of the summary report, the recommendation was that two to three drinks per week is probably okay, but it is no guarantee.
The Chair: Has there been any data unfolded in sorting out, for example, scotch in association with that?
Dr. Anand: It is the effect of alcohol as opposed to a type of alcohol. Some people would say that wine is superior to spirits, which is superior to beer. It appears to be an alcohol effect. We never choose beer as the optimal number one choice because of the calories associated with it. The tie is between scotch and hard liquors and wines. There is a theory, which is not proven, that the tannic acid in red wine adds to the protective effect but it appears to be just an alcohol effect.
The Chair: If we have time at the end, I want to come back to talk to you about ethnicity. It is easy, for example, with 500,000 Chinese in downtown Toronto but East Indians are more scattered.
Senator Pépin: Thank you for coming here today. I have been reading your document and listening to you. I believe there are as many women as men suffering from heart attacks, but is it the same percentage that we have with the other sicknesses? Do women have the same percentage or risk to become as seriously sick as men?
Dr. Anand: Yes. In many studies now, we know that the risk factors for heart disease in men are the same as in women. Women do not have a separate type of risk factor. Smoking, high blood pressure and diabetes are common to both men and women. The difference is that men develop heart disease, on average, 10 years earlier than women. Women tend to become like men in their risk factor profile after menopause. It is really between ages 55 and 60 where women become a higher risk as opposed to men where that is more between ages 40 and 50. It appears to be more dramatic because a young man is struck with heart disease. Women will get it; it is just 10 years later.
Senator Pépin: When I was a student nurse, few women suffered from heart attacks. Perhaps it is because of our lifestyle change. Women were working at home and not outside the home at that time. They were raising families. Maybe lifestyles have changed since then. Women are now doing things similar to men to earn their living and they are catching up with heart attacks and sickness.
Dr. Anand: That gap may close. It is possible that, as women become more like men in their lifestyles, the gap may narrow.
One thing that has been good for women is that during the time of prohibition and other social norms, it was not socially acceptable for women to smoke cigarettes, for example. That was a good thing for women. Men smoked much more than women and that is one of the major risk factors for heart disease.
However, there are changes that occur when women lose their endogenous estrogen at the time of menopause. Therefore, their lipid profile, or cholesterol, looks good until the age of about 50 or the onset of menopause. Following that, it changes to be similar to a man's cholesterol profile.
Also, with menopause comes the shift in fat from the hips to the central fat. Therefore, a number of changes that occur in women tend to occur a little later than in men. There is still a 10-year gap.
However, women live longer than men, up to age 85. Therefore, if you looked at total percentage of heart disease, the total burden would be equal because women live longer.
Senator Pépin: I have another question, but I will let my colleague go first and will come back to it.
Senator Callbeck: I was interested in the cardiovascular prevalence on page 4 where you compared the ethnic groups.
The difference is about four times if you look at south Asian and Chinese; it is double between European and south Asian.
You mentioned diet. The Chinese have less saturated and trans fats and eat a lot of vegetables. What other factors do you think cause the differences here in these figures?
Dr. Anand: The big risk factor differences across the groups would be diet, the rates of smoking, the rates of high blood pressure and the average cholesterol. If we take those main factors into account, we can explain much of the differences between the ethnic groups.
For example, Aboriginal people are high on all of the risk factors. They end up with the highest burden of heart disease. The Chinese tend to have the best profile — the lowest diabetes rates, the lowest body weight if you will, relatively low smoking rates, and they end up with a low percentage.
This was first-generation immigrants who had lived in Canada at least 10 years.
We do not know that the same pattern will hold true for Chinese children who grow up in Canada from day one. We are seeing in some childhood studies that the Chinese are not immune to the effects of weight gain. Therefore, the average weight is increasing among Chinese children and, with that, comes higher rates of diabetes. Heart disease is low in their parents.
However, it is the reverse if I showed you another set of bars which were cancer mortality. The Chinese have relatively more deaths from cancer compared to south Asians who have lower deaths from cancer. It is almost as though one group tends to get one chronic disease more than another, but both are getting one of the diseases.
Senator Callbeck: You mentioned a number of factors that caused this. One was tobacco. In your study, did you actually study how many smoked?
Dr. Anand: Yes, we did. Close to 50 per cent of the Aboriginal people used tobacco, either first hand or second hand, compared to the Europeans at about 20 per cent. It was actually the lowest in Chinese and south Asians.
The reason I raise that for the Aboriginal people is because it is a difficult issue. When I went to the Six Nations Band Council and presented my findings, I told them the two risk factors they can do the most about to have a great impact on the population would be to address smoking and obesity. The mean Body Mass Index on the reserve is 33, which is very high.
Smoking and tobacco use is complex on Aboriginal reserves. In particular, Six Nations have their own factory where they produce cigarettes. On one hand, we say jobs are important, economics are important. They have their own industry. However, it is an industry that produces high-nicotine cigarettes that are available for a very low price to their people on the reserve. It is a complex issue.
Senator Callbeck: On page 6 you talked about the number of government-sponsored programs that are disconnected and the need to have a coordinated approach.
