Proceedings of the Subcommittee on Population Health
Issue 4 - Evidence, April 18, 2008
OTTAWA, Friday, April 18, 2008
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 9 a.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: Good morning, ladies and gentlemen, honourable senators. This is truly an exciting day for us in the Senate Subcommittee on Population Health to have such an outstanding group of people around the table to help us find our way in our report.
As you know, we have issued four preliminary reports. The first was on the international scene as it relates to population health. We tabled our second report after our visit to Cuba. Fundamentally, we wanted to look at Cuba's polyclinic structure, which fascinated us along with their statistics. Cuba has the health status of a developed country. It is very similar to our own and well ahead of the other Latin American countries. In many areas, it is well ahead of the United States of America. We were interested in how they achieved that outcome. That study and its conclusions constituted our second report.
The third report catalogued what exists in Canada at the federal, provincial and territorial levels. At the end of that report, I wrote a statement and that is one reason we have called on all of you to come help us find our way in the fourth report.
The final paragraph in the third report indicates that despite all of the resources that Canada has poured into health, we really have not achieved the desired outcomes. Various data shows that we are not doing nearly as well as we would like from a health point of view. The WHO data ranks us ninth among thirty countries in terms of life expectancy of women. Ms. Bégin may reference this data later. UNICEF ranks us twelfth out of twenty-one industrialized countries in terms of children's well-being. The most disturbing report I think is the recent Euro-Canada Health Consumer Index that places us twenty-third out of thirty in Total Index Score, and most disturbing, thirtieth out of thirty in Best Value for Money Spent. In other words, Canada is bottom last when it comes to value for money spent.
This subject has interested us for some time and we feel that we have been doing something wrong. We feel like we must correct this error. At first glance, it appears to be a lack of concentration and investment in population health and a paradoxical over-investment in a health care delivery system that is not nearly as efficient as it should be.
We will be proceeding over the summer and fall with a number of hearings and in December we will issue our final report. We hope that report will assist all levels of government and NGOs. We hope that report will assist all the resources we have in this great country to come together and find a solution to correct our indefensible health disparities. We hope to report on how to improve our overall health status and ease the burden, from an upstream perspective, on the health care delivery system. We all know that system is experiencing terrible problems.
I will introduce the participants. We have Mr. Steven Lewis from Saskatchewan, who has come here today to coordinate this entire event. You will be hearing a great deal from him as time goes by. We have Ms. Barbara Reynolds, the brains of our committee, our clerk; and Monique Bégin whom I think everyone knows, the current WHO Commissioner. Senator Art Eggleton is a good friend of mine and chair of the Senate Standing Committee on Social Affairs, Science and Technology. I berate him every time I visit Toronto for not having built a tunnel between downtown Toronto and the airport when he was the Mayor of Toronto. He also has cabinet experience in government in various portfolios. He is a tremendous resource. Next is Mr. Mel Cappe who is President of the Institute for Research on Public Policy and has tremendous government experience in the past. Ms. Glenda Yeates was also a deputy minister, but is now CEO of the Canadian Institute for Health Information, CIHI. Senator Hugh Segal harasses me in the Senate on a daily basis, but I believe he is a man who knows all things; he can speak to any subject. He will tell us today how to approach this issue from a public policy perspective. We have Ms. Debra Lynkowski, CEO of the Canadian Public Health Association and Mr. Lars Osberg from the Department of Economics at Dalhousie University. Senator Catherine Callbeck is the former Premier of Prince Edward Island and she brings an interesting perspective to our committee along the way. Dr Jeff Reading will join us shortly. Ms. Diana MacKay is from the Conference Board of Canada. She recently coordinated a round table on the determinants of health. We have Mr. William Tholl from the Canadian Medical Association; Ms. Laura Corbett, one of our resource people; and Ms. Beverly Nickoloff, another resource person. Next is Ms. Armine Yalnizyan, Senior Economist at the Canadian Centre for Policy Alternatives and Ms. Gina Browne from Systems-Linked Research Unit at McMaster University. Mr. John Wright, former Deputy Minister of Finance and Health in Saskatchewan who has a very interesting overarching perspective on all of this is with us today as well as Senator Joan Cook from Newfoundland who has all the wisdom of Newfoundlanders and Senator Joyce Fairbairn. Sharon Manson Singer joins us from the Canadian Policy Research Networks and David Dodge my goodness I almost ignored Mr. Dodge.
Participant: You will pay for that.
The Chair: We will pay for that.
The man who made all of us see that the rich are poor.
Senator Segal: Several times in both directions.
The Chair: Mr. Dodge was an outstanding Deputy Minister of Health before he moved into the job at the Bank of Canada.
We also have Dr. David Butler-Jones who is the Chief Public Health Officer and head of the new Public Health Agency of Canada; Ms. Louise Potvin from the University of Montreal; and Senator Lucie Pépin, who also is Deputy Chair of this committee.
Steven Lewis, Consultant, Access Consulting: Thank you and good morning all. Welcome to what I hope will be an exciting day.
I will not say much by way of introduction. I want to set the agenda in terms of what we hope to get out of the day. As you all know, there is a rich and deep understanding of the social determinants of health in Canada and a long intellectual tradition of elaborating on that subject. We also have a long tradition of trying to figure out what to do about it. It is difficult to address health inequalities and disparities. This subcommittee has set itself the task of moving the agenda forward in a way that has not been pursued vigorously or successfully before in the country.
We have invited a deliberately diverse group of people to begin a conversation that may take the country in a different direction. While we will be reviewing a number of aspects of the dimensions of the problem, our hope is to focus on strategies and tactics to move forward. We hope to move forward so that governments, the private sector and citizens in general take the issue a little more seriously. We hope to find a way to make investments, policies and decisions that will overcome some of the disparities that cost the country a lot of money, a lot of health, and some rather unhappy rankings in the international league tables, as Senator Keon has said. If all goes well, and if you all vigorously take up this challenge, I will not have to do much today, which is my goal, not to need to be heard from too much.
We will take the opportunity to probe you if we think we need a little more elaboration, and we will try to move you in what may be modestly uncomfortable territory at times, that is, we do want some concrete suggestions, if possible, as to what we might do.
Obviously, there is no bible of how to do this well. There are some international examples that the committee has examined that show some inspirational successes, but as far as the Canadian context, how to move from a situation of significant inequality to reducing it substantially is a daunting task.
We hope for some creativity today. While we cannot say that nothing will leave this room, because the proceedings will be fully recorded and available, this is in the spirit of a creative experiment in policy deliberation. If we embrace that spirit, I think we will find this to be an incredibly useful day as the committee moves forward in the coming year or so.
That is all I will say by way of introduction, except that we do have four presentations, which are deliberately brief. While of course you will have the opportunity to ask for clarification and to ask direct questions, they are mainly intended to stimulate conversation, so do not feel there has to be a one-on-one with presenters.
Please feel free to engage in a dialogue with each other. If you hear something that stimulates you to a rejoinder, to take something in a different direction or to ask for an elaboration, even though this is a fairly large group, we would like to keep this conversation as informal as possible.
Senator Keon is, of course, the chair and I am the animateur. We will see how it goes in the morning. We plan to stick with our agenda, obviously, but if we think, after the morning session, that we might want to add a little wrinkle here or there, we will let you know before we start the afternoon sessions. We have thought about this carefully and hope these questions are the ones that have engaged you as well.
Without further ado, I would like to turn the proceedings over to our first presenter, Glenda Yates.
Glenda Yeates, President and Chief Executive Officer, Canadian Institute for Health Information (CIHI): Thanks very much, Steven, and thank you, senators, for the invitation.
My role is really in my capacity with the Canadian Institute for Health Information. Although I have many personal opinions from having been a Deputy Minister of Health and Social Services in the Province of Saskatchewan, I will wear my CIHI hat certainly for the presentation portion, and try to set the stage. You asked me to speak about what we really know about health disparities, which is our first theme, and you have asked some specific questions about the role that data and information can play.
There I wear all the hats that I have ever worn. I am a passionate believer that data and information are enormously powerful tools. In the options paper the committee asked some questions about how we move this forward and how we can change the national conversation on population health and health care. I am a firm believer that information and data are a part of that solution. You are asking some specific questions about what we might do there.
No data presentation is complete without PowerPoint, so for those of you who are sick to death of PowerPoint presentations I will apologize at the outset. I will apologize particularly to Monique, since I gave her a late night, I understand, as a result. I do want to take you through the deck very quickly, which will set the stage. I know that the committee and those around the table are very familiar with many of these questions.
[Translation]
You asked us what we know about health disparities and what we are still exploring. Those of you who read the CIHI reports know that we often cover what we know and what we do not know. In population health it tends not to be so black and white but rather what we are still exploring, because there are some areas where the data is indicative but not entirely firm. Finally, what can we do to fill the gaps in terms of information? You are looking for action, and we have some thoughts there.
In terms of what we know about health disparities, differences in life expectancy is dealt with on slide 4. You have all seen these. I have put them together in this way so that you can see that internationally Canada does fairly well on the life expectancy dimension. However, when you look within Canada you see the differences. There is an 11-year difference between British Columbia and Nunavut, for example. There are differences even within individual provinces. In the Province of Quebec, you can see the life expectancy differences between Montreal and Gatineau. There are differences even locally of over two years in that instance. Looking even more locally, work done by the Montreal public health department shows a greater than 13-year-difference among the areas within Montreal.
Again, the data really matters. It can change your view of where the problems are and where you might find the successful intervention points. I will suggest later that that local level of information is one area where we can act most effectively, and we do have challenges in terms of using information in that area.
Slide 5 shows the life expectancy differences for females between First Nations and other Canadian females. The good news on this slide is that it shows that over the 20-years from 1980 to 2000, we see a diminishing difference, but it is still very significant.
Recent studies from Statistics Canada show areas inhabited by Inuit versus the Canadian population. The results show a lengthened life expectancy for the Canadian population as a whole but no improvement in Inuit areas. There are clearly significant challenges in terms of the First Nations and Inuit population. We know less about the other Aboriginal populations just because of data.
Slide 6 deals with infant mortality. Much is often made about how Canada ranks in this measure. In terms of an overall population measure, how well are we doing on infant mortality? We have looked at this in some detail, and we know that there are some differences in how Canada collects data, so I would caution that the data are not perfectly comparable, as probably no international data is perfectly comparable. Nonetheless, we see here that while infant mortality has been getting better in Canada, there are many countries that do better than we do on this measure, which is a fundamental population health measure.
I did not want to inundate you with too many slides, but there are significant differences between provinces, and between First Nations and non-First Nations, for example. That figure is an average which, to a certain extent, hides a significant disparity.
People have been doing a lot of good work here in Canada about the reasons. Statistics can talk about what we can see, but there have been many people looking at this in Canada, where we have a strong research tradition, and trying to get at those social determinants. In the next slides I will touch on what we know about income, education and a few other indicators. People have been documenting the range and complexity of the social determinants of health.
The income gradient, on slide 8, is well known to this committee. Distressingly, it is very robust. Those who report their health self-reported very good or excellent. We consistently see a significant difference between lowest and highest income, and even between middle income and high income. I find even the upper levels of the gradient interesting. This is from survey data of 2005. That is from individual responses.
Slide 9 has a slightly different take on this, looking more ecologically at neighbourhoods. This is for men for two different years. We see the differences in terms of the poorest and the richest neighbourhoods. There you see an income gradient by neighbourhood. Again, I suppose the good news here might be that we do see that decreasing somewhat. If you look at the 2001 versus the 1971 data, that income gradient looks like it is narrowing slightly, but it is still very much in evidence.
The next slide looks at education. There is often a lot of question, what is the causal root; is it income or is it education? They are very closely aligned. We can look at education in different ways. It is often a bit easier to look at, but again, the health status and the link with educational attainment tends to be very strong in Canada and internationally. Again, it is one of those very fundamental issues of which the committee is well aware.
Slide 11 looks at early childhood. Many of the presenters you will have seen, as I read through your earlier documents, focused on early childhood. In Canada we are familiar with Fraser Mustard's and Margaret McCain's very strong work that looked at early childhood.
Again, the research evidence here is interesting and very strong. This looks at some of the child readiness. This is some of the school readiness indicators at the age of five, and we see the income gradient is very evident already at the age of five. Again, we do not always know the causal links, but this is from the National Longitudinal Survey of Children and Youth. What we can see is a similar gradation already very apparent at an early age.
Slide 12 looks at some of the personal health practices. When we talk about population health, there has been a lot of what has entered the literature, or even the public consciousness, is this sense of personal health practices. If we could only get people to stop smoking or eating more fruits and vegetables that would be the solution. There has been much interest, obviously, in that issue.
We talk much less about the fact that there is also a gradient by socio-economic status on those factors as well. Perhaps it is not so much on eating our fruits and vegetables. None of us in any of the categories, I would say, grouped by income do terribly well on eating our fruits and vegetables. Apparently there is not a strong difference there, but certainly when it comes to tobacco use or physical activity, we do see a certain income gradient. It begs that question about where are the intervention points. Are they at the individual or at a more population or community basis? It is clear that those individual factors as well show a gradient.
The next slide really just wants to look at some of the information bases. What do we know? What do we track? What do we measure? We at CIHI and Statistics Canada, in the late 1990s, developed a health indicators framework that we put out, widely used by a number of organizations and we are working to populate this framework.
If you see the areas of the domains that are circled in red on this slide, those are the years where, while we do not have perfect information, we are starting to at least have measures that you can measure and monitor over time. We are starting to know much more than we did 10 years ago, or certainly 15 or 20 years ago, about how we are doing on accessibility, how are we doing on some of the health behaviours.
What we know less about and what we do not monitor at the current time, which I think is the equity line you can see down the side. It is relevant to some of the questions asked in the committee's paper. The question of whether the gains we are making and to what extent they are spread or there are still health disparities, whether they are increasing or decreasing, that is not something at the current moment we monitor, although we do have a health indicators framework that certainly makes room for that and speaks to its possibilities.
What are we still exploring? In some ways the question that you posed to us when we appeared here before is the causality question. We see all of this data. We see the ecological data. What are the root causes? What can you tell us about what really causes these disparities?
Our view of the literature is that we are still exploring this as a research group. There are certain things that are starting to emerge, but there are some puzzles around how does that gradient in health stay so robust. Is it about hierarchy; is it about income; is it about status or relevance? What are the links and what causes those links between socio-economic status and the behaviour gradient that we showed?
What I can tell you is there is a lot of robust research on this question. There are certainly things starting to emerge, but there is nothing that I would say meets that gold standard of absolute evidence. It is clear that there are interesting pieces of work that are starting to emerge on individual causal questions.
The next question we would pose is what works? In some ways when we look at this information, the question that people ask is what would we do about it? If we had the political will and interest, what interventions work? This is an area that is hard to generalize. There are starting to be studies, but they are small, about what interventions actually make a difference.
The fact is that we would suggest we could use more information and evidence on actually what interventions affect the population health in the long term. There is some evidence on effectiveness that is starting to emerge, particularly on those interventions that are aimed at individuals, but again, less on the murkier and tougher questions to research about what combination, when you do those big policy questions, what impacts they have on population health.
Health indicators, these are the areas I have circled that are the areas that we would like to populate more. If we had an ongoing indicator that looked at equity, for example, that looked at some of these other questions, would enable us in a better way to monitor and answer how we are doing in those areas.
The next slide I just put out on the table. For a number of years, the United Kingdom has had a specific focus on health equity. With their increased information, health professionals are searching for the answers. They have actually put in a requirement for these health equity audits. I know of no similar requirement in the Canadian context, but they are suggesting that at the local level, as well as at a national level, this be something that be monitored including by primary care trusts and others. It is early days. We do not have something that would say we see these audits are having such and such an impact. However, we can certainly see a real focus and a sustained focus in the U.K. on having those equity audits.
The last portion of the slide is about what we can do. We are firmly of the belief that information is a powerful tool at not only supporting decisions, but also helping to focus attention and understanding. It can focus attention on the impact of the policies and the steps we are taking at a population health level.
On slide 20, I would just flag the fact that it would be enormously helpful to capture more socio-economic status, SES, data. If we are going to try to get at this question, it would be helpful to have that information. We do see, for example, in the United States, birth registrations routinely include maternal education, which again is often a very good proxy for socio-economic status. That gives them the ability to look at these questions in a much more robust way.
Certain provinces, as you will see on the slide, are implementing that, have implemented it. Quebec, for example, has maternal educational status on the birth registries and has for some time. In the West, we see some provinces that indicate Aboriginal status here but it is probably more limited at this stage to First Nations status. We do see some of those markers beginning to be placed on birth registrations and in some cases death registrations. That, again, gives us some more fundamental tools to understand analytically what is happening. There are also opportunities on administrative data if we can collect some of those population indicators that would help us in the research community do research over time.
The next slide points to another specific information gap that I think we could fill. When we are looking at health disparities, some of the very groups that you would most want to know about are groups that because they are difficult to get at we tend not to create and gather information about them. For example, seniors or others living in homes for the aged or homes for the disabled and the homeless are not groups of people on whom we routinely collect data. In some cases on-reserve populations are excluded from surveys.
Again, if we are trying to understand disparities, filling out our data by trying to specifically gather information from those kinds of groups I think would be useful.
With respect to data linkage, the next slide in some ways is perhaps a response to the question you asked in the options paper about whether we would create a national population health database. One of the observations we make is that the relevant data on a population health basis will lie in different spots.
We have heard from people at local levels who are connecting to school board data, people who are connecting to community-based data. We have heard of people at the national level, who are connecting the census to administrative data. The ability to put that information in one spot may always be limited. If there is a climate in the country for appropriate linkage, and obviously that means being very clear about privacy concerns and making sure that individual Canadians have safeguards to their privacy, we have to be clear about when data on a de-identified basis can appropriately be linked to answer these questions. I think creating that strong privacy framework and then building the climate that would allow us to link data, whether at the local, provincial or national level, would in our view, provide us many more opportunities for insights on these questions.
The next slide is one small example of where we have been able to achieve that linkage. This data has not yet been published. Working with Statistics Canada, we have linked census data to hospitalization data. This information concerns ambulatory, care-sensitive conditions, things you should be able to treat in the community, such as asthma, diabetes, and high blood pressure. This information shows that even when accessing the health system and the hospital system, there is more need for lower income people to be hospitalized for the conditions we should be able to treat effectively in the community. We can get at this, again, by linking census data, which contains the socio-economic data, with the hospital records. This is one small example of creating that climate for linkage, but it does allow us to focus on those population health questions.
The next slide, in terms of regional and local analysis, deals with our sense of what can be done. The intervention points will be at a local level. For that, we need robust data sample sizes. I know it is not the stuff of headlines, perhaps, but having additional data at greater levels allows people at the local level to act on that data. We have been doing work with the urban public health officers in the country, and when we are able to provide data that applied to the neighbourhoods in their city, it is tremendously powerful.
The electronic health record also offers great opportunities for population health monitoring. When I read your paper that talks about whether there are options for building an electronic or a population health database, my sense is that it is probably not a single database. The fact is, with the investments we are making on an electronic health record, which are absolutely necessary for that first-line clinical care, there are also opportunities here if we ensure they have appropriate safeguards for what data can be shared and for what purposes on a de-identified basis. I think that allows us the potential to essentially fill in many of the questions on a population basis that would be fundamental to us.
I will stop there. I know this is meant to stimulate the discussion, but my conclusion is that we do know a lot. There is a lot we still do not know definitively, but research is starting to emerge. There are some real opportunities to increase the information that would continue furnishing the basis for this to be an issue that people understand and act upon.
Louise Potvin, Professor, Department of Social and Preventative Medicine, University of Montreal: I think what Ms. Yeates presented encapsulates what we know and do not know.
I would like to highlight two things for the committee. One of the things underlying the presentation is the total lack of trends data. In Canada, we are no better than the rest of the world. There is very little capacity in the world because there are very few instruments but many hard methodological issues to record how we are doing over time. There are technical issues and indicators of disparities that are not as easy to grab as central tendency indicators, such as means. That is one of the issues that I think should be emphasized more.
The other issue I would like to emphasize, is if we are doing research on disparities, we are not doing research on intervention and evaluating those interventions. There is yet unpublished data that was completed by IPPH, the Institute for Public and Population Health, together with other institutes interested in those issues. I can tell you that less than 10 per cent of all population health projects funded through CIHR between 2001 and 2006 deal with intervention.
Not only are we not aware of what works and what does not work, we do not do research on it, essentially because we are not well equipped to pair intervention projects with good and relevant research projects. Those are the two issues I would like to emphasize as arising out of this presentation.
Hon. Monique Bégin, P.C., Commissioner, World Health Organization Commission on the Social Determinants of Health: It was an excellent presentation. It was very clear and comprehensive. It reminds me of an issue that this Senate Subcommittee on Population Health should address head-on, and that is the issue of there being a lot of knowledge but, at the same time, not enough knowledge.