Have you given thought to how that can be done? I guess the federal government should be taking the initiative here.
Dr. Anand: Yes. I recall one meeting where we were trying to understand the rates of diabetes and if they are going up in Canada or not. We had representatives there from the Canadian Diabetes Strategy. They have the data but it would be difficult to access it.
If clear recommendations from a high level came down saying, ``Each year we need to understand the following trends and we need to allow researchers and educators and policy-makers to access the data across these strategies in an easy and efficient way,'' we could already understand more about Canada. That would help us form a prevention strategy. One of the goals of the new Canadian Heart Health Strategy is to get that type of information. However, it may even involve replicating some of the information we already have.
Across the Public Health Agency of Canada, PHAC, and other branches of the federal government, information exists. It is just difficult to access.
The other issue is that we are a public health care system unlike any other in the world. Yet we do not track individual health problems in a systematic way. We could do research for a much less economic investment if there was a computerized-based system to track the use of diabetes services, the use of smoking cessation services, et cetera. We do not do that.
We have everything to do that, but there has not been a high-level recommendation to provide the impetus.
Senator Callbeck: I have some other questions but I will go to the second round.
Senator Munson: I have a lot of questions but will only ask one.
Whether you are rich, poor or in-between, groceries are expensive. It seems to be one of the most expensive things every month that we all have to do. It is a necessity of life.
There has been so much talk about an emerging food crisis. We have seen all kinds of headline stories to do with food. In your recommendation, you talk about subsidizing or making affordable and available healthy foods such as fruits and vegetables.
I am curious to know if people come to government and say, ``You have to legislate, you have to do this.'' I would like to know where the food industry's responsibility is in this equation and argument.
Dr. Anand: That is an excellent question. In some areas, the food industry has started to work together with researchers. An example of that is lowering salt and trying to take out trans fats from some foods. That has been an effective relationship between what we know in science and what they are able to sell.
Some people say that, if you take out trans fats and saturated fats, people will not buy the food because it is not tasty. I think the food industry has a responsibility to try and experiment with different preparations of foods to still make it palatable yet healthy at the same time.
The second complicated area is subsidies. I am sure you know much more about it than I do — the current subsidies we give to certain groups who produce, for example, red meat and certain grains. They do get subsidies, yet we do not give subsidies to farmers who may be producing apples and locally produced fruit.
It is cheaper to buy a foreign-produced apple — an apple from China — than a local apple. There are lots of issues. However, we know that red meat consumption is a risk factor for heart disease and cancer. We know that fruit and vegetable consumption protects you from those conditions. Why do we not either work with industry or farmers to encourage the production of the healthy food? Hopefully, that will lead to more people eating the healthy food.
Senator Munson: I have a basic question. You always hear what is recommended — five fruit and vegetables. What is that? Is that one banana, one apple, one melon, one strawberry and one glass of juice?
Dr. Anand: A serving is equivalent to what you can hold in the palm of your hand.
Senator Munson: Some people have small hands or big hands.
Dr. Anand: It is relative to your body size. One apple, one banana is a serving. How do you quantify mashed potatoes? What you can hold in your hand? That is equivalent to a serving.
Senator Munson: You just hear it a lot. I will go back to my fruit plate here.
That is what I have for now. I was curious about the food industry's responsibility. It seems we are asked as governments to make all kinds of decisions.
Can you explain a bit more about giving economic incentives to municipalities who build exercise-conducive communities?
Dr. Anand: There is a whole body of research now that has characterized something called the built environment, and that means how walkable can you make a community. Does the community look pleasant with trees and parks so people want to be there? Can you access shops by walking instead of driving? Can you make your communities safe so women, for example, can run, jog or walk at night?
We know the characteristics of communities that lead to more exercise, yet if you look at — in my own community of Hamilton — what is being constructed are suburbs and subdivisions where all you can do is drive to get there. There are no stores except superstores about a 20-minute drive away, and between the superstores you have to drive. Those are not communities designed to promote exercise, yet they are cropping up all over the place.
How can we get urban planners engaged in designing communities that are healthy, and what drives the creation or construction of the suburbs? It is of economic benefit to somebody. Can we craft it in such a way that, if a construction firm wants to build a new subdivision, they have to comply with certain standards that would make that community walkable?
Senator Munson: Thank you.
Senator Cochrane: Following on with the concept of developers and town people building a community or having a built-in that follows certain guidelines, that does not seem to be too difficult.
Dr. Anand: It does not.
Senator Cochrane: Why is it not done?
Dr. Anand: I think part of the reason is the research is just emerging. If we looked at the studies around built environment and activity levels, really they came up about four to five years ago, so it is still new. If you took a room full of doctors and asked them about the built environment, maybe 10 per cent would be aware of it. If you talked to urban planners, probably more would be aware of it but the field is new. That is probably one reason.
There has not been enough push on communities or cities yet, from either the medical community or government levels that are higher than their own, to get serious about it.