The evidence-based medicine approach to life has now permeated into every bureaucratic organization. The fact that we do not know everything will be easily used to dodge the issue by any deputy minister in the system. We know a lot and our grandmothers know more than us, but they cannot prove it.
What we know from hard science and from grey literature or observation, when it is well-done, logical and systematic, it is considered evidence. Therefore, the evidence-based approach to life should be addressed in this committee.
William Tholl, Secretary General, Canadian Medical Association: Thank you for the invitation to be here.
My first point is that if we were here 10 or 12 years ago, we would not have near the data set that we had presented to us here this morning. Well done, Ms. Yeates. I was privileged enough to sit on the Wilk task force that led to the development of CIHI. This glass is half full in what we know and what we do not know about health and health care.
I have two or three comments. First, I would like to discuss how, in a short period of time, we have fallen from the top in the world, fourth or fifth in infant mortality, to where we are today. One of Ms. Yeates' slides shows us at twenty-second in the world. Yes, there are differences in the way one collects data, but there is not much of a difference over that period of time. The same basic instrument is being used. For me, it raises the issues that the national health forum, Mr. Lewis and many others, have looked at before. Why have we come up dry? Why have not we made more progress? I leave that question for the group. What do we need to do to create the burning platform for change in health that we have seen in health care?
Can we do for health what we have done for health care and wait times to raise public awareness and get people pulling in the same direction to make a meaningful difference, first by measuring and then by managing?
There has been reference to the Lalonde report in some of the background material. We got together as a clutch of those people who actually helped write the Lalonde report 30 years ago and asked them to do a retrospective on a new perspective. One of the things they observed is how it is that we led the world in thinking about and measuring health — things such as potential years of life loss — but now we are laggards in the world in delivery of health and health care. One thing they observed was the lack of this burning platform for change.
I will leave that with the group and maybe come back — if you think it is important — to how we might do that.
Senator Fairbairn: At the very beginning, I want to raise one issue that touches almost everything that you were saying. That is the question of literacy.
We have had very good hearings in this committee under Senator Keon, but as I look around the table I see people who have had to deal with this in their past: David Dodge, Mel Cappe, Senator Callbeck as a premier, Senator Cook in Newfoundland. It sticks in every corner of Canada. As we go around the table, I would be grateful if some of you might give thoughts on that issue. I know Senator Segal has been very engaged in literacy as well. I would like the group to turn its mind to the fact that in our country something like 30 per cent of its adult citizens are not in a position to do what is required of them in terms of literacy, reading and understanding.
It seems to me to be a foundation issue to pretty much everything we will talk about today. I thought I would get that issue off my chest first thing.
Mel Cappe, President, Institute for Research on Public Policy: In the committee report of April 2008, there is reference to the inability of many Canadians to read and manage their medication. The issue that Senator Fairbairn is raising is far broader than that. Rather than a functional capacity, it is much more endemic to the determinants issue. I was not going to make that point. I do not want anyone to take my intervention as being anti-analytic, but I want to distinguish between data, targets, and the analyses done with the data and the targets that may be set up.
It was my experience in watching the U.K. closely that they measure everything that moves. When you measure everything that moves and you set targets to them, managers manage the movable, but they do not manage the important things. If you measure what is measurable and establish your targets around that, you run the risk of establishing the wrong targets. I want to make a strong distinction between the data for use of analyzing the problem and determining pathways to deal with the problem, as opposed to the targets that may be used. I notice again in the report you talk extensively about the use of targets.
I will use one example. In the U.K. they had league tables of hospitals. There was a complex measure of 32 indicators on which they ranked the hospitals. One of the 32 measures was the patient response to quality of food. Another was the return of breast cancer. If you are a hospital administrator, one of those indicators is easy to manage and one is difficult to manage. By setting up targets like that they skewed behaviour in a way that I do not think improved the quality of health, let alone health care.
I want to make that important point, that we need the data and analysis, but do not make the very quick step of setting targets.
Mr. Lewis: Are you saying that as CIHI and others contemplate a disparity oriented information agenda there is a danger of collecting the wrong information that is of secondary importance?
Mr. Cappe: I believe the marginal value of information is positive across the board. I once heard someone say there are some things you do not want to know — you do not want to know what your daughter did on her date last night or when you might die — but you want to know pretty well everything else. You need to know all those things. Do not, therefore, say that we will take the measured and say that is the target we want to improve. Go back to the overall conception of health outcomes and what you think you can do to improve health outcomes, but do not just do the things you can measure. Keep a very high level of focusing on the more unmeasurable.
Mr. Lewis: What can you not measure about this? What are you worried about as this elusive, unmeasurable phenomenon that we cannot get at?
Mr. Cappe: If you are going to look at neighbourhood incomes, there will be a tendency to say we should target this neighbourhood and fix that income problem. It is not that simple. There are many more determinants of income inadequacy and the transmission mechanism into the quality of health.
David Dodge, Former Governor of the Bank of Canada, as an individual: Another way to phrase that is we had better not confuse correlation with causality.
Mr. Lewis: That is a way to phrase it that will appeal to the researchers, to be sure.
Senator Callbeck: First, I want to thank the presenter for a clear and informative presentation. I have a question on the electronic health record, which you mentioned. In my own province they are making great strides in the last few years with this record, and now all the hospitals are using the system. They are moving towards a more comprehensive system.
I wonder about other provinces. Where are the other provinces concerning this HER? Are provinces working to have the same data collected? Are they all collecting different data? It seems to me if it was the same then it would be much better, because we could use it.
Ms. Yeates: I think there is significant progress being made across the country. In some ways it is early days. It is a very big project. We start to see the kinds of progress you have experienced in your province and we see that across the country.
I think we are starting to see the early wins on the clinical side. The fact that an X-ray or a CT scan goes electronically so it is there when people need it, we are starting to see that for those who have focus on that area.
The thing we have talked much less about, and which will not, in my view, come to bear unless we consciously decide this is what we want, is if we have to standardize certain things to make sure we can use this data for population- health monitoring.
We have not talked about that as much. We have not determined what the rules of the game will be, what will be shared, and why it would be important to standardize certain elements. There may elements that do not need to be standardized. If they are different from one part of the country to the next, it will not matter.
There are other elements. In trying to understand if we are making progress in diabetes, is incidence better, is the treatment better? If we are actually going to know that over time, we must standardize certain definitions. We have to agree that there are certain things we would use — clinical extractions, essentially, from the electronic health record, which will have all the details and all the identifiable information. We have to agree under what rules, prohibitions and privacy safeguards we would extract for these population health measures, which will be enormously important.
The electronic health record is currently going very well in various parts of the country although, we are not yet at that stage where we are consciously thinking about what we will use the record for in a population health context.
Lars Osberg, Department of Economics, Dalhousie University: I would like to emphasize an issue that is important for data, analysis and policy purposes, and that is the long lags that are inherent in some of the socio-economic determinants of health. If you think of some of the socio-economic determinants of health as shocks or injuries or stressors to the system, very often individuals and families can buffer them for a while and the impacts do not show up right away, but they are latent and show up way down the road.
In terms of extreme events, we have known for a long time that low-birth-weight babies have poorer health while infants, and then all sorts of poorer health outcomes later on, through their entire life course, because of injuries in utero.
In less-developed countries, it has been known for quite some time that if there is a famine and poor nutrition, young children lose height and never quite get it back. Years later, they have poorer cognitive and social outcomes in many different directions. In terms of extreme events, we have known this for a long time, but many of the processes we are trying to tease out are subtler.
Think of the impact of a spell of poverty on a child. The Panel Study of Income Dynamics in the United States started in the 1970s, and they are now following up on some of the children from those families who are entering their mid-30s. For people aged 18 years to 20 years, their youth is a tremendous buffer against many ailments, so many conditions did not show up for several years. However, when they are entering their 30s, some of these latent injuries that were received early on in life do start to show up.
The data problem in Canada is that we did not have a similar study to the Panel Study of Income Dynamics starting in the 1970s, and we are only instituting those kinds of surveys now. The problem there is that some of them are on six- year rotation panels, so we will not ever get this long span of data that we need to fully analyse it. We have to depend on administrative records for at least some of our reaching back in time.
The policy problem is that if you dismantle the social safety net in the mid-1990s, a lot of things will not happen right away, but you are increasing the depth of poverty and that will have some impact down the road, years later. The government that makes the decisions one way or another does not pay the price, in health costs, for their social policy decisions. Similarly, the government that makes the decisions to improve social policy does not themselves reap the benefits in terms of health care costs because they are way down the road.
There is a data problem, an analysis problem and a policy problem, and they are driven by the long lag between injury and outcome, as you often observe in the socio-economic determinants of health.
Senator Segal: I find myself in agreement with both Mr. Osberg and Mr. Cappe, particularly in the context of trying to do an impact assessment of the various factors that impact on public health and trying to have some weighting. We are far away from knowing that; I understand that. Clearly, from the point of view of public policy and from the point of view of what governments should do with their limited resources, having some understanding of that will be of immense assistance.
I also think that to some extent it is of value, in the use of Ms. Yeates' CIHI statistics, for us to also reflect on what government does well. Government does not do all things well, no matter who is in power; and government does some things extremely well.
To the extent the committee, in its wisdom, will be offering advice as to what government might do about increasing the positive aspects of population health, it will be important to marry the numbers with some sense of what we think governments — federal and provincial level — can do well, as opposed to those things which evidence has indicated consistently, whether it is a government of the left or the centre or the right, or a mix of all three, just cannot do well because it is beyond the range of what governments can do in a host of different ways. While that is a tall order to ask any subcommittee or committee to assess, the salience of the advice that is offered and the degree to which it is picked up quickly and used will depend on how far the committee is prepared to go on those kinds of recommendations.
Mr. Lewis: When you hear where we stand in some international rankings, whether or not we can quibble with the methodology, we are dead last in value for money in our health and social spending. Is that a motivator? Is that the kind of data that might make this a little less obscure?
Should governments collectively be confessing and saying that for some reason we have this fundamentally wrong and it has something to do with our inability to reduce inequalities, which I think is at the root of the value-for-money issue?
Senator Segal: I share that perspective intensely, Mr. Lewis, and will be making brief comments along that same theme a little later in the agenda.
Let me also make the case that there is a correlation, and I think a causality — if I may be so bold, in the presence of intense economic skill sets that I do not share — with regard to the core question of poverty. I think it emerges directly from Ms. Yeates' numbers. If you look at those countries that are doing better than we on certain measures, the answer is they are doing better on population health for reasons that relate to the way they have narrowed the gaps. From Disraeli to Adlai Stevenson, people have been grappling with that issue, and it is my view that it is something on which the committee should offer some reflection.
Dr. David Butler-Jones, Chief Public Health Officer, Public Health Agency of Canada: I would like to wade in on the numbers debate before I address the other points. Concerning correlation and causation, I cannot count the number of times I have seen umbrellas cause rain because there are more on a rainy day. When the numbers of umbrellas are reported, those numbers then drive the decisions. The nature of evidence is something that requires work.
To return to Mr. Cappe's comment about what gets measured does get done, we have seen that in terms of Maclean's surveys and others skewing decision-making in order to look good. It is really important to make clear what we actually decide to measure and track, and the context in which we measure and track it. Where we do not have data on something that is important, we need to find a way of either measuring it or at least understanding the logic model behind it.
Part of the challenge for data is that poverty, for me, is a constellation. It is not simply an issue of economics. It is a constellation of poverty, relationship, community, education and literacy. To tease out the determinants as isolated components, as we tend to do in medicine and other realms, is exceedingly important in understanding the dynamics and the interrelationships, but also very difficult to do.
One thing that has always intrigued me, having looked at this issue for a few decades now, is why is it that in neighbouring outports, with the same economic conditions, the same geography, the same everything, one is healthy and one is not? What are the factors? We have not done enough research on that. We have some ideas about that, but we are not so sure.
We have not used natural experiments enough, both internationally, in terms of policy decisions and implementation, and even nationally. In the 1990s, one of the best things Saskatchewan did for health was provide benefits to low-income families coming off welfare so they did not lose their dental and drug plan for their kids. That had as big an impact on the health of that province as just about anything else in terms of narrowing the gap. We have data to support that, but we have not effectively used that data.
I share Ms. Yeates' enthusiasm for the better collection of data. However, part of the challenge is making sure we understand the purposes and the differences between surveillance, where we are collecting data on a routine basis to track things, and routine data collection for the purposes that Ms. Yeates is talking about with CIHI and others and research. We need to be clear about the question we are asking and what is the best way to get at it to elucidate the fact that it is not the umbrellas causing the rain or other things, and then how applicable is it and in how many places beyond the place that the research gets done.
Finally, back to Ms. Bégin's point, at what point do we know enough? Do we have enough information to make some kind of a decision or move in this direction rather than another and then to evaluate and assess it? It has been in the population health debate for a long time now. We can do a number of things at the community level to make a difference in people's lives. We have to do macro-policy, which became an excuse because while we are working on this, we do not have the focus and energy to do the things that make a difference in everyday lives. It is a combination of those. It is not an either/or situation. It is that interface between the various dynamics of the determinants and poverty, and the relationship is not simply government or individual but rather the constellation of those that reduces disparities and improves overall health.
The Chair: I would like to tease something out that has been of tremendous importance, and it has been raised first by Ms. Bégin, then you, and Mr. Cappe is raised it as well. As we try to contribute to the system in our report, at what point do we settle on a subject and decide we know enough about it — even though we do not know everything — to make some very firm recommendations. Let me give you the example of early maternal health and early childhood development. We went to Cuba because that very poor country, which cannot afford the kind of health care delivery systems we have, asked itself what it would concentrate on and decided to concentrate on healthy mothers and healthy children. Believe me; Cuba has accomplished that goal. I want to use that as an example because I think that in this country, we could have a tremendous health, economic and productivity impact if we zeroed in on maternal health and early childhood development.
Gina Browne, Professor of Nursing and Clinical Epidemiology, McMaster University: Thank you for your invitation.
I thank Ms. Yeates for her data. I do research and I do read CIHI reports, but today I would like to respond to some of your points, Ms. Yeates, from the point of view of 30 years as a practicing family therapist.
Picking up on the senator's idea of maternal and child health, I would like to tell you about one of my families where the mother is a product of a heroin mother, so she was born brain damaged. She now has a brand new little child who is perfect, so far; however she has poor income, is on social assistance, has housing problems, interpersonal difficulties and problems parenting. She has every problem that you mentioned.
To return to the idea of causality, when you listen to the intergenerational stories about people with mental distress much of the everyday mental illness goes unrecognized. That is to say, that 97 per cent is undetected and reported as depression and anxiety, often coexisting. I am not referring to serious mental illness, which is horrible, but it is only 3 per cent.
With respect to severe major depression, anxiety and panic attacks, in my study, 61 per cent of mothers on social assistance have just that amount, and not only do they have two or more mental health conditions, but 40 per cent have three or more serious physical health conditions and children with behaviour problems and so forth.
All of these issues of education, income, healthy practices, birth weight and so forth could all boil down to — I do not like to make things so simple — the presence or absence of poor mental health, which gives rise to poor parenting practices. Some mothers with depression do not have bad parenting practices, so it is not a straight line. However, problems with mental health affect child stimulation, learning and their literacy. It affects their income, and it affects their ability to buy fruit and vegetables. Many people use substance abuse as a form of self-medicating behaviour. It gives rise to interpersonal difficulties and problem solving, giving rise to further adverse events in a person's life.
I agree with the point that it is a constellation of types of impoverishment that are interacting. These kinds of adverse events change biology and genes, and then it becomes intergenerational. We know that even if people are born with certain limitations, a good environment or whatever can set them apart better than others. Therefore, in all the literature about determinants of health, I never see people's mental illness emphasized enough. We treat mental illness as if it is just one other organ, namely, the brain, whereas I see health defined as the capacity to respond to life's predicaments and challenges. If you have mental illness, you cannot respond as well, and it is not under your control. That is what I wanted to say.
I agree with all of that, but I think it boils down to underlying mental health issues on which we have very little data.
Dr. Jeff Reading, Scientific Director, Institute of Aboriginal People's Health for the Canadian Institutes of Health Research: Good morning. I would like to thank Dr. Keon for inviting me and recognize the work of the Honourable Monique Bégin and the World Health Organization Commission on Social Determinants of Health, with Sir Michael Marmot.
One of the things Michael Marmot talks about is the causes of causes, so when we talk about disparities, everyone here understands that they are caused by socio-economic circumstances. In Aboriginal health, we talk about the causes of causes of causes. In other words, the causes of poverty relate to the political economy of Canada and the historical circumstances that have placed Aboriginal people, particularly First Nations, at a disadvantage. Many of us believe that we are in a post- failed-assimilation context, whereas if assimilation had actually worked, Aboriginal people would have been part of mainstream Canada and the problem would have been solved. It has not worked; it has been a colossal failure. In fact, in most of the evidence we can see now, more Aboriginal people are self identifying. There has been a turnaround. Therefore, the problem, if you want to characterize it as a problem, is that it is getting bigger. More and more Aboriginal people and more and more First Nations people are proud of who they are, and it is an urban problem as well as a rural, northern and isolated circumstance.
I characterize it as a problem, as many people do, because there is this gap in life expectancy that we all know very well. One of the problems about my talking to this group is there is little that I can tell you that you have not already heard. We all share that information and we are preaching to the converted in a sense. However, a couple of things are important to underline.
The first one has to do with data. I liked Mr. Butler-Jones' analogy to rain and umbrellas; I like the rain analogy. In Aboriginal health, we are raining data, but there is not a drop of data to drink. That is the problem. We tend to be excluded from access to the information that would improve our lives. We have made some progress, but we could be making more progress in terms of looking at how we would democratize access to data and information that would provide us with the opportunity to make convincing arguments to improve our health care strategies.
I underline what Ms. Potvin mentioned in her presentation about interventions and what works and at what levels. Ms. Yeates wrote, ``Very little research output addresses intervention research related to health disparities.'' That is true. Canada has failed to actually invest the resources to do long-term studies that test interventions, particularly related to sustainable economic development in marginalized populations and communities. In the end result, it is the sustainable economic development, the access to resources, the elimination of extreme poverty and the ability of those families to purchase other determinants of health that will improve the health and well-being of those communities. We have known this for 30 years or more. Social theorists have shown that Aboriginal self-determination would be connected in the long-term to improvements in health, but we failed to do that. The most promising opportunity and failure was the Kelowna Accord, where $5.1 billion was allocated in a unique partnership that would have narrowed the gap, or begun to, but at the eleventh hour that was actually disbanded.
We are in the post-Kelowna Accord environment where Canadians are starting to think, well, maybe the gap in life expectancy and well-being for Aboriginal people is acceptable for Canadians. Maybe we have come to the point where we accept the fact that that will not ever change. I think that is unacceptable. It is unacceptable for Canadians, our system of equality and fairness and the social things we consider to be our values.
The final point I want to make has to do with international comparisons. There are striking similarities between the circumstances and history of Aboriginal people in Canada and indigenous populations worldwide. In the recent opening of Parliament in Australia, the Prime Minister gave a four-page speech about ``stolen generations,'' like the residential schools thing that happened in Canada. What he said was remarkable, and it was a complete political turn- around for Australia. They have also launched something called Closing the Gap, and it interesting that in the federal report here we use the same terminology.
Australia is doing a whole-of-government approach to look at the broader social determinants to close the 22-year gap between indigenous Australians and the rest of Australia. Their economy is strong right now, and perhaps it is a good time for them to consider that approach. We need to focus our efforts in the international area to look at promising practices that occur in other countries.
It was disappointing when Michael Marmot finished his report and did not have an indigenous lens. We had the poverty lens. We had some language about social exclusion. However, there is a unique indigenous lens that is connected to the history and the present circumstances of Aboriginals in Canada, in the North and also around the world.
Sharon Manson Singer, President, Canadian Policy Research Networks: Thank you very much for the invitation to be here today. I want to speak a bit to the quality of the data available on a provincial basis. If we are to come to a place where we can democratize the data and make it accessible to citizens, it has to be at the provincial level. Newfoundland has probably done the best job of making their data available to citizens through their community accounts, and it is really quite spectacular in terms of being able to measure and compare across communities. British Columbia also invested fairly significantly in looking at regional socio-economic indicators that helped to determine on a health region basis, down to about 55 different regions. Similarly, Manitoba has done a very good job in linking their data sets. The point is that it is very uneven across the country. Ontario, for example, has very little to offer its citizens in terms of being able to measure and compare what is going on.