In my own daughter's school, they can still buy soda pop and chips as snacks. We knew five years ago we needed to get rid of it; it is still there. It is a combination of community action, physicians being aware, and putting pressure on the people who make decisions to comply with that.
You are right. It seems quite simple and the solutions are not complex.
Senator Cochrane: Not only that, but to me it would make a desirable city or community because people today are aware of the good things, walking and swimming and different activities. To me, that would seem like something people would want to live in.
Dr. Anand: Yes. It is quite easy to do.
In the greater Toronto area, there are subdivisions going up all the time, but they are built again in a way to support the use of a minivan and not to promote people walking and exercising to get from point A to point B. We need to change that and I think we could.
Senator Cochrane: In regards to investments, the money that is set aside for strategies, et cetera, I am appalled that only 5 per cent goes to prevention.
I have read a report from the Cancer Advocacy Coalition of Canada. They say only 6 per cent of all the money being spent is on cancer prevention.
Dr. Anand: In my response to the cancer question, cancer is behind cardiovascular disease in understanding the major causes. I can list for you the nine risk factors that, in fact, predict 90 per cent of who will have a heart attack versus not. We can clearly target smoking, cholesterol, diabetes. Cancer is not even close to that. They really need to go into the etiologic research of understanding the causes first.
If you go to the Canadian Cancer Society website, what will they tell you? Eat fruits and vegetables, do not gain weight, exercise and do not smoke. Those are the four things. Think of the people you know who have developed cancer. Most people are not doing those things yet still get cancer.
Senator Cochrane: Exactly.
Dr. Anand: I am pleased that the Canadian Partnership Against Cancer has now put $40 million towards creating a large cohort study of 300,000 Canadians; 150,000 of those will be in Ontario. I am representing the Heart and Stroke Foundation of Ontario, and we are now working together with cancer in the Province of Ontario to create a 150,000- person cohort study. We will measure a myriad of factors at baseline, everything from toxins in the water, to how communities are constructed, to understanding obesity, and we will follow that group forward for 10, 20, 30 years. That type of research will allow us to understand causes and then develop prevention strategies.
Cancer is probably 10 to 15 years behind cardiovascular disease. They have the added challenge that there are multiple cancers. There is breast, prostate, many cancers where heart attacks seem to be relatively the same in all people.
Senator Cochrane: It will take a long time to give the general public the preventative information. There is $40 million, but it will still take a long time before we find the bottom line on prevention.
Dr. Anand: Probably take your mother's advice — live in moderation, live like people did in the 1960s and not the way they do now.
If you look at what happens to immigrant populations and their cancer rates, Japanese women in Japan have low rates of cancer. They immigrate to the United States and Canada, take our lifestyle on, whatever that is — is it your diet, is it the plastics in the environment, is it the stress of how we work — and then their cancer rates go up. It is not a genetic issue. Genes do not change in five or ten years. It is a lifestyle. We need to understand what that is before we can prevent it.
Senator Cochrane: Here is an example of prevention, which I think is pretty good. Last week Dr. Yusuf was here. He is from McMaster University, as you know. I was struck by his description of how our society promotes physical inactivity through our use of tall buildings with elevators and escalators.
He observed how people rarely use stairs anymore and how our buildings are designed to have stairwells back in dark corners where you cannot see them, out of the way.
The idea would be to put the stairs out front so people would be tempted to use them. What do you think of ideas like that?
Dr. Anand: We have to get creative. We do not need to disenfranchise people with disabilities who need to take the elevator.
Senator Cochrane: I do not mean that.
Dr. Anand: The majority of people are actually fairly healthy. Why is it that we need to park right next to Wal-Mart versus having the parking lot off to the side? Why can we not walk between supercentres instead of driving our car 10 metres here and there? How can we, again like the communities, design our lives to subconsciously promote more activity?
The solution is not saying everyone must join the health club and do the elliptical health trainer three times a week. That is not the solution. It is designing communities to make people do more exercise without them even knowing.
Senator Cochrane: We need to be innovative. Whatever we think, we need to publicize it.
Dr. Anand: I agree.
The Chair: As usual, senators, time is catching up with us. We have Senator Fairbairn and Senator Brown left.
Senator Fairbairn: I apologize for being late. I came in as you were talking about your concerns about Aboriginal people. That affected me personally because I come from Lethbridge, Alberta, which is in the southwest corner of the province and is surrounded by Treaty 7. You know that smoking is part of the history and life of Aboriginal peoples. They socialize with it and it is part of their religious events.
Do your surveys and studies show much difference beyond the reserve? Is there much difference with young Aboriginal people or adults in urban situations? Have you any evidence that, when they move away from the reserves and work in outside communities, they pull away from that?
Dr. Anand: Unfortunately, it is difficult to study Aboriginal people who move to urban centres. It is difficult to track them. We were lucky to work on the reserve where 10,000 Six Nations people live. However, there are another 10,000 who live in cities and other communities in Canada. There is no way of tracking them, so I cannot answer the question about whether their behaviours change.