When we come to the place where we are asking our professionals, our experts, our researchers to analyze the data, it has to come back to citizens who need to be able to look at what they have in their hands in terms of how they are measuring themselves against what is going on. Putting the information and power in the hands of citizens allows those communities to take action. It will also help us, as experts and researchers and politicians and policy-makers, begin to determine the answer to the question, why are some communities healthy and others not? How do people use data to actually turn things around? That is fundamental to the way in which we have to conceptualize this problem. It has to come down to the ability of citizens to ensure that they understand their health. The legions of evidence that we have in so many of these places does not matter a whit if the Canadian public does not believe it.
The Chair: We are running out of time for our first theme and I want to think about something Dr Reading raised, which is the whole-of-government approach to population health from Australia, Britain and so forth. Somewhere between up there, a whole-of-government approach, and down here, at the community level for implementation, we would like to assist governments, NGOs and the population at large find a way through this morass to begin to effect change in population health.
We will now turn to our second theme.
Mr. Lewis: We will go directly to Senator Segal who will talk to us about reorienting government policy, which moves us into the main theme of the day.
Senator Segal: Colleagues, I appreciate the invitation to this Population Health Round Table. I know that your work embraces all the determinants of population health and not only poverty. However, I also know from my own experience in various governments that government does not do all things equally well, nor does it have the capacity to do everything. Therefore, choices must be made. Advising on what works best and where the lion's share of resources should go would, in my humble submission, be the most politically salient and impactful counsel this Senate committee could offer.
I will therefore, try to make the case this morning, that poverty is the most seminal and efficiently addressed of the many other important determinants of public health. When poverty is properly addressed, the results are outstanding and far-reaching relatively quickly — more quickly than other determinants you might address with equal determination.
I will suggest a broad reorientation of social policy, which will offend people equally on the left and the right. I will certainly offend all bureaucrats presently in the employ of most governments on this issue, simply because it attacks a core inertia and sense of comfort that we all have acquired, in my view unjustifiably, from the social safety net as it now exists, as we quietly whistle through the graveyard at the failures that are absolutely apparent.
I will make the case that if we could get our government to focus on a negative income tax guaranteed annual income it would, if structured generously enough, bring all Canadians above the poverty line. It would force a regional and effective definition of that line, encourage tax filing compliance, and protect filers' privacy, much more than is the case in our welfare system now. It would increase children's chances and opportunity, improve the database on active poverty, which would be renewed annually and reduce multi-illness life pathologies caused by poverty. It would reduce pressure on hospitals; begin adding to healthy life spans; and increase the penalties for fraud, which under the tax act are more serious than penalties for gaming the welfare system. This occurs on occasion and we need to be a little sensitive about it.
As we consider design elements and comparative costs, it is my hope that we would look beyond the provincial general social assistance costs, exclusive of education, health care, seniors' pension and Old Age Security entitlements, which I suggest we do not change. We should add those costs to the real costs of running our prisons, our justice system, children's aid, the cost of dealing with family violence and Aboriginal poverty, to determine how much the actual price tag is for the absolute absence of a coherent anti-poverty strategy now.
Around this table, you will perhaps understand better than I ever could, the interwoven pathologies of poverty, poor nutrition, low educational attainment, low exercise, and preventable but expansive chronic and acute diseases. Dr. Keon will be upset I did not mention trans fat on that list. However, it has not reached my heart yet, although I know it is very important to him.
Of all the things we might do quickly to reverse this pattern, I submit with respect that reducing the percentage of our population who are poor is the least expensive, the most time efficient and most easily done. I would say, as I joked with Dr. Butler-Jones over coffee, we should not be seduced by the constellation of factors. All that does is divide our resources in a thousand different pockets and envelopes, none of which is likely to achieve any meaningful impact in the lifetime of people who are poor and likely to get sick now. Not future generations, but people who are poor now and living unbearable lives.
No government alone has the tools, cash or constitutional jurisdiction in our federation to increase exercise, improve nutrition or keep people in school beyond university. However, the Government of Canada, under the federal Income Tax Act, and by virtue of tax collection agreements with nine provinces, has the capacity to deliver quickly on a universal anti-poverty strategy should we have the courage to put it into effect.
The basic elements are already in place. A GST tax credit automatically deposits cash into the accounts of Canadians who earn beneath an established threshold. A guaranteed negative income tax credit could do the same. Over time, compliance would go up, privacy of filers would be more seriously protected than are the rights of welfare recipients now and efficiencies could be real and measurable.
Fewer children, colleagues, would be professing to have left lunches at home that were never made. Fewer people who hold down jobs but are among the working poor would be encouraged to slip into welfare. The self-employed and farmers would be protected, as they are not now, when their luck was down and not left out of the larger family as they are now.
Let me summarize. Social policy is public health policy. According to Statistics Canada, and I quote: ``. . .in 1996, 23 per cent of years of life lost for all causes to age 75 in Canada could be attributed to income differences.'' Poverty is bad for your health. According to research by Dennis Raphael, professor at York University's School of Health Policy and Management, children who live in poverty have higher incidence of illness, death, hospital stays and injuries, more mental health problems and lower levels of school achievement.
Canada does not have an official definition of poverty. As a result, by the measure of the Fraser Institute, which uses an awfully meagre and far too narrow ``basic needs'' approach to poverty measurement, we have more than 1.6 million Canadians — hundreds of thousands of whom are children — living in serious deprivation. By the measure of the Make Poverty History campaign, almost 5 million Canadians live in poverty. Whichever measure is used, poverty is increasing for youth, workers, young families, immigrant and visible minority groups. Poverty among Aboriginal groups, as was mentioned earlier, remains appallingly high both on- and off-reserve.
All of those poor Canadians will get sick faster and stay ill longer. They will be subjects of interest for the police, courts and prisons far more than those not in poverty. They will likely be users of drub rehabilitation centres and substance abuse services far more than others. They will be more likely to contract HIV/AIDS. They will be abused and will abuse more than others. They will have shorter, more painful lives, and their children will have diminished prospects with lower literacy and educational attainment passed from parent to child.
While thoughtful yet cautious bureaucrats may use the priesthood of complexity to protect the theology of inertia, also described, by the way, as tiny steps in a myriad of constructive areas without any particular intensity or focus, we should not let ourselves be seduced by that.
A clarion call by this committee to use a negative income tax as part of an integrated population health strategy will be of huge value and real import. In the end, poverty, which is so often at the root of illness, family violence, low literacy and reduced educational attainment — all of which also contribute to shorter lives, more illness and disability — actually is about simply not having enough money.
When you go down to the causal root, you get deferred into the benefits for future generations. Those fellow Canadians suffering now just get left off the list, and we have done a pretty good job of that as a society.
Our present welfare and multi-program, multi-level piecemeal approach assumes, because it is based on the old notion, that there is a moral weakness to poverty that the system dare not tolerate without putting people through some tests. That is absolute Victorian piffle. Poverty is not, as some academics argue, a condition to which one can respond through a broad range of educational, health care and community service instruments, all of which have equal value or impact, or value or impact we cannot measure for generations.
People who are now poor will die poor, or in prison, or from domestic violence, or earlier than necessary from disease while more complex programs are being designed and shaped.
The best way to deal with poverty and its impact on public health is by bringing those beneath the poverty line above it. This can be done directly and simply, so that they can benefit from full access to the economic mainstream with all the personal, health status and personal benefits that we know will accrue when people are living above the poverty line.
I thought I would make this small, non-proactive intervention and invite whatever discussion and personal attacks it might otherwise suggest.
Mr. Lewis: Thank you very much. I would imagine that if I said, ``Raise a hand if you have a response,'' we would be doing group exercises, but feel free.
Participants, I just want to remind you that we want this day to end up with concreteness and suggestions. Senator Segal has made a number of suggestions, as well as a diagnosis. You are quite happy to have additional diagnoses. You may want to take issue with anything anyone says, but the conclusion of your intervention should be: ``Therefore, I propose that we do this.'' That would be very helpful to start building the inventory.
Ms. Bégin: I do not want to pit one eminent, remarkable senator against another. I admire the work of them both, and I have no idea of the politics of their concurrent committees. In the notes that I have distributed for this afternoon I have not touched guaranteed annual income in the work of Senator Segal's committee. When I discovered that months ago, I was very excited.
I must say with humility that I am biased. When I became the Minister of Health and Welfare in 1977, I thought I would be the minister who would implement a guaranteed annual income for Canada. There are many different techniques and I am not an expert on that. I discovered three months later that, because of the recession, I would be lucky if I could save the best of the past, which was not very glamorous.
Politics is the art of the possible. I know that intellectually the ideal is a federal-provincial-territorial, real workable approach to the constellation of social determinants of health. However, I cannot assess at this time in Canadian politics which theme or recommendation will work best. I cannot easily portray a future for the comprehensive approach to life, but it may have an immediate future.
If the federal government with the help of the provinces could adopt the guaranteed annual income concept, I think it would be an extraordinary boost to the social determinants of health. This is because politics is the art of the possible. This is one huge piece of social determinants.
When I did the Child Tax Credit in 1978, I discovered that some social reforms have a capacity to satisfy and appeal to both the right and the left in cabinet, and that worked in favour of the Child Tax Credit. There was no demand; we created it from the remarkable research and planning branch of my then department.
In the same way, I am absolutely sure, not from an evidence base but from knowledge, intuition and experience, that the guaranteed annual income will do that. It offers control. You have elegantly pointed to some right-wing, good aspects of it. It offers control, efficiency, and a choice and respect for individuals, et cetera.
It has an additional extraordinary dimension. I had lunch in the Parliamentary Restaurant with Noel Starblanket, who I believe was then the head of the National Indian Brotherhood. He was pragmatic rather than dogmatic. He decided that, because the income tax form must be used to deliver the Child Tax Credit, which was the first attack against the virginity of the income tax system, of which I had been the minister previously, he agreed. Now Aboriginal mothers file a very simple, one-page income tax form. We all know the historical opposition to the tax system under Aboriginal privilege or social contract. This easily makes them part of it. For me, that addresses the question of the situation of urban Aboriginals as well as those on reserve, et cetera. In case you think I am not in favour of it, I am.
My dream is that the two subcommittees somehow form a coalition. I am not in a position to assess the politics of it, for obvious reasons. I have red shoes today.
Senator Segal: I have a brief point of information for Madam Bégin's edification.
The Minister of Human Resources and Social Development, Monte Solberg, has indicated that his department is prepared to put out a working paper on the issue; just a working paper, not a white paper, but a working paper to discuss the pros and the cons. Therefore, I would argue that implies a measure of promise without anything else at this point.
Ms. Bégin: I totally forgot one key issue. Since my years in government — which is a long time ago I realize — things have not changed structurally. A big challenge and object of discussion with the provinces of the guaranteed annual income approach is that it roughly doubles the catchment area because the causes of poverty, like unemployment, disability or this or that, are no longer in question. The cause does not count, which is great, but it multiplies the catchment area because it means all those whom we call the working poor, and that is great.
Armine Yalnizyan, Senior Economist, Canadian Centre for Policy Alternatives: It is a great honour to be here. This is a remarkable group of people and I am daunted by actually weighing in on this topic at all, but I feel that I must.
The presentation that you have provided, Senator Segal, is passionate, succinct, and entirely compelling, and poverty is about not enough income. In fact, the lack of income is about poverty being about not enough everything; not enough education, not enough food, not enough decent housing, not enough places to play, et cetera. We know that poverty is about not enough in a variety of things. It is really important to know that across this country four jurisdictions are dealing with developing comprehensive poverty reduction strategies of which income improvements are only one element.
Three federal parties have poverty reduction strategies on the go. There is a parliamentary committee in the House of Commons that just started meeting last week to talk about what we can do about reducing poverty. Income is but one of a handful of things. There is also housing, access to health care, access to education, and making sure that children are not left behind all over this country. This is an important element that incomes can help address, but you will never be able to supplement incomes to keep up with the soaring housing markets.
You can get money in one pocket and it will come right back out the other side in terms of the increased costs that are being driven for many people, and it is not just about the extreme poor. It is urgent that we act on what is happening to extreme poverty. More and more people are being sucked up in this squeeze play where incomes are stagnant and the costs of the basics are soaring.
As you have pointed out in your speech, this is something we must consider for the next generation, for the newcomers in our midst. There are some serious issues we are dealing with that will accelerate health disparities, not least of which is an increasing demand for two-tier health care, which puts access to primary health care out of the reach of many people.
As an economist, I want to also address your comment that governments cannot do everything, they certainly cannot do everything well, and that there is an issue of scarce resources. How do we actually allocate the money we have available?
Mention has been made that guaranteed annual income is an idea that has reappeared on our public policy firmament, as Madam Bégin has pointed out, many times in the last few decades. Not for the last 15 years or so, but Doug House, from the Government of Newfoundland, was the last iteration of this in 1993 where the guaranteed annual income at that point would be roughly $3,000 per adult and $1,500 per child.
Previous to that was the McDonald commission in 1986, which was roughly of the same order, that is a guarantee of poverty. If you are going to spend all your money in that direction it would be difficult to then — and the Macdonald commission indicated — be able to do this. You would have to roll up every other form of income support, which is highly problematic, as you can imagine, from a public policy revolution point of view. You would not be able to address the fundamental issues like housing, health care, education, how we welcome immigrants on whom we are going to be entirely dependent in the next generation.
The Caledon Institute of Social Policy has suggested one way of reducing poverty amongst families raising children is to enhance the Child Tax Benefit. That benefit was introduced in the 1970s and wholly enlarged in 1993. The cost of that single measure would be $4 billion a year, which is a pretty hefty price tag, and that is only for families with young children. Therefore, I do not know what we would do about the rest of society where, for example, the highest rates of poverty is amongst single men, living by themselves, between the ages of 45 and 64. What does it mean to eliminate poverty and what is the price tag if we are only going to do it through the income lens?
The title of this session is Reorienting Government Policy and, indeed, there seems to be something blowing through the land that is starting that process. You have two senators from two other Senate committees, one on rural poverty, one on urban poverty sitting at this table. We are kind of rowing in the same direction. The federal government has actually put in its budget that this is the year that the government will adopt an action plan for women. Around the world that means reducing the vulnerabilities of women and often addressing the feminization of poverty.
Indeed, there is a momentum that is building, and one of the things that will have to come into play is how we are spending our scarce resources. To provide a thumbnail sketch, in the last decade, between 1997 and projecting to 2013, our federal government has allocated $340 billion of our resources to reduce taxes. The OECD indicated about six weeks ago that that tax cut program has redistributed incomes towards those already most affluent.
Yes, there have been government priorities, and yes there have been scarce resources, and they have been directed in a particularly strong direction in the last little while. I do not think we can afford to simply say income is the only solution to poverty. We know that is not true and we know it will be like the tail wagging the dog if we put all of our eggs in that basket.
With due respect, I would urge us to consider the huge political momentum that is building across this country to address poverty in a comprehensive manner and that indeed would address the determinants of health.
Mr. Lewis: Of the four provincial initiatives, would you describe any of them as a model or a beacon to take more seriously than the others?
Ms. Yalnizyan: The one in Quebec is already underway. The one in Newfoundland is in the development process. The one in Ontario is an inter-ministerial initiative, which acknowledges that the root causes of poverty are happening in the labour market, incomes, housing and education. In each one of these jurisdictions, there is not a bullet measure. It is taking a look at the comprehensive nature of it, which we have not done since the 1960s.
Debra Lynkowski, Chief Executive Officer, Canadian Public Health Association: I would be hard-pressed to argue in terms of the importance of poverty, but I do want to address some of the issues and options we have in the paper.
I have been involved in a lot of different tables over the years where we have talked about inter-sectoral collaboration. One of the things that has always been impressed upon me is that we often talk about it but we are talking about it to ourselves. There are usually a number of health people around the table. We are dealing here with a really complex systems change. We have to find a new kind of leadership model.
In my brief experience in government, there was not a formal mechanism as such for integrated policy development where we could actually look at some decision making. There was a lot of good will with many departments coming together, but we still tend to use this language that to me is a barrier.
We say how will we influence transportation, how will we engage them, how can we ensure compliance, as opposed to saying how will we get them to lead jointly with us. That does go back to some really sound change management principles in terms of articulating what is in it for them; not only from the health perspective but in terms of what is in it for them within their own departments and within their own spheres.
I notice that we are talking about perhaps the need for a federal framework or a federal strategy. I have been involved with a few of those. For this to be successful, it has to be considered a strategy of strategies. Senator Keon, that goes back to your point that somewhere between here and there is how it will succeed. The leadership has to come not only from the federal government — and I believe the federal government has a key role — but it has to come from the bottom as well. That is the only way this is going to work. Some of that cannot be prescribed. Some of that is very organic. You either have champions rising from local and community initiatives or you do not.
I have a bit of a plea. Traditionally population health has been seen as a public health system kind of initiative. I think that public health deals with population health, and yet traditionally public health and the public health system has been chronically underfunded. We know there are health human resources issues. We are lucky now to have the Public Health Agency of Canada and our CPHO, but if we are going to really re-orient government policy we also need to make sure that the infrastructure is there to actually support the implementation of that policy. That does mean sustained investment, not for a three- to four-year period but for a much longer period where we can actually ensure that happens.
Ms. Potvin: I have two or three ideas. First, I think this is an idea that should be pursued. There were studies and experiments completed with negative income tax. There is a wealth of knowledge about it, and it accomplishes some of the goods that it delivers on those aspects. It is important that it could be a flagship type of program, but that should not be the only thing to happen.
One of the things that you did not mention and that our studies in Montreal have shown using the Quebec birth cohort is that poverty is not something you are in or out of. You are in and out. The various trajectories into poverty throughout early childhood are what our data is showing. Early in and out of poverty is what is detrimental towards children's development. In my opinion, the most interesting outcome of such a measure is to eliminate this transience. That is one of the good outcomes.
Less interestingly, however, and from a population health perspective — and Sir Michael has been quoted here — it is also the gradient. Such a measure does not do any good to the gradient, or does marginally well by addressing the needs of those at the bottom.
Of course it has some effect, technically, upon the steepness of the gradient, but one of the reasons why Canada was doing poorly in that international comparison is because our gradient is steep. It is much steeper than the gradient in the Nordic countries, for example. Therefore, such a measure does not do much; it only has a very marginal effect on the gradient. One should be aware of that.
This is what I would call a vulnerable approach. You tackle one dimension of vulnerability, and poverty is a dimension of vulnerability. Being a woman is also a dimension of vulnerability and being an Aboriginal in Canada is a dimension of vulnerability, but I do not think poverty is the mother of all vulnerabilities. It is certainly a very important dimension, but we will not solve the problem of population health in doing that. It is certainly one important piece to the puzzle, especially to the extent that it would address health issues in young children during development.
Mr. Lewis: Senator Segal is proposing something analogous to cutting the tail off waiting lists. You want to cut the most disadvantaged tail off the population. If you eliminate poverty, in and out is not logically an issue anymore. You are never in it.
When you come to a prescription, there is a gradient, and nobody anywhere in the world has figured out how to get the middle class as healthy as the upper middle class and, frankly, nobody cares much because it is not steep up there. It is shallow.
Are you saying implicitly that you worry about this approach, or that this approach explains 20 per cent or 30 per cent of it?
Ms. Potvin: I would say that it is an interesting approach. It is the first building block, but it will not accomplish everything that we want to accomplish, which is to pull Canada up towards the healthiest or the one of the healthier nations in this world. I am convinced that it will help some, but what is happening? We have interesting data about what is happening at the poverty line.
We do not know much about what is happening with those who are in and out. We do not know very much about how their circumstances affect their lives. If you make up your mind that you will not have breakfast most days of your life, it has a different outcome than if suddenly you cannot have breakfast for three months because you are too poor and then you can have breakfast for three months because you can afford it.
We do not know much about what is happening there. We do not have many studies, which take huge numbers. In Canada, we do not have a panel cohort that we can follow through time. My advice is that we should go for it but not expect to accomplish everything with it.
Mr. Lewis: Would anything do better? I am not trying to put words in your mouth, but I think Senator Segal is saying that we cannot solve the whole gradient; the biggest problem is poverty. Therefore, the best thing we can do is to solve that problem. Are you saying it is not the best thing we can do?
Mr. Tholl: I am not an expert on poverty, but what I observe is that if you want to draw an analogy between health care and health, as we pick up on Mr. Lewis's point, when it comes down to managing wait times, you have a concept of relative medical necessity that ought to drive who gets access to what first. I observe that there does not seem to be a discussion occurring here about relative poverty versus absolute poverty and what happens if you move everyone up.
My point is with respect to what I detected from Senator Segal's passionate and persuasive argument. I detected a need to focus on a few things and try to get something done in a few key areas. I go back to your comments before the break about the children and commend to the committee that we ought not to allow Dr. K. Kellie Leitch's report to gather dust when it comes to issues around early childhood development, child and youth. We should listen to her recommendation for establishing a senior officer in the ministry of health or straddling health and what used to be welfare.