With regard to smoking being a traditional practice, it was traditional to pass around a peace pipe in the sweat lodges. Nicotine is addictive. Manufacturing cigarettes en masse and selling them at discount prices on reserves is not tradition, but it can cause people to become addicted to nicotine in no time at all.
The traditional use makes the matter complex. No one is telling them to change their tradition, but the mass production and cheap sales of this addictive material is hooking young kids in large numbers, and that is a difficult addiction to break.
It is a complicated problem. The people on reserves say they pay more taxes to the federal government on their lucrative cigarette production industry than they receive back in transfer payments, so they really feel that they are giving back to Canada, if you will. It is too complicated for me to take on. I just give the information to the health committee.
The smoking issue is devastating. Luckily, the health authorities on reserves recognize it is a major health problem and are working toward stopping it. However, it is like a little goldfish swimming against a strong current. A few people in health concerned about a problem will not be able to crack the problem if people are making a lot of money from the business.
Senator Fairbairn: Hopefully, as generations grow older and new ones come up, there will be a different turn.
These people are a wonderful part of our population and our history, and we certainly want them to have the best possible opportunities.
You talked about the kinds of things that people eat and smoke within regular communities. If it is any comfort to you, in one school in my hometown of Lethbridge, the young people said they were not going to buy food at the cafeteria because it was all junk. They decided to bring their own food, which is good.
Dr. Anand: I believe Nova Scotia has made similar changes.
Senator Fairbairn: These things are moving along a bit.
Senator Brown: Dr. Anand, I was buoyed by reading the nine risk factors and your conclusion that no alcohol was a risk. I talked to many people about that, and we all agreed that we should consume alcohol. However, you told us that after some people said they should have three drinks a day, you said it should be three drinks a week so we were brought back to earth.
On page 6 of your brief you said that other disease conditions and risk factor strategies should look to the success Canada had with the tobacco strategy as a successful model of coordinated risk factor prevention. I picked up on that in a previous meeting with other doctors.
I recently saw the statistic that 52 per cent of Canadians do not read newspapers or watch the news on television. We are looking for a coordinated approach to effect change broadly across the country. As you suggested, we could copy what was done with tobacco — that is, the government could impose increasingly more stringent labelling on certain unhealthy foods.
Television is the only medium I know that reaches a large majority of the population. If we were to spend some money on short, repetitive ads about individual risk factors over a period of time, as we did with cigarettes, would that not be more beneficial than almost anything, other than the research you have done, to show where the risk factors are?
Dr. Anand: The tobacco strategy was multi-pronged, and the most effective influence in reducing smoking rates was increasing the price of cigarettes. The more cigarettes were taxed, the lower use was. That was a high-level government decision, as was banning cigarette companies from sponsoring sporting events.
Although advertising the risk factors on television would make people aware, without a high-level strategy to change exercise patterns and make healthy foods available, I do not think that would do much to improve diet and increasing physical activity.
I believe a multi-pronged strategy is needed, but there needs to be community-engineered, high-level policy changes in addition to educating individuals about how to change their lives. Both must happen in order for us to make a difference.
Senator Brown: I agree with you 100 per cent. I was just thinking that we could cover all the risk factors with advertising. We could encourage people to walk regardless of whether they have sidewalks. As you said, they could walk in parking lots.
The other risk factors can all be labelled as bad things and more positive behaviours encouraged. Long-term advertising must have an impact. When cigarette labelling was first introduced, not many people paid attention, but over a generation it was repeated on every package of cigarettes. It was repeated and enforcements were made in buildings and public places. It seems to me if we took that broad approach repetitively on everything you are trying to say here in short documentation, which is really good, and duplicate it somehow in advertising, I believe we could have a broad impact.
The Chair: Honourable senators, we are delighted now to have the second set of witnesses who are again outstanding, beginning with Karen Hitchcock, Principal and Vice-Chancellor of Queen's University. I had the pleasure of having breakfast with her a short time ago and a delightful visit to Queen's during some presentations on population health.
She has an impressive background — president of the University of Albany in New York, also served in various capacities in Chicago, was a scientist and was funded by each in her own field of cell development and biology.
We are delighted to have you here, Ms. Hitchcock, and I will go ahead and introduce Kristan Aronson, Professor of Epidemiology at the Cancer Research Institute and the Queen's School of Environmental Studies. She is the founding director of the Queen's Institute of Population Health and Public Health and her research focuses on the environmental epidemiology of cancer.
Karen Hitchcock, Principal and Vice-Chancellor, Queen's University: Thank you for the invitation. I am delighted to have the opportunity to speak with you today on an issue of tremendous importance.
I began my tenure at Queen's in 2004 and have to put a plug in for Queen's. I had learned before my arrival that Queen's was an excellent institution, offering world-recognized excellence in research, teaching and public service. Canadian universities on the whole are recognized for such excellence, for innovation and for public service throughout the world.
As we all know, the success of Canadian universities rests in large part on commitments from, certainly, the provincial governments with direct and indirect support from the federal government as well.