That might also be an interesting thing to consider. Why did we separate health and welfare if we are interested in progressing health determinants? As a historical point, we separated Health and Welfare on exactly the same day as we brought together all health and welfare transfers under the Canada Social Transfer. I am sure that was coincidental. I do commend to the Senate committee the Kellie Leitch report in all its parts but, in particular, as it relates to this office for child and youth.
If the Senate committee manages to focus on a few discrete things, the strategy needs to be a combination of two things: A push strategy, which includes all the normal advocacy stuff. I am reminded, Ms. Bégin, when we were back at Health and Welfare Canada in the late 1970s and early 1980s when you and others created the political need to move our health care system forward with an SOS medicare conference in the fall of 1979. Where is that burning platform, that gathering place where people will focus on the few things that can be done in the lifetime of people around the table?
On the pull side is the enabling part. What can you do to help parents? I am struck by Ms. Browne's comment about the effects of early addictive behaviour on the health of young children. What can you do to help those families in tangible ways? One without the other, as someone recently told me, is like basketball and being able to dribble with only one hand. You need to be able to dribble with both hands. In the Canadian context, you have to be able to stick handle and shoot the puck both ways. My point is that pull and push forces will be required.
Mr. Cappe: It is true that poverty is about not enough income, but the solution to poverty is about more than just more income. I think that we do need to look at this more broadly, as Ms. Yalnizyan and Ms. Potvin were saying.
With that said, I think that this is a noble effort and should be pursued. In particular, I want to underscore two of the arguments that I think are most trenchant that will bring political support to the public but also federally and provincially. That is the cost of inaction. I do not think we spend enough time, and Senator Segal did refer to this, looking at the costs of not doing it. We know what the costs of doing it are, at least it is relatively easy to identify. However, the costs of inaction are very difficult.
The second argument that is important is the intergenerational argument, that we need to break the back of this for the purpose of the children of poor families so that they are not destined to bad health and bad economic outcomes and more poverty.
It is interesting that Ms. Manson Singer, Ms. Yeates and I spent endless hours in federal-provincial meetings and endless telephone calls working on the National Child Benefit. It was very painful. It was a no-brainer, but the mechanisms of delivery were very complicated.
I remember having to deal with the Deputy Minister of Finance of the day, who is also in the room, trying to resolve some of the technical implementation issues that were bloody tough. We have two former deputy ministers of finance in the room. Do not underestimate the implementation mechanisms and how complicated they are. The incentive effects, the tax-back rates and all the stuff that goes into how you actually structure it are bloody tough.
I come to a very important initiative, absolutely essential and worth doing, which is to take the long-run view. Here I will fall into Senator Segal's trap of proving my background with, what was it, the hymns of further study and the religion of inertia for bureaucrats or something like that? I think what is required is much more analysis of the technique and the how-to.
I want to pick up on Mr. Butler-Jones's point from earlier. This is ripe for experimentation. There is a real opportunity here to see how people respond and whether you can — again, over the long run — bring the next generation out of poverty.
Here is one of those examples where I do not have the evidence to prove the policy, but my intuition is that this is worth doing, and if you get the incentives right, it could be very successful.
Dr. Reading: I just want to begin by talking about global health and how the elimination of extreme poverty has emerged as one of the most important Millennium Development Goals. It is consistent with the thinking.
In his book about the elimination of poverty, Jeffrey Sachs, who is a well-known economist who focuses his efforts on global health, talks about sustainable economic development, which is connected to what I alluded to earlier. He refers to natural resources as part of assets, and I am specifically thinking about First Nations and Northern communities here. When those assets are extracted, they basically remove wealth from a region.
Often in that process there are environmental contaminants that are left behind. That has impacts on future development of regional resources, but it also impacts on traditional lifestyles. We cannot forget that Canada was built on a fur trade. The Hudson's Bay Company and the Northwest Company were the first to trade in this country and built the wealth of this nation state. People still derive part of their nutrition and their foods from traditional foods up in the North. When economic development is undertaken and it reduces that ability through environmental contaminants, it becomes a problem. This is not an abstract concept. It has been proven by Eric Dewailly at Laval University, and other places, as part of the Arctic Environmental Strategy that environmental contaminants are showing up in the breast milk of Nunavut women who breast-feed. That, in turn, results in going to food that is bought in stores which does not have the nutrients that would be contained in traditional foods.
This boils down to assets being reduced. It is important to recognize that, in a model of sustainable economic development, there needs to be an opportunity for Aboriginal people to be players as working with industry and working with the private sector interests to be managing renewable resources. They have a vested interest in the long- term sustainability of those resources. Eliminating poverty as a goal is laudable and extremely important. However, it is not a panacea. It has to be connected to parallel investments in community development.
The final point is that an economic system goes around the borders of Aboriginal communities. When money goes into a community, it goes out of a community immediately to purchase goods and services. Economists have shown that, if you can have money change hands several times within a community before it leaves that community, benefits are accrued each time those resources change hands. However, there have to be investments in economic development for that to take place. The model points to having the exchange go from eight to ten times before the money leaves the community.
I would argue that is what is missing. It is the provision of goods and services at the local community level in terms of distributing resources. We talk about income level, which is extremely important. However, we all know it is the distribution of income and the benefits that accrue from income distribution that are equally important in terms of determinants of health.
Mr. Osberg: I am worried about the ``faint praise'' phenomenon. When I hear Mr. Cappe talk, I think of being in grad school. It was a long time ago that I was in graduate school. However, they were running negative income tax experiments back then. A lot has been learned about this over the many years since then.
Sometimes there is a question of whether we know enough to try to push it through? I would argue yes. I like the directness, the vision and the feasibility of this proposal. I think some of these are faint praise and it comes from the realization that a negative income tax is not only about health and it is not all of health policy. We can have a perfectly reasonable discussion of a negative income tax on the idea of economic equity among all of Canada's citizens, over and above and irrespective to its impacts on the health status of Canadians.
When we think about the health status of Canadians, I do not think Senator Segal is trying to argue that there will not still be some need for some services; some people need training services or rehabilitation services. Having more cash will not solve their need for services. It will, however, make it much easier for them to avail themselves of services and it will reduce the stress in their lives.
You were making this comment about going in and out of poverty and the anxiety that people have in facing the future. You were making comments about anxiety and its impact on mental health and the stress of being poor. There is a huge dimension to the negative income tax that is all about reducing insecurity, reducing anxiety about the future and having a real social safety net that underpins the worst possible outcome that you can anticipate in a reasonable vision of your future.
There are many benefits from it over and above health and by indirect paths to health. I like the emphasis on the feasibility of it. There is the affordability issue, but we move a lot of money around in Canada. Just last fall, we had a series of tax cuts on a five-year basis were costed out at something like $55 billion or $60 billion over five years. None of that stuff went to anti-poverty policy.
The total poverty gap in Canada — the amount of money it would take to raise all poor people in Canada to the low-income cut off — was something like $13.6 billion, in 2005. We have just recently moved around lots of money, enough to solve the poverty issue.
A key thing to remember when we think about anti-poverty policy is this: If you do not have much, it does not take much to make a big difference in your life. The percentage difference in the financial security of poor people, of relatively small-dollar amounts, is huge. Those same dollar amounts are a very small percentage of the income of the top quintile. I refer to the top 10 per cent or, especially, of the top 1 per cent of the income distribution of Canada — who have been doing very well, thank you very much — even as their tax load has gone down and social assistance payments have been cut and the poverty gap has risen as a consequence. There is a need here. I am not a ``faint praise'' type. I will go for it. I like this.
Mr. Dodge: I am pleased to come in after Mr. Osberg, because I think this is absolute nonsense. Let me go back and start at the beginning. I want to start where Ms. Lynkowski started.
Historically, and today, public health is extraordinarily important to population health. We have starved the public health sector for years and years. To go back to Mr. Tholl's words, somehow we have not been able to create the ``burning platform'' for public health. Indeed, one can argue that we have been going backwards on the public health side. It is easy now to forget, but we do not deal with the basics such as clean water and so on. We do not deal with those issues and we have Aboriginal communities where we do not deal with those appropriately.
Environment raises an issue; at least the worst aspects of the real toxic elements of environment. That was why we were there, if you go back to the founding of the Department of Health and Welfare in 1919. However, 1919 raises another very important issue of public health and that is infectious disease prevention. We had a lesson in this country. We are forgetting that lesson very quickly. Dr. Butler-Jones is trying to make sure we do not forget the lesson quickly and get on with it. However, we do not have a public health sector that is very well organized. Pity the poor local medical officer of health in trying to deal with it. I will tell you, far from any negative income tax or anything like that, if we have something really serious in terms of an Asian flu or whatever, that will be the burning platform, all right; we will end in burning.
I think, Mr. Chair, it is extraordinarily important in your final report to start with that basic platform on public health. Much can be done at a relatively low cost — relatively low cost compared to any the health care side of things — to improve the situation. Information is very important because that is what we learned in SARS: We could not pass the information around correctly.
If you are talking population health, your first section had better be get the public health aspects right and remember that this was the traditional role of the department. Let us not abandon that traditional role. Indeed, it is one where federal, provincial and local cooperation can be had. Let me start there.
Second, there has been a lot of discussion here around this table on poverty. We need to be absolutely clear that we do not want to take away from Canadians the freedom to fail. The freedom to fail is a very important thing to have, which Senator Segal would take away from us.
What does that mean? That means you really ought to start with: What is it that will allow kids and, indeed, fetuses, to have the start that is likely to put them in a position to be healthy people throughout their lives? That starts with maternal health and money is not the only answer although it is an important answer.
The second thing is the school system. Once people get into the school system we actually have good ways in the provinces of dealing with them. The great problem is the early childhood side, which is a huge problem. You flagged that yourself, senator, at the start. Clearly, a much-enhanced Child Tax Credit may well be a very important federal contribution to helping to deal with that. Perhaps it can be the best single federal contribution that can be made. I have no apologies for saying Senator Segal is right for family with kids up to the ages of five, six or seven. That can be very helpful in improving that issue. However, it is not the only thing, as we well known. We are learning from research that, if brains are wired badly, it is extraordinarily hard to reverse it later on. Indeed, the more recent work indicates that genetic composition can change your life and that could well be affected by this early period. That does not mean when things go right that everyone will succeed. That is why I said that you do not want to pick up the failures later on; you want to make sure that people get a start. Overall, that would be the best for health.
Senator, you raised the need for a whole-of-government approach. There are many things but if we think of what it is at the federal level that is important and, indeed, in some sense is a whole approach, first, make sure we have a public health system that works and is robust. Then focus on kids in the womb and in those very early years. The evidence is clear that, regardless of income later on, if you have a bad start, you are in deep trouble in life. If you are looking for a focus for a whole-of-federal-government, focus on that very early period and focus on public health.
Mr. Lewis: I want to clarify. If I heard you correctly, are you saying that eliminating formal poverty by raising everyone to the LICO or something with a negative income tax will sap their will to succeed?
Mr. Dodge: No, let me be as provocative as Senator Segal. One of our problems in this country is that we abhor failure. People have to keep trying and there will be failures. There will be communities that fail. We have some Aboriginal communities that are enormously successful and others with higher incomes that are huge failures.
I do not think we should be quite as afraid of failure at that level. However, if people have not had a chance to get started right and then fail, that is a collective problem. If people get started right, some will fail later on — and some communities will fail later on — but that is not so much a collective problem; that is a problem of that community or that individual. However, you have to get the right start.
We know from social science, but increasingly now from biological science and medicine, how important that getting started is. If you need focus — and you do need focus — you have to create a platform. I would submit that the great advantage — but I am not a politician — of focusing there is it is not seen by middle-income people or upper middle-income people as taking something away from them to give to someone else. It is clearly something that is seen as a focus, something that they would focus on themselves for their own kids.
Politically, in terms of involving the whole society, and on the basis of our scientific understanding and from social sciences, that focus right at the beginning will pay the greatest dividends, at least over a generation. You cannot solve all these problems overnight. In the end, it will help Senator Fairbairn's literacy problem more than anything else.
Mr. Lewis: Would not the population health researchers tell you — and they can tell you directly — what you suggest to focus on is exactly what we have focused on? We had the early comprehensive childhood development programs from the 1990s. We are focusing more on public health. We have the Public Health Agency of Canada, and they would say you cannot help the kids if you do not help their families. It is the context of the parents that influence the kids. Are you saying that this is palatable because it does not involve the kind of redistribution that you have in mind and it is politically sellable?
Mr. Dodge: No, it redistributes to a place that every middle-class person would feel is important.
Mr. Lewis: What if they are wrong? What if the middle-class view of what is acceptable redistribution is not effective?
Mr. Dodge: The science says that is where we should go. Follow the evidence; the evidence is very clear.
Ms. Manson Singer: Let me reflect briefly on some of the evidence from our foray into the National Child Benefit, to which Mr. Cappe has already referred. British Columbia implemented a national child benefit a couple of years in advance of the NCB and we were able then to look at what happened in terms of the population and what made a difference.
The first thing that happened — and it was actually much more exaggerated than any of our expectations — is that people flew off of welfare. We had a reduction of over 40,000 kids on income assistance in the first year that it was implemented.
The other thing we underestimated was the direct economic benefits to communities. My colleague in finance came back to me and said, ``Our sales tax revenue is up in all of these cohorts.'' I said, ``Yes of course, because when you match our welfare records to where we are spending the money, there is a significant payment going into those communities.''
Poor people do not save their money, they spend it. As a direct consequence, there was quite a lot of direct economic benefit to the province. The benefit did not cost as much as we had estimated and although it went out the front door looking like a very large sum, it came back to the province in many other ways.
The point around the investment in terms of reducing poverty for children, and the way we have done it through the National Child Benefit, does not answer the questions or the need for a comprehensive early child development strategy that is directly targeted at young children and their parents. Even with those amounts of money that I may gain as an individual mom, with that small amount of gain, I cannot create the conditions that are necessary to foster this kind of caring, collaborative community that will really make a difference in terms of my child's health and my ability to parent that child.
I do not think we can say it will solve the problem. Also, many would say that it costs a great deal more to do it and it will strip out all of our other social programs. I do not accept that argument because it flows back to the country and provinces in different ways. However, I do not think that we can answer the problems of public health and raising healthy children with simply doing it through income redistribution. We need a parallel strategy that will be going there; otherwise, we are in danger of thinking we have the solution whereas, in fact, we have not.
We can point to one-size-fits-all approaches — for example, our whole progress on deinstitutionalization. I remember all of us putting our hands up and saying what a wonderful idea. Of course, now our communities have a great deal of difficulty in dealing with the consequences of it.
I think it is an important idea. We have had good evidence with the National Child Benefit of how that has made a difference for families, how it has redistributed money. However, what has been more important is that the agreement Canada struck with the provinces was to ensure that the reduction in their expenditures was reinvested in four pillars of development that were really important in work and training for families on low income, but also in early childhood development.
Those kinds of structures and frameworks, where provinces can choose how to reinvest within three or four broad areas, are essential. If the federal government cuts a cheque and does not hold the provinces accountable to reinvest those monies saved into something that is much more productive, on early childhood development — I am with Mr. Butler-Jones on this one, and with many of you in this room — then we will see merely cutting off the tail of the distribution without any of the supports that are necessary to create the conditions that will enhance the ability of children to grow up in a healthy and contributing way.
We had coined a phrase about this some time ago, that it was really about population prosperity. In order to have a population prosperity approach, you have to invest at the front end. You will see definite returns on your investment and a population that will become much more prosperous than it is now.
The Chair: Can I tease this out a little bit? A concept that we are struggling with in coming up with the report is the distinction between parenting and daycare. Daycare is for the benefit of the mother, but what is needed for early childhood — wait a minute — you can all join in the dance but I want you to educate me first. I want this teased out. Early childhood development is dependent on appropriate parenting, is it not?
Ms. Potvin: No, that is only one item.
The Chair: If appropriate parenting is missing, I am told that warehousing a child will not produce a good human being.
Ms. Potvin: Do not listen to those people.
Mr. Cappe: We need the professionalization of child care, because child care should not be just warehousing. The professionalization of it becomes an issue.
Ms. Potvin: Early child development is the key issue.
The Chair: The reason I went to Cuba was to observe this system. There, grandparents can get a BA in early childhood development because the parents are working and do not have time to participate in the development of the child. The grandparents substitute for them. They have superb daycare, do not take me wrong, but it is much more than daycare.
Ms. Manson Singer: You are absolutely right. Early childhood development is a very important component of a child's early start and can help to determine how that child will contribute to Canada. I would caution the idea about warehousing daycare — a lexicon that we tried to get rid of — because many parents need child care during the night time and on weekends. There is a way of thinking about daycare as being from 8 a.m. to 4 p.m. Monday to Friday, which is not what we need in this country.
The conceptualization of child care often depends upon where it is located within ministries. For example, if it is in a ministry of human resources, it has a labour market focus to help parents to get to work. If it is in a ministry of education, it has a focus on early child development ensuring that there is a good bridge between zero and readiness-to- learn. If it is in a ministry for women's equality, it has a distinct focus on ensuring that women have equal positions. We need to rethink that way of dealing with child care. We agree with you that there are significant problems when you try to dissect what it all means.
An early child development approach to child care is a comprehensive approach to ensuring that the best conditions for a child to grow are present. That means many more things are in place beyond just good parenting. It is the conditions to maximize the development of that human being. What are those necessary conditions? We come back to the list of determinants of health. Within our early child development approach, we need to focus on all of those determinants to ensure that we have an enabling condition to result in population prosperity.
Ms. Potvin: It takes a whole village to raise a child.
Ms. Manson Singer: Was that helpful?
The Chair: That is just what I wanted to hear.
Ms. Potvin: Interesting data have come out of Quebec on that point: The quality of daycare. The public system daycare seems to be of the highest quality in Quebec. Daycare quality can help poor kids to overcome some of the disadvantages that they have at home. This one redistributive measure directly affects childhood development globally and on a population level.
Mr. Cappe: On this point, Fraser Mustard talks extensively about abuse and neglect and neglect is one of those great problems. It can occur in the home as much as anywhere else. In that sense, a more professional developmental child care system can have this huge effect on population health.
Ms. Potvin: We emphasized that point. When we looked in British Columbia at readiness to learn as being a marker of how well our children were being cared for, the real problem was not in the tails of the distribution but was in the middle. We saw significant problems in children's readiness to learn among the middle class. This was very much a problem in terms of thinking how to use redistributive efforts to solve problems of readiness to learn. We had to look at a much more comprehensive approach in order to ensure that we were working across the population.
Population health from that perspective requires a holistic approach to the population, such that we are providing those kinds of resources and support across the population.
John Wright, Former Deputy Minister of Finance and Health, Saskatchewan, as an individual: I hate to pull this back to the negative income tax but I will, which, on the surface of it, looks like a great idea. Simplicity is next to godliness — the go-big-or-go-home strategy. It is leadership at the top; wonderful. There is only one little problem that Mel Cappe raised: the quagmire of federal-provincial relations. There is one population in Canada that is the responsibility of the federal government; that is the First Nations. What a wonderful incubator to test this out. What a wonderful idea: Put in a negative income tax for First Nations and let us see how it goes. It would move the agenda forward and we could learn from our mistakes and successes. I am not sure how it will address little issues like the lack of public health inspections on-reserve, or the housing situation on-reserve, or the quality of water on- reserve, or the lack of an immunization strategy on-reserve, or literacy issues on- reserve, but you have to start somewhere, so let us start there.
Mr. Chair, I propose, therefore, that the negative income tax proposal be adopted and applied to First Nations individuals in this country.
Senator Segal: That is a very intriguing offer. I have, on several occasions in this very room, the Standing Senate Committee on Aboriginal Peoples proposed winding down the Department of Indian Affairs and Northern Development, which is an abomination and an embarrassment to our country, and distribute the cash, plus legitimate mineral resources, on a per capita basis to every Aboriginal. I made that proposal not because of where they live but because they are a First Nation and we owe it to them. I am delighted to start there. Nothing would make me happier.
The comments and the criticisms today have been extremely constructive and helpful. Ms. Yalnizyan, if we were to begin by looking at the design of the income flow from a negative income tax, what elements would have to go into it? Maybe of the issues that you raised would have to be addressed in that mix or it would not be a legitimate design process.
I accept Mr. Cappe's comment with respect to the technical quagmire. We are not making progress with the $140 billion we have spent on an annual basis as of 1990-96 on aspects of our social service program. The numbers are not getting better.
Am I in any way in favour of diminishing support for housing or for the handicapped or for the intellectually disadvantaged? Of course I am not. A point for consideration: Mr. Wright's proposition is an interesting place to start. If we do not at least deal with what we can deal with as directly as possible, we will find ourselves around a similar table in ten years time wondering what we will do about the impact of poverty on public health.
I say to my friend Mr. Dodge, let us be clear: Some people have taken the view of freedom to fail. You did great things for the bank; I just hope the bank did not contaminate you.
Winston Churchill said in 1946, at a meeting of his party that, while he was against any limit on what people can achieve, there must be a balustrade under which no person is allowed to fall. That terrible, left-wing fascist, Winston Churchill, said that; and Disraeli said the same thing. Even Richard Nixon, Tommy Douglas and that radical left- winger, Bob Stanfield, all suggested that the freedom to fail has to have a limit because the cost we all pay when the failures are too intense, even for short periods of time, are too destructive of our values as a society and as a Canadian family. That is the only case that I make. I am not suggesting it should replace learning from the report by Justice Archie Campbell, Chair of the SARS Commission and all that we have to invest. However, I am suggesting that it might be one place to start. It is nothing more comprehensive or exclusionary than that.
Dr. Butler-Jones: This is a fascinating conversation, I must say. Obviously, I am not an economist. I have a long family tradition of buy high, sell low. It is probably a good thing that I am not allowed to invest directly in my job.
I want to make a couple quick comments. I will come back to where I started. Again, it is about balance. Much wiser people would say that real learning rarely comes from success; it comes from failure, but not devastating failure. Therefore, we have the basic concepts: What are the public goods? What is the level playing field? It is an important conversation about where that is and how you do it.
It is really good for me to hear conversations again about guaranteed annual income, what it would mean and do. That is an important debate to which I cannot contribute much other than to note the importance of the debate.
We are making some small progress on early child development. We are learning more, but again, there is small progress. We are far from being there. Issues exist and others have articulated them better than I can.
What I was trying to get at earlier is that it is not the action or the decisions about where you put your money, it is the thinking that has to be comprehensive in understanding the dimensions of poverty or the determinants and how they interrelate. If we think of them in isolation, and we have seen in this social policy, we risk doing more harm than good in terms of the incentives, motivation or people's sense of control over their own lives.
We have also seen this in public health when you think about chronic disease prevention. It is the eternal debate about whether we do large population approaches or specific high-risk population approaches; neither of which does it alone. The debate is around the balance that will provide the best outcome in terms of health and the smallest gap between them. For instance, people at any age, male or female, who are well connected with family and friends, have one-half the risk of dying than those who are poorly connected independent of income and everything else. If we are not allowing people to be engaged or encourage engagement in civil society, then we will miss it. There are political and policy dimensions around how much we do. My only appeal is that whatever actions we take should be in the context of thinking about how it all fits together.
Senator Eggleton: I like Mr. Dodge's thoughts about the first priorities. The first priority is getting the public health issues together and dealing with early childhood development.
When we talk about early childhood development, we need to shift more of the focus towards early learning or education. The public thinks it is primarily a responsibility of parents when we talk about child care. However, education is part of one's rights in society and it relates to the development of society overall. We need to focus more on early education. Yes, parenting is important, but so are the other elements that go into it in terms of early childhood educators.
I also want to address Senator Segal's intervention. First, I have an open mind on it. Obviously, it has appeal to it. Those of us dealing with the poverty issue at the Senate are grappling with different ways to deal with it, and Senator Segal's is one solution. It has been around for a while. Senator David Croll first mentioned it in his Senate report back in 1971. Senator Cohen and others subsequently have also touched on negative income tax.
The only way this would work is if it were done in concert with the provinces in terms of addressing the total picture. There is the question of affordable housing. There is the question of early childhood development. There are so many other aspects and elements that are part and parcel of it. Income support alone is not enough. There has to be this broader picture. I would like to see how this will all fit together.
I will get a little political here for a minute, because I have a concern. Senator Segal says, well, Monte Solberg is interested in doing some work and study on this issue. I think that is good. I would be more interested in knowing what the guy in the front office thinks about this because, ultimately, we hear that is where all decisions are made. However, this current government has more focus on the particulars of the constitutional division vis-à-vis the federal government and the provinces. It has the philosophy of less government is better government. Therefore, I wonder in all of that how much attention will be paid to pulling all these pieces together since many of these pieces are and would continue to fall in provincial jurisdiction.
If a negative income tax is implemented, it has to be looked at as a whole package. How much interest would there be in that given the government's direction? At the end of the day, would this be a method of simply washing its hands of the whole thing? Put in the negative income tax; that is income support; we will do that; we are federal. Now go away, provinces, you do your own thing. I know you do not think that and I would hope that would not be the case. However, anything you could say to overcome that political suspicion I have would be helpful.
Mr. Reading: The issue of public health is extremely important. I think Dr. Butler-Jones talked about correlation and causation. When we model health and wealth, we come up with a linear pattern, but that distribution is not perfect. There are points above the line of identity and points below the line. That means some communities at an equal level of wealth are more resilient than others. Income alone is not the only answer.
Issues around culture and community readiness are connected to this concept of resiliency. That focus is something where we look at promising practices. We look at community development projects that have achieved a level of success and how we model that in the context of improving income.
When we talk about fixed income in the context of Aboriginal and Northern communities, we have to ask ourselves what the cost is of an essential basket of health determinants in these circumstances that are different from our own. We could look at the cost of adequate food, water, housing and education and apply a certain amount of money to that. However, we know the cost and availability of this basket of essential services varies a great deal across the country. We have to look at a means test in filling that basket with what we consider to be the essential things that would optimize the developmental trajectories of children as they progress through the life course.
Data presented from CIHI showed an 11 year gap comparing the life expectancy for men between Nunavut and British Columbia. That means children will have a life expectancy of 11 years less than other Canadian children will if they happen to be born in the part of Canada called Nunavut. That is less than what male children in Turkey can expect which is a middle income country. That is a severe problem for Canada. I would say it is connected to double jeopardy. It is connected to the fact that these communities have to pay more for what I call this basket of essential health determinants and they have fewer resources to pay for them. It is not as simple as applying a national minimum requirement saying we will take everyone out of poverty. There are community circumstances that are different and the cost of creating a level playing field will be different. That holds true for other circumstances as well.
Ms. Yalnizyan: There is a reason to row in the same direction where so many committees and various governments are going. I echo what Mr. Dodge has said. It is easier to talk about what is happening to kids than almost any other group. You could affect a huge swath of Canadians. Forty-seven per cent of Canadians live in households raising children under the age of 18.
If you want to do a negative income tax, the Canada Child Tax Benefit is there. It is in place. It brings lots of people forward. You do not need to reinvent the wheel. You need to augment the wheel. However, as we said over and over again, income supports are not enough to deal with either poverty or with the determinants of health. There is a committee chaired by Senator Eggleton that talks about the critical nature of housing. This is something the federal government played in between 1948 and 1993. It is time to get the feds back into the game.
We keep bringing immigrants into this country to deal with the critical labour shortages. They come to the largest cities where there are already housing shortages There is no way those municipalities and provinces can deal with those pressures without some federal vision connecting the need to bring people into the country and where they will live when they come here to help us with our labour shortages.
There is a large federal role in housing, early childhood develop, income support. However, I do not think you can parse it out and say this is the magic bullet.
The Chair: The clock tells us we have to suspend for lunch. I want to thank everyone for the very candid conversation this morning. It has been extremely helpful. We have gleaned a great deal already and we are looking forward to this afternoon.
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The committee resumed.
The Chair: Honourable senators, guests, ladies and gentlemen, we will begin the afternoon session now. I hope it is as interesting, productive and animated as this morning was, because we are focused on some of the issues we need to address.
Again, I turn it over to Mr. Lewis.
Mr. Lewis: Thank you, senator.
This afternoon we hone in on, in a sense, the broader small and the political agenda for a disparities reduction initiative. How do we galvanize more support for this initiative? We have not talked much about the roles of sectors other than government sectors, but there is obviously a non-governmental sector, a private sector, and citizens to engage with this issue.
Hence, we asked for two presentations from people who have lived in different sectors and who have taken a long, hard look at some of these issues. We hope they will enlighten us as to how some of these cross-sectoral partnerships might be built.
We will start with the Honourable Monique Bégin, and then move on to Senator Art Eggleton.
Hon. Monique Bégin, P.C., Commissioner, World Health Organization Commission on the Social Determinants of Health: I learned late yesterday that Ms. Yeates would use that beautiful Powerpoint presentation, which I could not emulate because I was attending meetings and then a conference at night. Before midnight, I quickly wrote down some points, more for myself, and I have already changed some of them in my head. Of course, it is pretty dirty to ask a Liberal to speak about the politics of today. I will do my best in terms of eternal truths about politics.
I will start with how social change occurs. For decades, I have been interested in that issue. It is now known that social change occurs both from the bottom up and from the top down, and it usually starts at the grassroots level. Cause X, Y, or Z finds at one point a champion at a high political level. That is the history of social change; for instance, the civil rights movement in the United States. It is documented in the past and in the present all over the world, as a general rule. Of course, someone will come up with an exception, but that is the general rule.
The demand from the grassroots or civil society — whatever name we want to use — for addressing the social determinants of health, in my perception — which is that of a learned citizen but not of someone from within politics, government, or any decision-making body — is not visible in Canada these days. The demand may exist, but it is fragmented and, in my opinion, unidentifiable for the political order at this point in time.
However, there is a long-standing tradition in Canada of demanding what amounts to policy along the lines of social determinants of health, but the sector does not call it social determinants of health and does not feel comfortable at all with that labelling.
I did not discover that by myself. It is thanks to the leadership of the Canadian Reference Group set up by the Public Health Agency that we consulted some civil society NGO groups, and that message came out loud and clear.
Most civil society NGOs in the field of social justice, social planning, and all social advocacy — anti-poverty, status of women, public housing and I could name many more — which are all pieces of social determinants of health, have recently seen their federal grant contribution or assistance reduced or cancelled. Lack of funding limits enormously their capacity and it even prevents them from any networking or joining of efforts vis-à-vis a certain initiative.
Moving on to social determinants of health, we cannot avoid stating that it is value based and value-laden. It is not obvious that the usual themes of social justice or equity would trigger any governmental action.
A business case for the social determinants of health has not yet been developed in Canada. Canada is not the only one that has that problem. Our international World Health Organization, WHO, commission is also struggling with that problem. We do not have a business case to prove that if we invest in a certain area, we save in another area.
However, we have common sense and we have fragmented evidence. For example, Diana MacKay may share with us statistics she quoted yesterday of the cost of absenteeism vis-à-vis the economy and the health care system.
The business case has not yet been developed, and it is essential and urgent. I am stealing words from Senator Keon. Generally, we over-invest in the high-tech medical health care system, which is not sustainable the way it is, and that is the problem of every province and every actor.
The last observation on social change is that it is, by nature, long term rather than short term; and governments are, by nature, the exact opposite.
The federal government has a direct responsibility and mandate for Aboriginals' health and general well-being, both on reserve and in urban Canada. The government has a shared responsibility for housing and, in particular, public or social housing. The government implements income redistribution, regressive or positive — and it has been regressive for years — to individuals through the income tax system. For the last few years, it has benefitted from financial surpluses, and will benefit from surpluses in the coming years, even if they are at lower levels. The federal government delivers entrenched and ad hoc transfer payments to provinces and has a constitutional responsibility of equalization throughout the regions of Canada.
Of course, the federal government will dodge the issue — I do not point to any individual, but it is human nature — on the grounds that health is a provincial matter. It is too easy to do that when we speak of social determinants of health. However, the government should be held accountable for its various federal responsibilities.
The provinces are probably the most important actors. I think if one province begins to focus on the social determinants of health, it would have a snowball effect.
I was interested to hear Ms. Yalnizyan's comments earlier, when she gave us a concrete example from which she concludes that the landscape may be changing. She referred to the Ontario special mandate that Minister Deb Matthews has to fight poverty. I do not know any more about that mandate. It is still in its infancy. The question remains as to how some provinces become involved, from what basis and for what reason.
It seems to me that the municipal and regional levels of government can play a critical positive, although limited, role. At least, I see that at first glance. I started thinking about that role when a colleague on the commission told me about the healthy city programs, which we no longer speak of in Canada but which are alive and well in parts of Europe.
My neighbour has been in charge of the biggest city of the country and may want to comment on what is feasible in regard to housing, urban planning, urban transport, and parks and recreation.
Cities deliver social services in some parts of the country. They can move on their own on many issues with minimum interference of politics at other levels of government. I think there is a space where they can do things and they do not need to wait for their peers to be ready. One city here and one city there can do things on their own that are positive.
The fourth report by this subcommittee offers operational mechanisms or tools for working on social determinants of health at the federal level. Some of these mechanisms have been tried and have failed for whatever reason, for example, national health goals. In my judgment, this mechanism is a failure, as is the Kelowna Accord, which Mr. Reading mentioned this morning.
In my political opinion, these mechanisms will not be revived easily. When the opportunity has been wasted, and investment of heart, intelligence, time and energy has been wasted, people will not be ready tomorrow morning to start again. I flag that situation.
Other such mechanisms have not yielded obvious or concrete results. Here I want to say a word about the famous federal-provincial-territorial layers of committees. I no longer practice that approach. I never did, in fact.
From the outside, that mechanism would be the ideal one because it would involve all the key players — the feds, the provinces and the territories — but from the outside, it looks as though there are millions of subcommittees of subcommittees of committees, and it looks a bit paralyzed. I do not know how that mechanism can be reformed to deliver. I do not know that, but it is worth some work by experts on what the conditions for success should be because it remains the ideal mechanism, as far as I am concerned.
One mechanism that the report does not list at all is that of every department having a research and planning branch. The research capacity of the federal government, from which I benefited enormously when I was there, no longer exists. It has not been there for many years, and there is no institutional memory in many fields. Consultants who are paid good money phone people for their views, free of charge, of course. I am always in meetings. I have so many meetings I can never return the phone calls. It is all fragmented. The people they call do not have a responsibility except to give their opinion. They do not belong to an entity, so it is worth studying whether that research and planning capacity should be reinstated, under one form or another, in the federal government.
That notion takes me to the intersectoral mechanism, or, as some call it, ``whole of government,'' that is needed to undertake social determinants of health.
If I can share international observations we made at the WHO commission, it takes not only a nice network of deputy ministers — like the one that exists now, and I do not criticize it; it is probably good to exchange ideas and whatnot — but a full-fledged cabinet committee that is intersectoral on social determinants of health with whatever number of departments it takes, chaired by a powerful minister. In country after country, we were told that it should be chaired preferably by the president or the prime minister, or the deputy prime minister or the minister of finance. In the case of Sri Lanka, the Minister of Health is number two in personal power of that country and close to the prime minister. With that exception, such a cabinet committee should not be chaired by the minister of health. In Canada, the rule applies particularly at the provincial level. In my time, it applied federally as well.
Ministers of health have the biggest share of the government budget. The natural fear of imperialism, which at times is not only a fear but a reality, and the fact that the minister of health is the voice of the most powerful lobby of any society, in my humble opinion and experience, namely, organized medicine, play against these ministers. I checked my figures last night, and those of you from the Public Health Agency were right. In Canada, the aborted initiative in 1997 followed the national forum on health. One of the problems was that the other departments and the other players were not convinced. Therefore, the minister of health should not chair this cabinet committee.
While the report speaks of mechanisms, it does not touch on the theme to be chosen. The ideal theme is the comprehensive approach. I will use that word in the sense of moving together on everything, an integrated approach.
Maybe it will happen, but I rely on the nature of politics, which is the art of the possible. Canada's culture has most often been a case of small steps, an incremental approach building on existing blocks. That is what might happen but anything can happen.
What I think — I handwrote it for myself this morning — is that my ideal and what I have been fighting for in my international commission is to start with early childhood development, giving a good start in life.
I forgot one thing when I spoke of social change. It was through the Royal Commission on the Status of Women, of which I was the executive secretary way back then, that I discovered the world as well as our society. Social change occurs through many parallel avenues that are not necessarily connected. We do not have the time to connect them and should not even try, and the sum total does the job, if that makes any sense.
In that sense, if I pick one goal, it is childhood education. I do not have any dispute with that goal. My practical problem, which is why I eliminated it from my written notes, is that in Canada today, early childhood development, which includes pre-birth and maternal health, might well be reduced to day care, and that is a no-no because of the current government. I am speaking pure politics and the way I read it. I may be wrong.
I enjoyed the discussion between Senator Segal and Mr. Dodge. Mr. Dodge appeared to be strongly opposed to the Guaranteed Income Supplement at first, almost on principle, favouring instead early childhood development. In fact, as the only means, it seems to me, for the feds to act regarding early childhood development is to increase the child benefit. The real difference between Senator Segal's and Mr. Dodge's options is about the total cost of expenditures involved in each case, Senator Segal's options ending up in a higher cost than Mr. Dodge's.
I tried to find a politically ``neutral'' theme, and I thought of housing, meaning public or social housing. A good case can be made for that investment. The lack of investment by many governments of all colours is such that the present stock is in bad shape, let alone that we have not met the new need.
Returning to the conceptual level, when trying to create a demand within public opinion, I have observed that both the notion of ``gap'' and the notion of ``gradients'' work. Gradients are much more powerful because they involve 80 per cent of Canadians, not only the top 20 per cent but all below.
Senator Eggleton: Senators have a lot of political will. We do not have a lot of political power, but if we conduct our research thoroughly, come up with good evidence-based recommendations and find public appeal to centre them on, then I think we have some influence. A good example was the mental health report produced by the full Standing Senate Committee on Social Affairs, Science and Technology under chair Michael Kirby and deputy chair Senator Keon.
That report was adopted by the government. I like that, and I hope that whatever comes out of this study will have that kind of success.
Talking about public appeal reminds me of the discussion we had on early learning and child care. Much more mileage and a lot more resonance with the public is to be gained on the issue of child poverty than on adult poverty, although we all know that children are in poverty because their parents are in poverty. Do not dismiss that, though, because resonating with the public in that way can be valuable in reaching the same end. However, we must deal with evidence-based recommendations, public appeal and all those components.
We have a complication at our committee because we come at some of these same issues in a different way. At this committee, we talked a lot about poverty, which is one of the major social determinants of population health. The Subcommittee on Cities is now studying poverty, housing and homelessness. When we finish this study, by the end of the year, we will go into other segments dealing with issues in cities such as transportation and immigration.
In that respect, the two subcommittees have a lot in common. They have even held joint hearings because much of the evidence is valuable to both.
In addition, on the recommendation of Senator Segal, the Standing Senate Committee on Agriculture and Forestry, chaired by Senator Fairbairn, deals with rural poverty. We must find horizontal links between the work of this committee and the agriculture committee on this subject. Let us at least ensure the committees do not conflict. We will have different reports, but hopefully the reports will be part of a broader picture that will help to advance the agenda. I believe we can accomplish that goal.
I wish to talk about political will in the government context. I was President of the Treasury Board in 1993. One of the first people I met was an assistant deputy minister by the name of Mel Cappe. He impressed upon me the need to have horizontal links within government. I thought that was a great idea. With all the stovepipe operations, we need horizontal links. I subsequently learned that trying to implement it is like pushing water uphill.
However, the idea is still worth pursuing because these things all link to each other, whether it be housing, early childhood learning, literacy or whatever. They cross into many different departments, and I believe we need whole-of- government or horizontal approaches.
Ms. Bégin touched on that need, and I agree with her that poverty must be championed from the top. The prime minister does not necessarily need to head up the committee, but the prime minister must make clear to whoever heads up the committee what the prime minister wants and the timetable within which to do it. Ontario now has that kind of cabinet committee, and I think it is a great idea. The premier does not head that committee, but it certainly has the premier's solid support and championship from the top.
That is what happened in the U.K. I think you all know that story with Tony Blair and Gordon Brown. Of course, they do not have provinces to worry about there, so they have a much simpler system to operate. We have three orders of government as well as the communities.
I have been at the local level of government as well, and I fully know that many programs and services relevant to population health will be delivered at that level, as well they should be.
We must recognize that Canada is now an urban country. Over 80 per cent of the people live in our cities and towns. Of course, in population health we must be concerned about 100 per cent, not only 80 per cent, but municipal organizations are the first responders in the government structure, and when over 80 per cent live in cities, municipal government becomes a significant part of dealing with this issue.
Municipal governments also have many great ideas. They have first-hand contact with community organizations and people. The problem is that they do not have the money. There is a great fiscal imbalance in this country. Under the Constitution, municipalities were not given any money. They have been able to obtain some property tax, at least. Of all the tax revenues collected in this country, municipalities receive 8 per cent. If there is a fiscal imbalance in this country, it is not between the federal and provincial governments but between those two levels of government and the local level of government. That situation must be addressed.
I do not want to enter into a constitutional debate, but there must be a change in attitude about where to deliver these programs from.