As Senator Keon stated, I do come from south of the border. I am an American. I come from a university at Albany that is only slightly larger than Queen's and it had a school of public health. I was surprised to find when I arrived that Queen's did not have a school of public health, and probably more surprised to learn at that time that there were no schools of public health in Canada. That was about a year post-SARS and I have since learned that there is a lot of interest now in such schools. There was, however, until recently, little progress but progress is being made now in that regard.
Evidence gathered by the federal government's national advisory committee on SARS, which was chaired by David Naylor, and by this Senate's own inquiry, has revealed critical deficiencies in Canada's public health infrastructure. All reports agree that there is a deficiency in trained public health personnel in Canada, and little opportunity for those who are in the field to maintain and improve their skills over the course of their careers. While there are programs, they are limited and much need is there and this comes out in every report that I have read.
Also, scientific evidence for public health strategies and approaches to disease prevention are only marginally funded. There is little information and they are only marginally funded.
The interest exists to do this. The issue we have to address is how one goes about that in a cost-efficient but effective way. Graduate departments in universities have degrees, epidemiology unit disciplinary degrees and, more and more, multi-disciplinary degrees. Masters of Public Health as well are appearing.
My thesis is that schools of public health, actual defined entities, being more robust, would bring a greater visibility to the importance and a much better approach to education in the many different aspects of public health that are needed than the single programs that exist today.
At Queen's I have made it my own personal priority to work toward establishing a school of public health, and Professor Aronson has been a leader in that on campus. I know you will enjoy hearing from her about what we are doing particularly at Queen's, and it might be something that could be applied to other initiatives as well.
I have also been working with colleagues, principals, rectors and presidents from across the country. I believe in the packet you had a draft of a national response to the issues of public health with regard to education and research, and these colleagues come from B.C., Alberta, Toronto, McGill, Montreal, Dalhousie and Queen's. We have come together to talk about how to put an effective strategy together for educational and research needs that are so critical in the field of public health. That document is entitled A National Strategy for Public Health Education and Research: The Canadian University Community's Response to Public Health Issues Facing Canada in the 21st Century.
Public health by its very definition — all the programs, organizations and elements that go into it — is multi- disciplinary. Understanding and responding to public health issues like SARS, tar ponds in the Maritimes, sour gas on the Prairies, HIV/AIDS in Vancouver, the health disparities between Aboriginal populations and the rest of the country, and endemic conditions like smoking, obesity, injuries and asthma that affect all citizens, demands a multi- disciplinary approach based on evidence and expertise — so high-quality educational programs as well — and universities are well positioned to bring that kind of focus to this issue and do it in a coordinated and collaborative way.
The proposal we have put forth fits very well into the tradition of public health in this country. The federal government led the world, actually in 1974, with the Lalonde report, looking at the determinants of public health.
The health of individuals and populations is a reflection of the quality and availability of medical care, but it is much more important that it is a reflection of, or determined by, the environments in which our citizens live and work and learn. That is what this Senate subcommittee is all about. The study of those determinants, their interrelationships and amenability to public policy, reflects the work of what we define as public health.
Important steps have been taken by Canadians and their elected representatives to correct weaknesses that exist in the national public health system. Most notable is the creation of the Public Health Agency of Canada — an important step towards meeting some of the issues we have been talking about.
There have been efforts to develop coherent strategies for pandemics, for influenza strategies preparedness, but a lot more needs to be done regarding the underlying problems in public health — again, particularly the lack of trained personnel in public health and the inadequate research into public health problems.
Our proposal envisages the creation of a public health consortium. We are calling it a Canadian association for public health research and education. It is meant to represent a coming together, a network if you will, of universities with schools of public health, other organizations and agencies around the dual goal of enhancing skills training, education and research.
The model that there be some schools of public health in Canada makes sense so we would seek to establish, or to enhance existing, schools of public health focused on producing more public health personnel, on providing critical continuing education for the existing workforce, and on encouraging and building up public health research and the translation of that research into applications on the ground. That nexus of theory and practice is probably more important in the field of public health than in almost any other field.
The national strategy we have proposed seeks to improve the health of the Canadian public and populations around the world. Our objectives are: to better equip public health facilities and personnel at local, provincial, federal and international levels to respond to epidemics and other public health emergencies; to address the complexity of public health issues through improved multi-disciplinary education and research programs targeted at public health, including management, knowledge transfer and intervention-based research; to bridge the gaps between academic and public health service delivery aspects to ensure that the education and training provided and research conducted are of the highest quality and relevance; to curb the multiple epidemics of chronic disease resulting from our modern economies and, hence, reduce the burden of illness and the distorting effects of health care services on government budgets; and to support the objectives of the Public Health Agency of Canada. We worked closely with it as we developed our strategy. It is an important unifying organization to help move resources to where they are needed; to ensure, with sensitivity to existing jurisdictional issues, that monies flow to the needs of local, provincial and federal governments for public health; and to develop strategic and tactical partnerships with community agencies. Delivery of public health is at the local level, and it is at the provincial and federal levels for organizations. It covers all jurisdictional levels. The public health agency can be an effective means to make that happen. It is important to create a national forum — academic institutions united in their commitment to public health across Canada so they can address and be aware of through dialogue and collaboration the needs that exist in Canada, and be able to address them in a way that affects not only the province where the university happens to exist, but also the quality of public health across Canada and, in fact, across the world.