What are the mechanisms to make that change? I have a suggestion that may not make sense on the national scale, but it may make sense to trial urban development agreements. Vancouver and Winnipeg have these agreements. The agreements bring the three orders of government together to work on precise and discrete projects with goals and timetables. Perhaps this mechanism can be used.
Another example is the national homelessness initiative that brought different orders of government together to talk about the best way of delivering these programs.
Intersectoral arrangements are worth pursuing to provide political will and ongoing monitoring of improvements in these areas that can be helpful.
We must consider whether, overall, we will approach population health, poverty and related subjects with the big bang approach that we heard about from Senator Hugh Segal today or whether we will try something more incremental.
If we proceed step by step, urban development agreements can be a good way of moving the agenda along and gradually accomplishing the same aim as the big bang approach.
Mr. Lewis: Thank you both for those presentations.
We have been speaking a lot about government, but ultimately, as people have said, we need to respond to the public, and the public needs to become engaged with this topic. I include in ``the public'' the media and other organizations and the private sector.
If anyone has ideas, suggestions or analyses about how to make the issue of inequality and disparity live more prominently in the minds of the public, that would be helpful.
One is mindful of the medicare analogy. When the head of a Canadian bank or the head of the autoworkers union says that medicare is a great idea because it is an economic advantage to Canada, it resonates with people precisely because they are not seen to be insiders from medicare promoting the system's own perpetuation.
Similarly, if we want this inequalities agenda to become prominent, finding champions who are not advocates from the ``natural constituencies,'' or even public policy-makers who tend to have an interest in these things would be helpful as well.
With that, the floor is open and I look forward to your suggestions.
Mr. Cappe: I was struck by Ms. Bégin's comment about the lack of a business case, and I think she is right, unfortunately. However, I said to Senator Keon before in response to his question of when do we know enough to take action, it strikes me that we face this problem in public policy all the time in every area. If we wait for certainty, we will never act.
In fact, the Parliament of Canada has passed legislation in the context of the environment incorporating the precautionary principle, which basically says there is an obligation to take action even though we do not have all the information we need. I do not think we should wait for the business case to be made in a way the business schools may want it, but I think we need this notion of consensus.
To turn to the question at hand — how we foster political will — I do not know the answer but I do suggest a few elements of it. There is a role for federal leadership. I say federal leadership knowing a number of former provincial officials are here who are ready to beat up on me I am sure, but the feds do not have the power to convene in a curious kind of way. The federal government would have been an instrument to bring people together, but I do not think it is actually there.
One could argue the Council of the Federation, which is nothing more than the annual premier's conference with a new hat, has the power to convene, but I think even the council does not have that power either.
The federal government — and I include the other elements of Parliament in this group — has the ability of setting the agenda, but it is set informally. I think you and your committee, chair, have that opportunity, in a sense. You can set the stage in which this issue becomes important.
You then look at NGOs and the role NGOs can play. The committee can provide the opening in which NGOs can put things on the agenda. There must be a way of focusing on that process.
I end by pointing to the federal leadership role that is possible by providing research and analysis. The data side is in hand as much as it can be in the sense that there are still huge gaps but we have made good progress between the Canadian Institute for Health Information, CIHI, and Statistics Canada. There is a good basis.
Again, Ms. Bégin has identified this gap, if you will, which is research capacity. I think governments have gone through cuts worrying about delivering service today, so they decapitate the government and cut off its capacity to think. Governments are incapable, then, of worrying about the future. An area for research and analysis is important.
I conclude with something that Mr. Lewis said; that there is both a demand and a supply for political will. The public demands that there be action, but if the governments of the day wait for the public to get its act together to demand something and then the governments will respond, we will not see any action. Therefore, there is a clear supply orientation towards where I would go with this issue, which is a government taking the lead and in a way, creating the demand.
Ms. Lynkowski: I think, as was mentioned, that we need to build public awareness on the issues. The way we do that is to recognize that we are trying to affect populations and social change, but that must be translated into something that is personal, and we have not done that successfully.
Ms. Bégin raised a great example in terms of the civil rights movement. We all know that it was propelled forward when Rosa Parks refused to give up her seat on a bus, and they still attribute the beginning of that movement to her. There is Mothers Against Drunk Driving, where a mother, essentially in her grief, transformed that grief into what we all consider to be socially unacceptable now.
We need a new way to tell the story, and we need to use the media to tell that story. We must do that deliberately and proactively. A study in the Canadian Journal of Communication in 2007 — and I am not an expert in communications — said that health reporters tend to de-emphasize the importance of social determinants and overemphasize the importance of the health care system and personal practices, or lifestyle, as we said. That is what they turned the issue into — lifestyle issues. It is then hard to find support for broad public policy measures because what they see are wait times or the hip that cannot be replaced.
It is incumbent upon us — and we have not done this well in the NGO community either — to tell the story differently. Probably the best example is through some of the Aboriginal populations because when we hear of a child living in a house with mould coming down the walls, it is pretty obvious that their early start will not be that productive. I challenge us to use that role. I do not know how the subcommittee can work with that information, but I think we need to engage the media.
Diana MacKay, Associate Director, Education and Learning, Conference Board of Canada: I want to comment as well on this issue of building the case and drawing a distinction for what the public sector can do and what the private sector can do. As Canadians, we have a culture of looking to our government to solve some of our problems whereas many other countries look to their private sectors.
This issue needs greater action by the private sector to understand the issues in addition to individuals and the government understanding the determinants of health.
One thing we focus on at the Conference Board is exploring how the private sector can understand the determinants of health better and take action where action is to be taken. I call your attention to a study that was done by the Halifax Chamber of Commerce where they explored the cost to the province in terms of productivity lost to absenteeism caused, in particular, by mental health issues. They estimated the cost was over $1 billion annually to a province the size of Nova Scotia.
Further, Deloitte in the States conducted a study where they looked at the concept of ``presenteeism,'' which is the affliction some of us have when we are at our desks, we are seen to be working, but we are not as productive as we could be because we are suffering from mental health issues, stress or all those other factors in life that take away from our ability to be productive. The issues are largely determinants of health issues: our housing, what our children are doing and so on. This Deliotte study showed that the cost was 32 times the cost of absenteeism.
It has been pointed out to me that the Nova Scotia economy may not be a $32-billion economy, but we are losing a lot of productivity in Canada due to these issues. If we can show to the business leaders in the country, to the people who care about the bottom line, the fact that they are losing this kind of productivity, this kind of drain on their bottom line, then that case is compelling. We should identify areas where the government and business leaders can collaborate on things like building projects in urban centres and focus on ways that the business community can take actions within their companies and within their communities to help address these issues in Canada.
Mr. Lewis: Where do you think the business community is on this issue? It is one thing to recognize the issue, but what would make it live for them? Is it only an economic argument?
Ms. MacKay: I believe it is only an economic argument, frankly, because that is what business people care about. We can talk about the values, but we will not make a dent in the business centre unless we talk about the bottom line, in my opinion.
Mr. Lewis: Do you think social entrepreneurship and these new ideas about the responsible corporation are rhetorical things?
Ms. MacKay: No, I think those concepts are valuable, but unless they are aligned closely with economic concepts they will not be anything other than a sideline business and something that is talked about but not acted on in terms of what happens behind closed doors.
Mr. Dodge: I want to concentrate on Mr. Cappe's assertion that there is no business case and Ms. Bégin's compelling argument that we need a business case.
I may be a little out of date but as I look through the literature, it seems to me that we have an extraordinarily compelling business case in public health.
One example of interaction with the business community came out of how they deal with business continuity at the time of an epidemic.
In fact, there are lots of examples of where particulars come together on the business and government side. We have good evidence on the public health side in a whole bunch of areas. The problem, as I think a number of people have pointed out, is that a provincial minister of health faces diverting a million dollars or several millions of dollars from insuring that someone has more access to have their knee fixed quickly or whatever, to something that will yield a result over a long period of time. Those politics are difficult.
This argument is one in which our peculiar federal-provincial system comes into play. The federal minister, as Ms. Bégin knows well, is not under that same problem of when the bedpan falls in East Armpit, it echoes in the legislature. I think there is a good partnership and division of responsibility in public health because every provincial minister knows well what the case is, but the politics of defending it in the provincial legislature is difficult.
On the public health side, I think, one, there is a good business case; two, we can involve the private sector; and three, there is a clear argument for division between federal and provincial authorities, given the politics of what the ministers must deal with.
On the early child development matter, the evidence is absolutely compelling. It is overwhelming. The problem is, it is so overwhelming that the universities out there are arguing that this is not such a good place because the evidence is that we are much better spending that incremental dollar or an existing dollar in early childhood than later on up the system.
That choice is difficult, but I do not think it is for a lack of business case in either of these two domains. It is difficult to articulate the case and as Mr. Tholl said, find that burning case to make it work. That is why I agree with Ms. Bégin. Absent a 1919 flu or something like it that galvanizes the country in a totally different way, then we need to build on existing blocks and proceed step by step. It would be extraordinarily difficult to take the big bang approach.
The business case is there, and I hope the committee's report reflects that fact.
The Chair: Can I stimulate this discussion further? We all know provincial budgets are structured so that health is dealt with in one part of the budget and everything else is dealt with in another.
Mr. Dodge: ``Health care'' is dealt with.
The Chair: You are right. That point is important. On this budget line of ``everything else'' are 11 of the top 12 determinants of health. In virtually all the reports we look at, productivity in a country runs parallel to its health status. Depending on what survey we read today, we rank somewhere between fifteenth or twentieth in overall health status, and we are similar in productivity. Perhaps Ms. MacKay would come back to that point.
Surely, it is horrible in a country like this one to have our productivity so compromised. How can we translate this statistic into something that the public and governments can understand?
Ms. Browne: Further to the business case, in Kentucky they can let someone die and it does not cost much that year. However, in Canada, if we do not help people with something, they will use — however inappropriately — something else that is insured.
My unit, as a little example, sits on 18 studies that show that if we do not help people more completely it will cost more that same year. If we help people, we will have more productivity. In one case, exits from social assistance doubled, or became 15 per cent more, than the control group. The study is a good one; they gave me a prize for it. For every 100 single-parent mothers and their families offered that intervention, we could save $300,000.
For Toronto, I worked out the implementation plan for their people and spoke to Deborah Matthews' committee. In Toronto 29,000 single-parent mothers and 50,000 children are on welfare. The proportion of children under six will be taken care of by Early Years and Healthy Babies. Sixty one per cent of youth in our study were over six. I am in favour of these programs. The mother is distracted from the early child by the 10-year-old lighting fires and the 15- year-old on ecstacy. Again, I emphasize a household approach. It costs us more in the same year not to address these problems.
I was able to show them that Toronto now spends, for that two-thirds of the single mothers, $295 million a year on social assistance. Based on our study, if we have a 15 per cent greater exit from social assistance, it will save $60 million. To implement the whole program for Toronto for that age group would cost $32 million. It is costing us more this year, right now.
Mr. Cappe: I want to go back to David Dodge. What do we want from the private sector? Is it only their permission? In other words, they understand the business case and are okay with a mixed public-policy approach to address this issue, or do they have a more direct role to play?
Mr. Dodge: I think there is a more direct role, but I prefer Ms. MacKay speaks to this question rather than me. From the pure public-health side, the business continuity side, the response has been strong. It was not a difficult sell and we made some yards on that side.
The much more difficult one is the kids. Especially for small business, having someone absent from the office for a year is disruptive. On the other hand, to attract the talent we need in larger organizations, we had to make it attractive for women in their child-bearing years to come to work.
There is a good case, as a large employer — I have to be careful here — to have a program that is supportive of women in their child-bearing years. That is the only way they can attract the talent to run their business.
Mr. Lewis, I do not see a conflict here. It is important to structure things properly. The small- and mid-sized businesses are a much trickier thing. One person missing in a five-person organization is a much harder thing to handle.
I think there are good opportunities for cooperation. If approached properly, it is natural almost for it to come.
Mr. Lewis: Ms. MacKay, do you wish to add anything?
Ms. MacKay: There are many things to talk about here. I think we need champions in the private sector who demonstrate how they can win as a business by promoting good health.
We can look at companies that we may think initially have nothing to do with this discussion, for example, Loblaws. Grocery store chains put their produce in one place and their candy in another. They put the candy near the checkout where the moms must shop. I have four kids under the age of seven and it is impossible to go to a grocery store and not come out with candy in my hand.
I would like to see a grocery store change the way they lay out their floor so the last thing customers do when they leave is pick up their fresh fruit and vegetables. People are inspired to do that by their visit to the grocery store. People in marketing think about these things. We need these business minds to think about what will create good health outcomes. Then we need a business leader to change their business model so they apply these practices and show other business people they are winning; they have better bottom lines by making those changes.
That is what I am talking about when I say, involve the private sector. We should identify which private sector players are able to make an impact on health outcomes in Canada. Perhaps, the government can take steps to create incentives for businesses to take these actions.
Dr. Butler-Jones: As a sidebar, 15 to 20 years ago, we worked with local grocery stores, with Loblaws, to do that in Simcoe County. It has fallen away for many reasons.
It is about engagement. I like the way Ms. Bégin described it as a series of parallel processes. There is not one way of doing this. Each generation discovers for itself what the galvanizing issues are. There were outbreaks of cholera and smallpox in the early days of Disraeli. However, in the latter part of that century, the British Army could not recruit enough soldiers for the Boer War because they were too unhealthy to be soldiers. That issue moved into issues of housing, financing and all that stuff.
Act Now B.C. is a cross-government initiative looking at physical activity with lenses on policy, et cetera. In part, that initiative came out of not only knowledge of the importance of these issues but also from compelling arguments from a business case standpoint that if they do not do something dramatic about the prevention side of the system, within a decade there will be no money for any department other than the health department and maybe education.
I am nervous about business cases. There is a compelling business case around a whole range of issues. It may not be totally coherent, cross all issues and speak to the whole subject but if we parse it out, there are many things on which to build a business case. One striking thing is we have a basic bias. The reason for this bias is that the business case is not enough, even when we have a good business case. I cannot count the number of times I have been in debate when someone says: All this prevention and promotion stuff is fine, but people live longer, they must go back to the doctor, they cost us more money, they collect their pensions, et cetera. They ask, why should we invest in that when we are not saving any money?
Why was my asthma treated when I was a kid? I am costing the system money. I may even retire some day. Why is it that, somehow, people living longer, healthier and better is a liability, but becoming sick, being treated and dying early is the normal course of things?
The other issue is finding what resonates for people. This issue goes back to the issue for each generation and the businesses. What is compelling for them? We all care obviously about children and we know that those pathways are set early. Finding and telling the stories and laying out the business case is important. However, the business case by itself is necessary but not sufficient.
Some things are already in place and working along this line. As Ms. Bégin is part of the WHO commission, we in Canada fund four of the few knowledge networks: two by the Public Health Agency of Canada, one by the International Development Research Center, IDRC, and one by Canadian International Development Agency, CIDA. In terms of the development of knowledge, we also fund the Canadian Reference Group to bring a Canadian context to the knowledge.
Additionally, we have centres of excellence that focus on these kinds of practical issues, working with the Canadian Institutes of Health Research and others. There is also the public health network. The point is absolutely well taken: If the knowledge remains within health, talking to itself, it will not go anywhere, whether it is imperialism or whatever. However, systems are in place in the public health network for engaging across the system and vertically within it to the conference of deputies where I sit, and then on to ministers.
Another thing that has not been spoken of much yet is the role of universities, the choices they make and the training they offer, both in terms of developing the skill sets for future professionals and others to support the kind of work that needs to be done, but also they need enough understanding not to obstruct what needs to be done. This point is important because in terms of those debates, people can say, it is a waste of time because people live longer — I thought that was the purpose of the health system.
In terms of research funding, most of these issues cross over the institutions. The issues are not only issues for CIHR, the Natural Sciences and Engineering Research Council of Canada, NSERC, or the Social Sciences and Humanities Research Council, SSHRC. Issues of the environment, biology, et cetera need cross-sectoral research. They are talking about that but I am not sure how much progress we are able to make.
In addition to Michael Marmot's report and the commission's report, in addition to the work of this committee, the first report of the Chief Public Health Officer, an annual report required of Parliament, is the status of public health in Canada. The report will have a theme in addition to the usual information: This is how healthy we are or are not and our comparisons with other countries. The theme of the report is health inequalities. This report deals not only with the inequalities and the underlying issues, but with the evidence for what we do about it and how different levels of society have taken on this theme, either as individuals, governments or communities.
Hopefully, that report will be useful to the committee in your dialogues as you move forward. I hope it will be tabled before the summer.
Mr. Lewis: We have five speakers left on the list and 15 minutes.
Ms. Potvin: I will take the ball exactly where Mr. Dodge left it. I wanted to start talking about the first report of the Chief Public Health Officer of Canada, which will be about disparities. Then, let me scale down our conversation to Montreal.
In 1998, the public health director in Montreal released his first report, Health Disparities, and that report had a leading effect: One thing led to other things which led to others. It brought him attention from other sectors. You cannot have a report on health disparity without being willing to sit on many committees such as transportation and education. The story of Montreal is that such a report is the first step.
Another thing I wanted to say, in answer to Ms. Bégin, is that business cases are good things, but I would rather talk about social and societal cases. When the private sector meanders into health, they come up with bizarre ideas.
Talk to anyone who deals with the Chagnon Foundation in Quebec and you will have an idea of how good intentions and good will can lead you directly to hell. You do not pass Go and you do not collect $200. I am not sure that the Bill Gates' of this world do much good.
As far as I know, within various Canadian documents, there are a few things we can build on. The way I read the 2003 First Ministers' Accord on Health Care Renewal, it says that the health system is there to increase the health of Canadians and reduce disparities. This building block is one on which to build.
The last thing I want to offer you is that when you start to compare yourself, choose the right people to compare yourself to. Then, you will start thinking more intelligently. We have a history of comparing ourselves to our neighbours to the south, and not on the right indicators. For example, we compare ourselves with our southern neighbour on wait times for health care, and not on access to health care. We compare ourselves on life expectancy and we look good. However, when we compare ourselves to egalitarian societies — to Denmark, Norway or Sweden — we do not look that good; that comparison makes us number 25.
I urge that we compare ourselves to where the real challenges are, and that we develop that culture of comparing ourselves. The people we should compare ourselves to are the societies of the Organisation for Economic Co-operation and Development, OECD, and probably Australia.
Ms. Manson Singer: I come back to the point that Mr. Cappe made earlier about the role for federal leadership. I strongly support that point.
I was thinking about the practicalities of explaining to the Minister of Health in Newfoundland and Labrador that today he should stand up and favour the collection of quality indicators on health, or foster a great support around the social determinants of health. I do not think he would be particularly receptive to my advice. Actually, I would be telling him to walk down a short plank, which is not the role of any deputy minister.
Coming back to population health, we are talking about the vision of our country. What do we want for our people? What kind of Canada do we want? That is the role of the federal government, to champion the kind of Canada we want for our Canadian people. Passing that baton, the leadership role, to the federal government expresses the obligation that we have to ourselves, as citizens, to articulate what we want as a country for our people. To me, that is not the role of any single minister of health; it is the expression of what we want as Canadians.
In this report, I urge that we give the federal government not only the right of taking the leadership, but also the obligation to take the leadership. To me, that expresses who we are as Canadians and what we truly value.
Ms. Yalnizyan: The question of this session is how to foster political will — and context is everything. The political moment will indicate where people are in terms of context.
When we started the inequality project at the Canadian Centre for Policy Alternatives, one of the first things we did was polling and focus groups on what people thought about inequality and disparity at the moment. We learned through a national poll by Environics that one out of two Canadians feels they are a couple of paycheques away from poverty. When we look at the data, that response is irrespective of region and income class. It is not about poverty; what we heard was financial insecurity.
The second thing people said — irrespective of political stripe, income class or region — was that any political party that moved on the following four things would have over 80 per cent of political support from Canadians. Those four areas, in order of priority, are more affordable post-secondary education for their children; more affordable housing; child care by which they mean not only zero to five because kids do not take care of themselves once they go to school full-time; and higher minimum wage so that someone working full-time, full year is not still in poverty. The definition of the minimum wage would be to raise someone out of poverty if they are working full-time, full year.
Those four things were the top priority for over 80 per cent of the population, dipping to about 76 per cent for the Conservatives in Alberta for some issues. I can make that document available to people.
If you want to foster political will, I could not agree more with Ms. Manson Singer on the need not only for federal leadership, but the federal obligation to set the tone. The tone is not only, what can we do to help the poor? I do not think the language of social determinants of health washes with people. I do not even think the language of poverty reduction washes with people. People need to see themselves and their insecurities reflected in what their governments are doing for them.
These four platforms — post-secondary education, child care, housing and higher minimum wage to lift someone out of poverty if they are working full-time, full year — reflect their concerns and insecurities. It is a short list. It addresses all the social determinants of health we are talking about.
Concern does not stop at early childhood education for the first five years, because the lost generation is 10 to 15 years old. Ms. Browne talked about what is happening in this group. I can tell you there are tri-level committees dealing with the guns and gangs from two years ago that are still trying to target initiatives to keep those kids off the street. One or both parents work all the time, and there is nothing for the kids to do where they live because they live in poor neighbourhoods. There is no funding for these things. Please do not think of early childhood education as ending when the child enters Grade 1.
Again, talking about how to seize the political moment to raise political will from both a leadership point of view as well as the grassroots point of view, maybe my middle initial should be ``P'' for Pollyanna. I think the winds of change are blowing because the Barack Obama campaign of ``yes, we can'' is infectious.
People are starting to think again that their governments can do something for them — any government, any leadership that takes action and says, this issue is not about poverty reduction but about prosperity. That is exactly what your agenda says; you do not call it the ``business case.'' You say, ``What is the economic case,'' and — in brackets, ``the prosperity case. . .?'' I can assure you, it is the prosperity case. It is the enhancing economic security case, because people do not feel secure right now.
We are at the end of a decade of blockbuster growth for this country. We should be embarrassed that we have not done more. This is a moment to move forward. There is an agenda that can be seized, if any party is willing to move forward with it at the federal level.
Mr. Osberg: Ms. Yalnizyan mostly said it all. The only thing I underline is the health implications of insecurity, anxiety and stress repeated over many years, particularly when someone is the sole parent. Many people are particularly vulnerable to the economic stresses they are exposed to, more than ever. They have a much greater distance to fall because we have cut away the social safety net over these past few years.
Mr. Reading: I was reflecting on the recent report on population health, which looked at a total of 360 programs and services available across 30 federal departments and agencies that target Aboriginal peoples in Canada. It has occurred to many people before that we ought to be able to align these programs and services with a goal of improved health. That alignment is what is missing. The departments are firing off in all directions and not actually hitting the target.
One fantastic idea is that there be a cabinet committee on social determinants of health. I am an academic and I think about social determinants. There is much debate about disparities and inequalities that lead to vulnerabilities. Average Canadians do not care much about the inner workings and how all these things split up. We study these issues but people are interested in improving the health of Canadians. A cabinet committee aligning whole-of-government approaches to improving the health of Canadians and to reducing vulnerability for future populations has a more politically viable and sellable ring to it than ``social determinants,'' which is a bit wordy.
There seems to be a lack of vision. We have all kinds of social programs in Canada that provide these services but they have not been aligned in recent years. The idea is to align under some kind of vision, be incremental in how they are played out through strategic investments and set specific goals and measurable objectives of progress against those goals. The report also talks about how the federal government initiated a set of goals in partnership with the provinces but that those goals were never adopted. It did not happen because it was a half-baked plan and did not have the political support of a cabinet committee to move the agenda forward.
On my final point, Regent Park in Toronto was a social experiment in Canada undertaken in the 1950s by well- meaning people who gathered in rooms such as this one to improve the public health of vulnerable populations living in an urban environment. It has been a colossal disaster. One reason it did not succeed is that the people undertaking the project never engaged with the people who live in the area about what the people wanted in terms of their health and well-being. The road to hell is paved with good intentions. Now, the City of Toronto is trying to reinvent the Regent Park area to improve it for all who live there. It is my view that community engagement is the key, and community engagement is connected to political will.
The Chair: We will begin our final session on theme four. Mr. Lewis will facilitate this session. I can assure you we will wrap up the session by four o'clock. Without any further ado, I turn the meeting over to Mr. Lewis.
Mr. Lewis: This last session is to generate some sense of priorities for accelerating progress. Since we have a large, diverse and committed group, consensus may be somewhat elusive. However, we at least want your concrete ideas about what you think we should do. Some priorities have already emerged.
Before we go to that part, I have two questions to pose, one to Ms. Yeates and the other to Senator Eggleton.
Ms. Yeates, given what you have heard today, what do you infer from this conversation about the information and analysis agenda that you think the country needs to pursue? Where are the gaps that you think most need to be overcome?
They may or may not deal with your own mandate directly. They can relate Statistics Canada and others.
Ms. Yeates: A number of things come to mind. First, people talked about push and pull on indicators. The focus on wait times has driven us to measure them, then to report and do something. It has created a demand for population health measures and, ideally, an inequality measure. Other countries have this measure. That would drive a lot of research on what measures are useful and we would then have a sense of how we are performing on these measures over time. That would drive the demand.
Second, I come back to the creation of a climate for linkage. In a sense, populating population health measures over time is largely about being able to pull data together. A lot of barriers exist to that capability at the moment, most of which vanish if we work on them. They are not barriers that cannot be overcome. However, overcoming them takes much energy, time and effort. We need to pull this data together for the country as opposed to having all these little pockets. These linkages would be created locally, provincially and nationally. Creating them would be a huge achievement.
Third, the greatest source for more data that I see on the horizon to establish those kinds of linkages is EHR, the electronic health record. I do not see a lot of opposition. Rather, no one has thought their way through this issue. We need a voice to be out in front talking about it as a potential source for powerful, ongoing, inexpensive, not redundant, population health data. It pushes a lot of buttons on efficiency. That role is huge because not many people think that far out.
Fourth — Ms. Potvin mentioned this point as well — having a greater sense of what works will be important. The business case needs to be made over and over again. The bar is high because of the latency and because of all the issues that have been raised. We do not devote many resources to this issue in our research agendas.
The federal government is a big funder of research and can play a role in devoting a greater proportion of that research enterprise to answering the question of what works. It is one thing to say we have a problem, but it is another to have ideas about how to solve the problem. At the end of the day, people will come back to whether this approach is making a difference, which is a legitimate question.
On the biomedical side, a whole enterprise is well designed to answer the question of, does this approach work? We do not have that same enterprise. There is a problem if we do not have that same kind of intervention research.
Last, there is a question of diffusion of the mandate. No one enterprise in the country will solve all this problem. Having spent most of my career in government, inherently, some of these questions will be uncomfortable for governments. We need to think about where we place the voice of these issues on an ongoing basis.
That may sound self-serving coming from an agency outside government. Therefore, I hasten to say we could play that role and I think others could play that role. I know playing that role from within government can be difficult.
Mr. Lewis: Senator Eggleton, you parked the intriguing notion of fiscal imbalance. You were the mayor of a Canadian city that has taken inequality-related issues as seriously as any. For example, the Toronto Board of Health has had a visionary leadership role.
Tell me if I am reading too much into what you implied. However, I think you said we should flow more funds to the municipal level where we may have a better chance of success dealing with some of these things. A lot of social capital is at the municipal level and the scale is small enough, even in a big city, that they can make headway. The determinants of health are visible on the ground.
These should be your comments.
Senator Eggleton: You said it better than I could. I agree with that summary.
I do not anticipate that the different orders of government will come together and re-carve the pie. It would be good for local government to have more progressive taxes, such as income tax or the sales tax. I do not think that is about to happen in a direct way, but it can happen in an indirect way. It is already happening somewhat with the gasoline tax that goes to local governments for infrastructure, which is an important part of what the local governments do.
We could have double devolution, as they call it. The federal government could devolve funds through the province, since they want to follow the constitutional correctness, down to the local level.
In an urban development agreement format, if the federal government is willing to devolve those funds, the federal government has some obligation to ensure that the government that is most logical to deliver the service will have the funds and resources they need to deliver it.
Mr. Lewis: We now open the floor for priority setting. We ask you to be as practical as possible and as directive as you are inclined to be in regard to what you think this Senate subcommittee should pursue to accelerate the uptake of the inequalities agenda.
You have heard a lot from each other today. We do not expect you to agree on everything. However, put some ideas on the table and we can discuss them and see where we end up.
Ms. Bégin: I listened to colleagues during the coffee break. There is no available business case in the classical sense of the term that we can easily use in Canada. Ms. Yalnizyan referred to the Environics study and the four pillars that people identified as their main worries. That language is equivalent to a business case. I ask, why a business case? Idealists dream to replace the use of the word ``equity'' with social justice words. I am sorry; they are like two constituencies.
Ms. Yalnizyan never used the words ``social determinants of health.'' I did not write down the four pillars, but I recall one is housing and one is financial insecurity. Using that language for Canadians in an agenda for prosperity, et cetera, is, to me, the equivalent of a business case. It is language understood by a vast majority of people, which is the language that is needed. It is a positive measure.
Mr. Cappe: I want to talk about collaboration. There seems to be a theme or a trend going through the conversation. My experience in government has been that something does not exist unless it has an acronym. I want to call for more acronyms. I want to talk about FPT and WOG.
One of my previous colleagues once said that it was the toadies in the TOAD, The Office of Acronym Development that exists in the Privy Council Office, which made government work.
FPT is federal-provincial-territorial collaboration, and WOG is the whole-of-government approach. We throw those words around as if we know what they mean, and I do not think we understand federal-provincial-territorial collaboration, cooperation or the whole-of-government approach.
In 1994, I chaired a deputy minister's panel on working horizontally. That term does not refer to the prone position but, rather, to working collaboratively. We discovered the blindingly obvious. We had 450 years of collective public service experience, and we figured out that we need to align objectives. No one is against improving population health, but translating that goal into something that is manageable, and that provincial ministers of finance and treasury can support, is difficult.
Aligning objectives is crucial. Respecting jurisdiction is a no-brainer. Not being too territorial is also required, and that is much more difficult. Give credit, not blame, and reward people for good behaviour. Those basic principles of good management and good cooperation are required here.
How to operationalize those principles is much more difficult. Sometimes, there is a conjunction of forces that come together to allow it to happen. The National Child Benefit was one of those moments in time when we were lucky that there was collaboration among ministers.
I will use the example of Pierre Pettigrew as the Minister of Human Resources Development Canada and Stockwell Day as the Minister of Social Services in Alberta. They were not exactly political allies, but they worked in the same direction to improve the quality of health and income for children in poverty.
There are ways of making it happen, and I emphasize the need for that cooperation and collaboration. At the end of the day, I do not believe that the Canadian public rewards acrimonious politics. I think they reward success, and we need to play to the success.
Dr. Reading: In terms of priorities, obviously I support a priority in the area of Aboriginal health. There is a perception, particularly within government, that First Nations and Inuit people want special treatment. What people want is equity. What people do not have is equity, and that principle is important.
What resonates in this government is this whole concept of First Nations and their special rights, et cetera. I am concerned that there will be some radical ``fix'' that will happen at some point in the future, but I cannot predict when. I am concerned about having a social safety net in place when that fix happens because it will be an experiment undertaken in realtime, with real people and with real wins and losses.
We forget that the highest rates of teenage suicide in the world are among Aboriginal kids, and that is a strong indicator of extremely difficult circumstances. We tend to turn a blind eye to those circumstances. It is out of sight, out of mind; let us not deal with that problem. Those circumstances can become better, but they can also become worse.
In terms of three concrete suggestions, first, frame the issue as a fundamental human rights issue. Second, look at income security, particularly directed towards families with children, and look at creating that social safety net for those families if they do not have one right now.
Third, there has been a lot of discussion about early childhood education, which I support, and I have been involved with Fraser Mustard and that group for a number of years. What people may not know is that there is only 25 per cent coverage of Aboriginal Head Start programs in this country. Certainly, a public policy lever would improve that to 100-per-cent coverage. We know it works. Seven generations of presidency in the United States have supported the Head Start program there. We know from the Perry Preschool Program and several other studies that it works.
In Canada, it is a no-brainer, especially in the Aboriginal communities.
Mr. Wright: Be sure to focus, wherever you go. You cannot be all things to all people. You cannot be the flavour of the month. We see that all the time. The issue must be dedicated, as we said earlier, championed and provided with leadership.
I think an excellent focus is children. We can all relate to children one way or another, whether we are grandparents or parents, or whether we were children once ourselves. Some of us still are. It is a tremendous opportunity to put a focus on all aspects. Aboriginal children are of particular note.
I encourage senators to think along those lines. The urban development agreements are a good model that can be utilized. One size does not fit all in terms of the provinces. The needs of every province are different, the needs of every municipality are different, and the urban development agreement has allowed for that flexibility.
The Chair: I totally agree. As a matter of fact, I had a preconception, and it will change according to what we hear as we go along. I had the preconception that when it came to programs, our top priority would be maternal health and early childhood development. I want to hear your comment that. I believe if a child is born of an unhealthy mother, that child is playing a losing game. Therefore, we need to back up to the mother.
With respect to the early childhood development situation, I teased an answer out of Ms. Potvin and Ms. Manson Singer this morning when they gave me the information I was looking for. That entire area will be important as to exactly how we deal with that situation so it is done right and so that there are not political movements that superficially pretend they are caring for kids and in fact, are doing them harm.
I want you to comment a little further on that point. I want to be sure I have your thoughts.
Mr. Wright: I think you have captured them more than adequately. I will begin at the beginning, which is with the parent and parenting skills; prenatal and post-natal.
I throw out a pitch for children's dental sealant programs, which is something small and simple. They make a tremendous difference in this country in many ways. The children cry out for a program of that nature.
I think you have it right. Proceeding step by step with great focus will produce great results.
Mr. Dodge: I do not have much to add because that is exactly where I would put the priority, as I said earlier.
You will have some nice wordsmithing to do, but one thing about focusing on the kid side is that you can express it in terms of creating opportunity. If someone does not start right, they are cooked from going on. That applies in all domains, but it is especially true in terms of living a healthy, productive life. You can then use that focus as a platform to deal with the special problems relating to Aboriginals, which are clearly in the federal domain, and you can use it as a platform to deal with the Canada Child Tax Benefit. Some things are right in the federal domain.
You can also deal with the issue as part of the platform on the public health side. I do not think we ought to forget that it is incredibly important that the great program of inoculation continue, and we are experiencing middle-class resistance to that right at the moment.
That gives you a tree on which you can put a few branches that relate to, in particular, the federal domain.
Mr. Lewis: We would be open to the charge that this proposal is not very ambitious: This is the same conversation that has taken place at 10-year intervals since 1975. You are right. Everyone says we should invest in kids, but the dilemma is that we seem to have a steep discount rate for those kinds of investments, and nobody seems to care. Once the realization is six years, seven years, ten years or fifteen years out, interest wanes quickly and the programs are limited quickly.
Is your message only realpolitik and that is all you will get? Are you saying to the Senate committee, Forget about grand ambitions here and forget about Canada entering into Scandinavian territory on the inequalities front: Keep doing your Canadian thing in voluntary increments, make a little progress and chip away at it?
Do you think there is room, and I think the Senate subcommittee is interested in this point, for accelerating that kind of change?
Mr. Dodge: If you do not have focus, if you try to go on some big grand thing, given that there is no particular economic or perceived social crisis on your hands, you will not go anywhere. That is the practical side. Therefore, let us do something that we know has a real payoff. Unfortunately, as in all these things, you have to keep hammering at it time and time again.
You are trying to make it more salient. This is so important to all of us right now because everybody is worried about the aging society, and rightly so. The best way that a 20-year-old or a 30-year-old can ensure that there will be people to pay their pensions and so on is to give the five-year-old coming into the system the best possible start.
The dynamics at the moment, it seems to me, may actually favour going after the kids' issue. We are all worried about this population problem in a way that, 10 or 15 years ago, when we were trying to push the issue, was not there. You need to find a political hook, but this is the right thing to do. We have all sorts of evidence that it works over time. This is the Senate, so it can speak the truth, and it seems to me that that direction is the way to go.
The reports from the Senate that have had a big impact are the ones that had a clear focus. I do not have any questions about it.
Mr. Wright: Sometimes, baby steps lead to giant strides. I want to see the agenda become gigantic, ultimately, but success breeds more success and so on. Start with the focus where you know you have a fighting chance. You know the provinces will be on side, and you are determined and you can move it forward. If you are successful, then the agenda opens up from there. Yes, we can be like whomever or whatever.
Ms. Potvin: I have four comments. If I had fewer, you would not believe that I am in academia. Let us be comprehensive and nuanced here.
The first comment is that something has not been said yet but I think should be said. It is from Len Syme, the University of Berkeley professor, who is at the forefront of all these fields, after all. I was with Len Syme last week. His main message, which is often forgotten, is that the paradigm needs to change here. If we still think in terms of diabetes, cardiovascular disease and cancer, we are talking about the consequences and not the causes. In infectious disease, we started to make huge headway when we talked about water-borne disease and air-borne disease. The same applies here. Canada is going backward, and this needs to be said, with a cancer initiative, a cardiovascular initiative, all those initiatives into which we put thousands and millions and hundreds of millions of dollars. This approach is going backwards. We should think in terms of the disease of poverty, the disease of low education, the disease of being Aboriginal and the disease of social isolation. These situations are the root causes. If we are still doing the disease thing instead of the causes, then we might still be there in 20 years.
Second, somehow I teach the history of public health when I have time. If public health has learned one thing over the 150 some years of its rejuvenation, it is that no single strategy is enough. We have two big strategies at this point in public health. We have an at-risk strategy, which was the Lalonde innovation, targeting the group at risk and lowering their risk. This strategy of at-risk had drawbacks, and blaming the victim was one; there were others. Then, in the 1980s and the 1990s, we developed the population strategy, and Canada was a big leader in that strategy as well, with population health all over the place. The population strategy has many benefits but also the drawback of increasing inequalities, and we can demonstrate that effect. We need a third layer of strategy that I would call a vulnerable population strategy, a strategy in which we address the root causes, the social determinants of health.
My third point, to emphasize what Ms. Yeates emphasized that I had emphasized, is if anybody tells you, senator, that they have a solution, do not believe them. We will learn while trying. If we have learned anything in public health, it is that not knowing all the problems should not prevent us from acting. We would be foolish if we do not learn while we are doing something about an urgent problem. I think there would be a missed opportunity if your report did not call for more intervention research.
The Population Health Intervention Research initiative for Canada, under the leadership of the Institute of Population and Public Health and the Chronic Disease Prevention Alliance of Canada, CDPAC, attempts to align the interests of those who are engaged in intervention and those who are engaged in research.
It is not easy. I think those people are looking for an issue around which people will rally, challenge them to tackle health inequalities in Canada and intervene in that problem. That public support would do a lot of good.
Finally, I want to re-emphasize what Mr. Reading said. I have been in the business of research on health inequality for long enough to know that the only way we can experiment in trying to intervene is with the populations concerned.
It will not happen in Canada that somehow, somewhere, the federal government will solve the problems of those people. I think the federal government needs to take some leadership in that issue, and to listen to and engage with people.
I will end with a quote that I heard last week. I was in France for a conference on intervention in health inequalities, and someone quoted Nelson Mandela, saying that if someone is doing something for the poor without having them at the table, they are doing something against the poor.
Mr. Cappe: I want to come back to your question to Mr. Wright and Mr. Dodge. I think they had the right answer, but they dodged the question. The Senate committee must think big thoughts, that this report is an opportunity, and you should not look under the horizon but over the horizon. The answer to the question about ambition is that you need to be fairly ambitious.
I come back to the earlier exchange between Senator Segal and Mr. Dodge. I would say that Senator Segal was overreaching with his guaranteed annual income proposal. However, there was actually concordance by the end of the conversation, because Mr. Dodge was saying you have to use income support for families with young children and there are ways of solving that problem.
I do not think it is simply an option of thinking small or thinking big. My answer to your question — although you did not ask me — is that the Senate should have ambitious plans but that it should reluctantly accept modest actions. The kinds of solutions that Mr. Dodge and Mr. Wright were talking about would lead to improvements in the quality of population health. I do not think it is actually a choice.
Mr. Lewis: Tell me how that future looks different from the past. We have made modest improvements. We have better child intervention programs in 2008 than we had in 1990, and they were better in 1995, and every province developed a child action plan that was intersectoral and it was pretty good.
If the Senate says that whatever the trajectory is, we want to make a difference to the slope, hopefully upward, where is the hook for that change? If we state great ambitions, saying we want to be like Norway, that approach will not persuade anyone to make that change.
What can the Senate subcommittee do, say or package that would make people more excited about speeding up? I do not think we have sped up. I will put it on the table. I think the slope of that curve has not changed at all. In some cases, it has gone backwards. Inequalities are larger in this country in some respects than they were, because the prosperity has been unevenly distributed. That is the backdrop.
Mr. Cappe: The challenge for the committee, with all due respect, is to pull this big car down the highway with an elastic band; and if you pull too hard or too fast, the band will snap. However, if you pull it with the right amount of tension, you will move that car, if it is in neutral; and the car, as you have alleged, is in neutral.
The real challenge is that if you reach too far, the report will be only another report on a shelf. However, if you simply propose an increase in the Canada Child Tax Benefit, that is not particularly aspirational. It may be Canadian, but it is not aspirational.