The funding for universities comes predominantly from the provinces as well as from tuition fees. Canadian universities are developing larger endowments but they are not great enough to support the urgency of need that exists in public health. It is difficult for Canadian universities to move rapidly to build new programs and launch new streams of research so the consortium of universities proposing this national strategy recognizes that considerable investments have already been made by the federal government in its attempts to correct and improve a very underdeveloped public health system in Canada. We are asking the federal government to do more, however. Canada has the opportunity to create an over-arching vision for an academic response and contributions to public health. Additional funding is required to support the objectives of the Public Health Agency of Canada. Many important programs have been developed but the funding is modest. Additional funding is required to reinvest in Canada's capacity to provide world- class public health professionals, educators and researchers.
A five-year funding commitment of the government, which is what we are envisioning at this time, would be in three major areas. The first is education of public health professionals and continuing education of existing professionals. It is in enhancing that continuing education piece where the impact can be most immediate. As an example, in Ontario there are some 4,000 public health nurses. Few, if any of them, are trained in public health. A continuing education model could be developed after an executive development program for people in other professions where the corporations taking the executive development refresher courses fund the programs. In this respect, the government would need to be that funder for public health professionals. Such continuing education programs addressed quickly could have an immediate effect, helped by the development of schools of public health and other programs to get degree programs lined up and people graduated.
Another audience for continuing education could be the military, given the need for emergency preparedness and the use of the military. Such programs could train military people involved in emergency preparedness on a continuing education basis for public health and they could be a dramatic and quick addition to trained public health personnel in Canada.
Education at all levels could be accomplished with continuing education as an initial rapid and effective way of quickly enhancing the level of quality of the public health professionals that we have. The quality of that education flows directly from the research. Universities are not the exclusive place for such research but, certainly, research is one of their prime missions.
The second commitment is funding more research in public health and intervention, prevention and knowledge transfer. Currently, the public health agency has developed some research in practice chairs. Enhancing and expanding that program would be important in order to draw the kind of people needed in the university setting to carry out this work.
I keep coming back to this nexus of theory and practice. We need to fund closer links between the knowledge producers and the knowledge users — the public health professionals, researchers and students — so that we can have accountability in public health program delivery. Thus, that nexus becomes very important.
To fund capital infrastructure and information technology, there has been a wonderful investment in Canada Health Infoway, which is a communications strategy for public health across the country. Dr. Anand has spoken to the need for better communications to be able to track people and to have good data analysis and communications. All of that is critical. A good start has been made so it is important to continue with it and look at ways to improve it. Universities can be helpful. Every element of public health should be a node on that network. All of it should be brought together so that data can be tracked and data analysis can be enhanced as you look for causes of disease.
A commitment at the federal level to enhance the capability of Canada's post-secondary education sector would enable us to leverage funding from the provinces and territories to invest in public health education. Right now, the university consortium is carrying out a detailed needs analysis so that we can provide guidance on the magnitude of what such an investment would need to be. Various institutions are at different levels of their development — for example, some have schools, some are getting ready to have a school. Some are looking at just a single degree program which they would like to expand or looking at the network of institutions, organizations and continuing education programs that would be necessary. We hope to have that in the next month or two.
We look forward to continuing this initiative and to talking with you about what we are doing. Thank you for the opportunity to appear before you.
The Chair: Thank you, Ms. Hitchcock. I apologize for my voice. This is a key area that we must address in our report — namely, the human resource situation that exists now. Many good things have happened, including the new Public Health Agency of Canada and the beefing up of the provinces in public health, but there is a tremendous lack of human resources. I am personally delighted that the university establishment is addressing this because there is little guidance at this point in time. We will be relying on your guidance in our report.
I had the privilege of talking to you at some length one on one, so I will not take any more of your time because only 20 minutes remain. I want to let the senators ask you some questions. I will come back with whatever time is left.
Senator Pépin, who is vice-chair of this committee, will begin the questioning.
Senator Pépin: We had our first public health and school university in 2006. It was at the University of Alberta. L'Université de Montréal has one in the planning, as does the University of Toronto. You will also do one. You will start on the right foot.
Ms. Hitchcock: Yes.
Senator Pépin: You mentioned the original school of public health. What do you mean by ``original school of public health''? Are there many differences between those schools and the universities and schools of public health? Is it other schools of public health? Should we only have public health at university? I understood that we should have regional schools, too. Did I misunderstand you?
Ms. Hitchcock: I was probably unclear there. I meant that it would be within the university, not a free-standing school. It would be one located in a way that it could deal with issues of a certain catchment area or region, but it would be within a university and networked to all the others around the country.
Senator Pépin: You spoke about the participation of the provincial governments and the federal government, but what level of participation by the federal government would you consider to be reasonable?
Ms. Hitchcock: With regard to types of investments, certainly research. The people and the research chairs that the public health agency has already spoken to is a logical place for federal investment.
There are also the skills training components. It is hard for me to envision a part of public health that does not fit a national jurisdiction because, by its very definition, it impacts the entire country as issues elsewhere impact the entire country. There is a global aspect as well as an international one.
With regard to the faculty, there are the chairs that could be established at an institution. Funding through the public health agency for skills training and continuing education programs would probably be carried out through such schools.
Senator Pépin: Would we have more personnel such as nurses and medical doctors?
Ms. Hitchcock: Exactly. There are so many different areas of types of personnel, be it an epidemiologist like Ms. Aronson or someone who is in emergency preparedness. That is a whole other area.
The birth of public health was food safety and water safety, so civil engineering. It is a multidisciplinary field and it is multidisciplinary in the environment. That is why a university environment makes sense because so many disciplines need to be involved.
To answer your question, I see the federal involvement — at least, as I understand the jurisdictional issues — as being a partnership not only with provinces, as provinces help to support the enrolment and support of students, but also with regard to the research and skills training component.
Senator Pépin: Thank you.
The Chair: Ms. Hitchcock, as the university consortium moves forward, which I think is terrific, are you interfacing, for example, with the federal-provincial public health establishment? Maybe Ms. Aronson can refer to this. Senators, Ms. Aronson did not have a formal presentation ready, but she is here to answer your questions.
The federal-provincial arrangements that the new public health agency is functioning under seem to be good. It seems to be working out well. I perceive there would be a tremendous opportunity for an evaluation of the human resource needs that the academic establishment across the country wants to address. Have you established any links yet as the consortium embarks on its fact-finding mission? Have you established any linkage with the federal-provincial meetings?
Ms. Hitchcock: We have worked closely with the Public Health Agency of Canada. We are aware of their particular directions and the particular approaches they are taking with regard not only to subject areas but also to that federal- provincial nexus. Ms. Aronson might want to add to that.
Kristan Aronson, Professor of Epidemiology, Queen's University: Ms. Hitchcock has met often with Dr. David Butler-Jones about these issues. At the provincial level, it was the province that gave Queen's University a grant to write a proposal for a school of public health. We were not given too much guidance, to be honest, but we had some guidance on the research areas in which they wanted to see expertise coming from the university. They are interested in affiliate agreements between universities in Ontario at the provincial level. We have worked with our counterparts in both the federal and provincial government and will continue to do so.
Jamie Hocjin, within the PHAC, has been in touch with us. Several people are trained already at Queen's in the executive leadership program, or MBA. It has an excellent reputation. Our idea there is to bring people from public health to the university and to work together to develop an executive leadership-type of idea within public health. Jamie Hocjin and I have been talking about this. First, the PHAC is doing an environmental scan across the country to see where the expertise is in this type of thing.
I will add one more thing. Continuing education is all the way from a one-day workshop on a particular subject that we need to know about quickly, through to this training of managers or higher-level people who show potential to be leaders in an area. That would be more the executive training. On the whole, it is a massive number of people.
Women who are trained as nurses often do not want to work shift work. Where do they go — public health. That is great and altruistic of them to do, but they have no specific training in public health. That is a real issue. While they are in the field, they cannot leave their job for financial and family reasons and then they need quick training that is accessible to them, either through distant education or through coming in for short bursts of intensive skills training that they can take back to the public health units. Those are some of our ideas and our connections, both at the provincial and federal level.
The Chair: Thank you.
Senator Fairbairn: Thank you both very much. It is uplifting and encouraging listening to you.
When you were talking about our soldiers and the situation that they have wilfully chosen to put themselves into, I wondered how we could help those who come back home with difficulties. It popped into my mind how sometimes putting things together that you had not thought of previously, produces something quite terrific.
Do you know anything about the program that has been engaged in the last year called Soldier On? It is a combination of the Department of National Defence and the Canadian Paralympic Committee. Carleton University has been very involved with it.
Our Paralympians have met with soldiers and encouraged them to get into sledge hockey, for example, that these things can be done. They are an amazing group themselves. I do not know how far it has gone — and I am very much involved with the Paralympic movement — but it has had quite a bit of interest and success in that it has, right off the bat, startled our soldiers into thinking: Good grief! On the other hand, if you look at those who are working with them, you think: They, too, have difficulties and they are doing it.
This has apparently had a positive response once they psychologically get through the whole thing. It has been a positive experience for some of our young soldiers who have come back and discovered that there are ways to carry on. I am wondering if you had heard of that program at all.
Ms. Hitchcock: Actually, I have heard of the program. I did not know it was called Soldier On, but I know the head of Carleton University and so I am aware of the program. It is exciting.
Senator Fairbairn: We were very involved in that, and it has made a difference with some soldiers. Is that the kind of thing that you think would be useful, depending on the issue?
Ms. Hitchcock: It certainly would be useful. Part of what we had been thinking about in conversations with our colleagues — of course, you know the Royal Military College is in Kingston — was the issue of the increased use of our military in emergency preparedness situations. There is a slightly different nuance to what you are saying.