Ms. Yalnizyan: Whatever this Senate committee report does, it must speak to the bigger picture, in particular, what the future looks like, with an aging society, on the one hand, and young families and newcomers whose incomes are increasingly unstable. There is greater inequality for that next generation, which is what all the Statistics Canada data keeps showing, report after report.
To be able to name that the social determinants of health are located in this particular conjuncture of facts is important. At various points in this document you say to include income, education and housing. Other issues have been brought to the table, including how to engage people, particularly young people, who may be suicidal or who may not have the right supports to keep them moving along.
You should name the list. You should also name what other jurisdictions are working on, including your colleagues on other Senate committees.
For example, the housing issue has not been reinforced much around this table. We all know housing is one of the determinants of health. We all know there is a federal role to play here that has not been played for about a decade but that had been played previously, and could be again. Housing is something that your colleague, Senator Eggleton, could really focus on.
Create interlinkages in your reports to say: Here are all the different issues coming forward; we know what the elements are; this committee recommends substantial advances in income security and increasing the Canada Child Tax Benefit to a maximum of $5,000, and we know what the price tag is on that increase.
You can do things that have been mentioned here that are discrete and that refer to all the other work that is being done in other directions.
Your question here is: What are the measures of success? First, political take-up is a measure of success. Having a plan that is doable and actionable, with associated price tags, I think, is helpful, as well as talking about the opportunity costs of not moving forward on those things.
It strikes me that the things mentioned consistently over the course of the day are a children's focus; a future focus; an opportunities focus, with one element being income-related and another element being support service-related; and obviously, a focus on Aboriginal populations. You have a little trinity that you could move forward on, but that trinity should not be the limit of it. The report should be couched in what the whole picture looks like: We suggest this approach and this is what other colleagues and other jurisdictions are moving forward with, which we endorse.
Mr. Osberg: You noted earlier that a number of provinces have instituted anti-poverty agendas and they are discussing anti-poverty policy as a major focus; not all provinces, but some of them. Whether it is because people are tired of stepping over the homeless downtown, or for whatever reason, this issue seems to be coming back on the agenda. It is not only about child poverty; it is also about adult poverty and what it says to everyone about the sort of society in which we live.
To pick up on something Ms. Potvin said, I am not so complacent that everything has been going in an upward direction. Many social indicators have not been going up. We see a big decline in the fraction of people who are caught by the social safety net when they become unemployed. We have large increases in the poverty gap, up by about half in Nova Scotia in recent years, for example. We see a lot of the stressors increasing now. We will see the impacts on health down the road as these people feed through the system.
When you said that no single measure in public health is a magic bullet for every ailment, I think everyone agreed. However, sometimes you can find a theme that draws together a whole bunch of other initiatives; a way in which you can establish coherence among a bunch of disparate types of intervention.
You phrased it as the ``vulnerable population.'' Another more positive way of thinking about it would be the idea of inclusive citizenship; that all citizens should have the benefits of what the favoured already have.
In that sense, it would come back to something Dr. Reading said at the start when he talked about the idea of the human rights and income security agendas. That was kind of duplicative because income security already falls under the United Nations Universal Declaration of Human Rights. In 1948, Canada signed on to the idea that security is a basic human right under article 25 of the universal declaration. We have had for a long time this rhetorical commitment to basic human rights.
Of course, everyone will sign on to the idea of childhood education. It must be a major priority. However, rights as a Canadian citizen do not suddenly terminate at age 22; they step in front of a bus at age 22, and ciao.
We also owe the less fortunate who have accidents after age 21 — or whatever age we pick to define as being less worthy of consideration — rights and obligations as members of our community who deserve the right to a healthy life and a healthy community.
I do not think that commitment will sap our national will to be a better society in any way at all. It will make us a stronger and healthier community. We can see that in the measurable health outcomes in physical ailments as well as in mental illness. You were talking about mental illness. We will see the benefits in many dimensions.
Senator Cook: I know our mandate today was to come and listen. However, I am preoccupied with questions that I need this learned table to help me with.
My Canada is a Canada that lives on subsidies and, sometimes, to be cynical, pilot projects. I think a lot of us who are trying to move forward face that reality.
We are a mercantile society. We will need money because without it we cannot do much.
I wonder how far governments can intrude in the lives of people while carrying out its mandate. The nature of this democracy is: We no sooner fix something and then a new group comes and they invent something else.
How can we move what you are helping us to wrestle with? Following that, how can we move beyond that point?
I confess that I know little about the workings of the Canadian Institute for Health Information, CIHI. Ms. Yeates, you have all this information. How available is that information? Are there restrictions on it?
We are a country called Canada, but we are really provinces and territories. It seems that if we pull on the tension too much we will skew the whole thing.
At the moment, I am sitting here paralyzed on which way to move. I think by the time I reach Newfoundland tonight I will have figured it out.
The world changes, but we are still people. When Mr. Butler-Jones used the word ``outports,'' I thought, Oh, good. I can get my warm fuzzy. I was born in one of those outports when life was much simpler. Somewhere or another, this society has passed that time by. The people are still the same and the needs are the same. However, everything is so complex we do not know how to be the best that we can be for them.
Who can help me explore this issue?
Ms. Yeates: I will tackle the CIHI portion of your question, and that will give others time to answer the other portions, as well.
The country is complex. I was a provincial deputy minister for many years; not from Newfoundland and Labrador but from Saskatchewan.
I am cognizant that the country is made up of provinces, territories, communities, cities and others. In some ways, the federal government or the federal level may not be the right place for all things. It is the right place for other things.
I am happy to say that I think CIHI is one of the pieces that work reasonably well. I am biased, of course. I think it is because CIHI is not a federal institution; it has ownership and control from the health sector. I think there are a couple of federal people on our board. Mostly, there are provincial deputy ministers and there are people from the health sector. They tell us what information they need and we make it available to them.
The answer to the question, is it available is yes, very much so. Obviously, the privacy restrictions apply. Record- level data is not as available. However, we have a mandate to make the data available first and foremost to those who run and fund the system. We do that. Researchers use our data regularly.
A third priority area for us is the general public. While they tend not to comb through the data, we certainly write all our reports with that voice; we try not to be technical, and put out messages and press releases that people can understand. The home care money is either going up or it is going down. The waiting times are going up or going down. The money is flowing here or there. We give people that kind of information as plainly as we can.
We try to fulfill that role. While I am sure not every Canadian finds health information as interesting as I do, we are pleased with the uptake, especially on the web. The hits are enormous. People spend a lot of time there. They spend on average 20 minutes. The numbers go up by hundreds of thousands every year.
Our sense is that people are interested in information if they understand it and if we make it clear to them. That is why indicators can be powerful because they encapsulate so much that is complex into something we can monitor.
Mr. Lewis: I extend this invitation to the senators who have been listening patiently: If you have questions or comments that you want to put on the table of specific people or generally, it is a good opportunity to do so here in this last session.
Ms. Lynkowski: I think the report needs to speak strongly to the need for intersectoral leadership. I do not mean only collaboration but a new and innovative way of looking at how we take intersectoral action. Ms. Bégin gave us a couple of examples of how that leadership might be implemented: a cabinet committee or whatever that might be. However, the report is an opportunity to articulate innovative mechanisms to deal with a specific issue such as early childhood. It needs to come out strong on that point.
This may sound self-serving. In the meantime, public health traditionally deals with these kinds of issues. Until we reach Utopia where we function in an intersectoral way, we need to recognize that public health will be called upon for this kind of response and will continue to be called upon at a community level. We need to ensure there is capacity at that level. The report needs to speak to that need, even if it seems like old news. As we discussed, our ability to respond still remains a problem.
I believe this report is an opportunity to make a compelling, inspirational case about why this issue is important to Canadians. With all due respect, some of us will not be here forever to continue to move this issue forward. I know I will not be nor will the esteemed senators. I have seen a lot of reports sit on a shelf. We know which ones they are. We need that kind of grassroots political will, and you need that healthy public outrage to keep something moving in spite of whether we will be at this table. This report has an opportunity to create that will.
The Chair: Ms. Lynkowski, we purposely did not involve community organizations around the table because we wanted to focus on the top level federal strategy. We have planned a number of visits to communities with organizations in place that I think can bring together the 12 determinants of health.
In my opinion, there are two big defects, and I expressed them this morning. One is that we do not have leadership at the top, and Ms. Bégin dealt with that point. She said we need a cabinet committee such as they have in Britain and Australia, with no mincing of words, and that it must be led from the top.
At the community level, where these determinants of health come together, we need to deal with everything that causes health disparities in the communities and try to change that situation. Structures must be put in place.
Senator Eggleton mentioned that cities and municipalities already have a sort of infrastructure to deal with this issue, but I think we must look at smaller community organizations where people in the community have real hands-on involvement.
I would go even further than this suggestion. I think public health should be integrated with the community health and social service support systems. In other words, instead of trying desperately to supply the resources to deal with what could be hair-raising issues in public health, such as a pandemic, for example, we build a connectivity to work with the community resources. I would like some discussion about that suggestion.
I raised this point with Dr. Butler-Jones about a year ago, and he educated me about the difficulties of implementing something like that, but I want him to repeat them on the record.
Ms. Lynkowski: There are challenges with that suggestion. Sometimes they work together in spite of the fact that we have not imposed a structure, and that is when it happens most successfully.
Having federal leadership that provides a catalyst and facilitation as well as acknowledging the need for increased tools and capacity would help to move that suggestion along.
Dr. Butler-Jones: Connectivity is key. My concern about structural responses to a problem is that we tend to jump to them rather that determining what elements we are trying to accomplish. Many of these things need an actual home or hearth. Public health thinks about communities and the approaches to them a little differently than hospitals do in terms of role and engagement. It has one foot on the social science and social services side and one foot on the medical sciences and epidemiological side. It is really the connectivity that is important.
I also have a great belief that communities organize themselves in ways that suit their needs based on the problems they face. Many communities naturally do many things to which we aspire, either nationally or provincially, because of the nature of the work and the engagement. They cannot afford not to work together. It is important to encourage and foster that working together. I am not sure it is a structural solution in terms of putting them all in the same place, but perhaps there could be shared space for certain facilities. There is a range of ways to work together.
I would go back to focusing on what we are trying to accomplish and what will help us move in that direction. That focus, in a way, would allow communities to develop their structures as it makes sense for them. The concepts that underlie this issue and the issues you are trying to address are essential.
Senator Fairbairn: You were looking for language. I have been working on literacy since soon after I became a senator in 1984. Literacy was not an issue then. In the Senate we had a special committee studying youth across the country, and literacy popped up everywhere we went. Literacy became my life, and it still is.
People often listen when we say that we are taking this measure so every Canadian can have a fair chance — a fair chance at many of the issues we have talked about today. For some reason, that approach works. If you want to play with that, feel free.
Ms. Bégin: On the question of eventually reuniting social affairs with public health, it is 15 years since health and welfare were divided. Human Resources and Social Development Canada is the welfare part of the old department. It went through several restructurings during these 15 years. These restructurings are one reason not to destabilize the department even more. I do not think it is a solution in itself. There are times when an electric shock is a solution and times when it is not. I cannot immediately see the interest.
In addition, as Mr. Butler-Jones said very well, the constituencies of the Public Health Agency of Canada and of HRSDC are not the same. I think that other methods of collaboration would be simpler and more pragmatic and would yield the same results.
I believe it was Dr. Maurice LeClair who joined the health and welfare department around 1972. I inherited a department that had been both for at least five years. It was distinct in terms of operations. I easily navigated from one branch to the other, but there were eight branches, including administrative, and research and planning. In my eight years, I do not remember research and planning ever being involved in medicare, which was a huge dossier. Rather, the social policy people were involved. I benefitted from that structure, but restructuring is not necessarily the solution.
Dr. Reading: At this time of day, it is hard to make a unique contribution because most things have already been said. I am fortunate to be the product of a university environment, and I like to think I contribute back to that environment by being employed there.
I think we are missing the role of universities in terms of research, training and community service. We have all benefited from that role.
I was privileged to sit on the committee for the National Collaborating Centres for Public Health chaired by John Frank, which was funded by the Public Health Agency of Canada. There are 50 to 55 emerging schools of population or public health that are connected to universities and colleges across the country.
Where they are in terms of any kind of accreditation is unknown, but one thing to consider is a network of environments that look at population and public health, based at universities but connected to communities and regions because it is clear that all this activity happens at the regional level. We need to turn our attention to training the next generation of scientists, activists and people who will engage in education and practice around population and public health.
That training leads to calling for investments in the area of university-based programs that are connected. This field is an emerging one. It is multidisciplinary, cross-disciplinary and interdisciplinary, and those distinctions are subtle ones, but it is a specialized group. What tweaked me to think about it was when Mr. Butler-Jones talked about how these two domains connect. It is much broader than that, when we think about how a young person might come into this field, the perspectives they might bring to the field, and how those perspectives would evolve and be a Canadian contribution to the international discourse on population health. Canada has a great history and a good tradition in this area, but we need to take it into the future and figure out where to go. Including universities in the formula would be appropriate for the final report.
Mr. Cappe: I tried not to enter this discussion. I cannot help but comment on Ms. Bégin's and Dr. Butler-Jones' interventions. The organogramme of government is much less important than how people work together. I align myself with the viewpoints of Mr. Butler-Jones and Ms. Bégin. It would have been nice if health and welfare were together, but it is not essential because they have to reach down the sleeve and pull it inside out to make it work. That is why I talked about aligning objectives.
We want a big group of people working in the same direction. If we think about who should be combined in this group, it is not health and welfare. It is HRSDC, as the current acronym is, the Department of the Environment, the Department of Natural Resources, the Department of Indian and Northern Affairs, Finance Canada, Health Canada, the Public Health Agency of Canada and so on. The list is long.
That leads me to the cabinet committee idea. I do not think a cabinet committee is the right way to go. It might be for a specific purpose. If we reach a point where there is an initiative that we are prepared to take, like an early childhood development program where the initiative becomes concrete, we might want a cabinet committee to deal with the initiative and move it along, but in a sense we want these departments and these ministers to work together much more informally. In everything they do, we want them to be aligned in focusing on improving population health in different ways.
Ms. Bégin: Regarding university training, and I cannot recall if the legislation included college training, but in June 1984, legislation was passed in the House entitled, if I remember correctly, Indian and Inuit Health Careers Program. That legislation was modelled on what a justice told me about legal training for First Nations at the time.
I was told that they cannot kill an act that fast or they do not put any money in it, but maybe someone can check. If you want to promote population health and knowledge amongst Aboriginal populations, that act can be revised and enlarged to include that and be put on the public agenda.
Ms. Potvin: I wanted to answer your question, Senator Keon, about where public health should be located. Look at Canada. Structurally, public health is located in many places, and it has evolved through the years. Nowadays, Quebec is reintegrating public health with the hospital and things like that. There are drawbacks and advantages to that approach. This integration raises a lot of fear that the budget will go to the hospital, but at the same time, it provides public health with a lot of opportunity to do some good work, given that the proper training is provided to people. One challenge now is to train those people who are administrators of those structures of public health.
To return to Dr. Reading's point, there is a general feeling in Canada that good will is enough, where it is not. We should train the right people in whatever the structure is, and the problem is not structural. The problem is having the right people with the right training. The health personnel and public health personnel, at this point in Canada, are not well-trained. That training is also a kind of constant that is said to be done but is not being done.
Senator Callbeck: Mr. Cappe raised the idea a minute ago that Ms. Bégin presented this morning about having a cabinet committee chaired by a powerful minister — the Prime Minister, the deputy prime minister or the minister of finance but preferably not the Minister of Health — and she suggested why.
Mr. Cappe, you said you did not agree with that idea. I take it that you think this should be an informal arrangement between ministers? Who should drive this arrangement?
Mr. Cappe: I will invoke Senator Eggleton's reference earlier to the front office. I do not dispute the premise that they need someone to drive this arrangement. Therefore, I would rather see all the actions of government focused on this issue and put through the lens of its impact on public health, as the fourth report recommends. However, I would put it in a mandate letter from the Prime Minister to the relevant ministers. All of them are relevant in one way or another. If the Prime Minister tells each minister to focus on the following three things, and one of those three things is the advancement of public health in Canada, it focuses the attention. The Prime Minister, as you know better than most people, has power only informally, but the Prime Minister has the ability to name ministers, and that is about all the power they need. Therefore, ministers will pay attention to that mandate letter. If the Prime Minister says, ``I want you to report back in a year on what you did and how you cooperated with your colleagues to advance the agenda,'' then I have more confidence in that approach than I do in an institutionalized cabinet committee with a secretariat and cabinet documents being prepared and a lot of paper being printed, which might not advance the agenda much.
Ms. Browne: As much respect as I have for public health, I want to go to the more compelling thing. I would unite public health with community and social services because the burden and the cost of so many problems are there, in terms of income maintenance, disability pensions and so forth whatever. I realize public health has different emphases, such as community capacity and development. They are good at that. However, our public health department would say half the people they work with are on social assistance. However, at the time, they only had 4,600 visits a year, and there were a hundred thousand people on social assistance. Public health has been so badly underfunded over the years that I am not sure it has the capacity to take the lead.
To become involved in direct service with public health, someone had to come to the attention of someone else to be referred, whereas that is not the case in the social services, food banks and so forth.
The Chair: It is interesting when witnesses come before us and fundamentally, their stories are universal. They say, they have this problem, whether it is a mental health issue or whatever, and they had to take time off work and ran out of money and had no place to go and they are receiving psychiatric treatment. Then, when they walk out the door of, say, the Royal Ottawa Hospital they do not know anyone to help them obtain social assistance, housing, food and all this stuff.
Surely the government can come together and find a way of providing community resources that produce connectivity for these poor people to have a place to go. It seems to me this problem is a huge missing link in our health and social service organization in Canada at the present time.
Ms. Potvin alluded to integrating public health for hospitals. Again, I am not sure that is the way to go because we seem to have an inability to think of organizing anything in health that is not associated with hospitals and doctors. On this one, to effect the 12 determinants, we need some kind of community infrastructure that can talk about the 12 determinants, not only one of them.
When I wrap up, I will allude to why I am looking forward to working closely with the Standing Senate Committee on Aboriginal Peoples on this issue.
Dr. Butler-Jones: In part response to your comments, senator, and hopefully what I am trying to be clear about is that there are different structural solutions to address that. Many provinces now have integrated systems, at least for health and many social service components also under the same administration. The provinces do not necessarily talk to each other.
I worked as a medical officer in Ontario. We had close linkages with social services, with education, with municipalities and others and sat around tables where we thought through the implications of each of our program's activities to try to minimize the disconnects in the system.
One of Saskatchewan's approaches is to have fora for assistant deputy ministers and regional fora from all the different sectors, come together to think through the problems. There are different ways of approaching it. A few people have asked what we are trying to accomplish in this approach and the necessity of it. If the expectation is clear that the performance of CEOs, deputy ministers, ministers or others depends on our ability to work across sectors and ensure that these gaps do not occur, it is much more likely to be done, whatever the structure. No matter what the structure, if we do not have that expectation in place, we have seen many of those structures where they are bunch of parallel silos even though they are down the hall.
The Chair: There is nothing left to do except to thank you all for spending this long and strenuous day with the committee. I am particularly appreciative of how many of you stayed around on a Friday afternoon. My experience with Friday afternoon meetings is they become badly depleted by about 2:30 p.m.
I was going to wrap up. I will not. You have heard all the conversations. I think you know where we need to go. We need to find a way of providing some leadership at the level of the federal government. What particular form that leadership takes we will need to consult some people and fine-tune this information.
I remain convinced that we also need to provide advice about how community services must be organized to bring together the determinants of health, whether it is around a town council or some other entity. A city the size of Toronto probably cannot approach this but there are many community organizations in Toronto where this issue can be discussed and where people understand the problem.
Our priority programs have not changed from day one. When we set out we thought they would be maternal health and early child development. I mean early child development in every sense of the phrase. The points are well taken that there must not be an abandonment at age three if these children are not ready to go to school yet. It must be an early life continuity of programs.
The other thing I feel we must address in all conscience even though it has been addressed in many ways, is Aboriginal health. Dr. Reading has been helpful, and the other people involved in Aboriginal health have been helpful. However, we must find a way of suggesting strategies to work around some of the tremendous difficulties that occur in moving an agenda through the Aboriginal community without interfering with their way of life and their own organizations. We have given that a lot of thought and I believe we can propose some structures that will help.
Finally, Ms. Yeates, we will nail you to the cross and be back over and over and over because we want to measure everything we are doing and see how we are doing it. You made the mistake, the first time you came before the committee, of saying you can do this measurement.
Thank you very much everyone.
The committee adjourned.