It was really given the fact that they are often thrust into situations of emergency as first responders. Public health training, be it in a continuing education or an executive training kind of situation, could be helpful and quickly increase the number of people who could be trained in public health when they are thrust into an emergency situation. It is a capacity-building kind of strategy.
The more those relationships grow, however, the more opportunities like Soldier On appear.
Senator Fairbairn: It speaks out, especially to the younger ones coming in, that there is another life.
Senator Cochrane: Ms. Hitchcock, in your brief you made reference to the underlying infrastructure problems that we have in public health here in Canada.
From your perspective, what are some of the most pressing infrastructure needs that we face now?
Ms. Hitchcock: I think the major one, to use the word ``infrastructure'' in an inclusive way, is the issue of trained personnel. That is the major infrastructure issue.
We have programs of different types, many very good ones, but if you look at the place of delivery, such as the local community, we have large deficits. There are wonderful studies. The Naylor report and others have quantified some of those shortfalls. I would say that is the major one.
Research is hard to separate from that because what you teach derives ultimately from quality research on intervention and public health practice.
Senator Cochrane: You are talking about doctors and nurses. Is that right?
Ms. Hitchcock: Doctors and nurses, epidemiologists, people in areas of safety, microbiologists and technologists. You might want to add to the list. We have deficits in all of those areas.
I think one of the needs analysis issues we are discussing is looking across all of those personnel needs and quantifying what it would take to bring people in the field up to a higher standard of expertise as well as new people entering the field, which will take incentives and education that there is another career path for people interested in the human life sciences.
Senator Cochrane: Is that the same right across the country?
Ms. Hitchcock: Yes. I am speaking from a national perspective now. Certainly there are areas that are better served. Certainly Aboriginal northern communities are underserved more than other areas. There are particular areas of the country that have greater needs.
Senator Cochrane: You say that the national strategy you and your partners are proposing would require federal investment. What level of investment are you talking about? Have you determined a dollar figure? Have you presented your proposal to the Minister of Health or to government officials? If so, how was it received?
Ms. Hitchcock: We are in the midst of the needs analysis as we speak. We hope to have it completed by the end of this month or next month.
The needs analysis will address the training aspects. It will investigate different programs that exist but need to be enhanced. It will create a number of schools spread across the country, and there will be research and communications issues. Some of these things are being addressed, albeit modestly at this point, through the Public Health Agency of Canada.
Certainly, the $100-million investment in Infoway is a wonderful beginning because communications is such an important piece of the infrastructure. We are in the midst of doing that right now. We have been working with the Minister of Health's office and the public health agency so they are aware of what we are doing, and that definitive proposal for exact needs will be forthcoming in a month or two.
Senator Cochrane: That is good to hear.
The Chair: We fundamentally have two minutes left. As chair of the committee, I want to ask you something important. Senator Brown, do you have an urgent question? I do not want to pre-empt you.
Senator Brown: No.
The Chair: At the community level, when in fact you begin to solve the human resource problem and people become available, do you think these people would be best integrated into community centres with community health teams and community social services, et cetera, or should the public health officers be linked more closely with the upper echelon of public health activities at the provincial level?
Ms. Hitchcock: My answer is ``yes'' to both questions but for different reasons. Given the fact that environmental, social and behavioural issues are so much a part of the determinants, having close linkages with agencies that deal with those directly is a good thing.
A critical issue, however, is that the entire public health apparatus of the country be networked so that you can have search capacity when there is a regional issue. The data across the regions must be brought together.
My background in this is the CDC, Centers for Disease Control, model in the United States. The CDC, which may be a counterpart of the Public Health Agency of Canada, is the governmental coordinating mechanism that recommends and sets standards across the country and has data protocols. They have ways to communicate across all of the agencies. An important note on that network is the New York State Department of Health which, second to the CDC, is the largest. The CDC acts not so much as a regulator as a facilitator of collaboration.
Having protocols for data reporting across all the aspects of public health is absolutely critical to quality public health delivery. Standards must be met, otherwise the data reporting does not provide the ability to determine the cause of a particular epidemic or issue. You need that, and the CDC acts in that coordinating role. It is a powerful model.
The linkage of public health not being isolated from agencies that can address some of the determinants around chronic disease issues is important as well, but there is a different rationale for it.
Ms. Aronson: Although clinics would be important, it may be too much in a medical model. As Ms. Hitchcock says, connection to the community agencies that are interested in increasing physical activity and decreasing obesity, et cetera, and legislative infrastructure are important pieces of public health that you do not think of in the more medical model of a community-based clinic.
The Chair: The thinking that is evolving from our information in population health is to move away from the medical model — in other words, to have a model that can embrace the dozen or more determinants of health.
Ms. Aronson: That is good and the interactions of those.
The Chair: That is right in order that healthy living and so forth can be promoted, and definitely not through the health care delivery system.
Ms. Aronson: That is encouraging.
The Chair: It should be allied with the health care delivery system.
Unfortunately, we are out of time. The human resource component is a very important part of our report and we are delighted that the universities have taken this on, and we are delighted with the leadership from Queen's. Thank you for coming here.
The committee continued in camera.