Proceedings of the Subcommittee on Population Health
Issue 5 - Evidence, May 7, 2008
OTTAWA, Wednesday, May 7, 2008
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:05 p.m. to examine and report on the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chair) in the chair.
[English]
The Chair: Honourable senators, I welcome our witnesses today. We look forward to hearing what they will be able to tell us. We have, from the National Collaborating Centre for Determinants of Health, Ms. Hope Beanlands; from the National Collaborating Centre for Healthy Public Policy, Mr. François Benoit; from the National Collaborating Centre for Environmental Health, Dr. Ray Copes; and from the National Collaborating Centre for Aboriginal Health, Ms. Margo Greenwood. We are blessed with scientific directors.
This is the second phase of our current study. We are looking for reactions to our fourth report, which is the issues and options paper. This meeting will focus on the issue of tracking health outcomes and supporting research interventions to enhance the health of the population. We would like each of you to provide us a brief overview and then respond to questions from senators.
Hope Beanlands, Scientific Director, National Collaborating Centre for Determinants of Health: Honourable Senator Keon and honourable members of the Subcommittee on Population Health, thank you for the opportunity to speak on behalf of the National Collaborating Centre for Determinants of Health, known as the NCCDH, at St. Francis Xavier University, situated in Antigonish in beautiful, rural Nova Scotia.
The Chair: I cannot resist saying something totally off subject here. My dearest friend and supporter for 30 years was Dr. Don Beanlands. Is there a connection?
Ms. Beanlands: Yes, there is, and I was at the party.
The NCCDH is one of six national collaborating centres for public health located across Canada. The mandate of the six national collaborating centres is to translate the existing and new evidence produced by academics and researchers in public health so that it can be used by public health practitioners and policy-makers. I am very pleased that I have three of my colleagues from the other NCCs here as witnesses.
The focus of the NCCDH is on the social and economic factors that influence the health of Canadians. As you know, income and social status, social support networks and social environments are some of the factors that determine the health of Canadians.
At the NCCDH, our mandate is the synthesis, translation and dissemination of existing knowledge of the social determinants of health using an equity lens. Our mission is to engage public health practitioners, policy-makers and researchers in applying the knowledge about the social determinants of health in policy development and in public health practice to achieve social justice and health for all.
I will focus my comments, as requested, on the first issue and the options presented in the paper. As stated in this paper, in order to track health outcomes, it is essential to have identified health indicators, health goals and desired health outcomes. I will speak about the two options separately.
The first option was to expand and enrich the population health databases. What more needs to be done?
First, we believe that we need to facilitate the collection, collation and analysis of disaggregated data to enable the development of customized public health policy responses and interventions. Sex-disaggregated data or statistical information that differentiates between women and men is an important path toward achieving health policy responses and interventions.
The 12 determinants of health can be used as a framework for community needs assessment, enabling the collection of neighbourhood level data in a manner that facilitates both management of change related to specific policy and program interventions over time, and it also provides an inter-neighbourhood comparison level of data. An example of this approach is provided by the Bell Island Health and Well-Being Needs Assessment conducted by Dr. Verlé Harrop for the Bell Island Health and Wellness Committee, Bell Island, Newfoundland and Labrador. I encourage you to invite her as a witness to appear before this committee.
The need for sex-disaggregated data is well demonstrated in a case study prepared by Dr. Beth Jackson of the Public Health Agency of Canada and Ms. Ann Pederson of the British Columbia Centre of Excellence for Women's Health entitled «Sex, Gender, Hips and Knees...Gender Based Analysis and Total Joint Arthroplasty (TJA).»
Second, there should be a focus on increasing the collection of data based on the social determinants of health, including ethnicity, culture, gender, social networks, social environments and working conditions, to name a few.
Third, we need to enable the collection of community-based or neighbourhood-based data to facilitate the measurement of customized public health and policy interventions.
Moving on to investing in more population health research and enhancing the translation of knowledge, the second option presented in the paper, at the NCCDH we believe that we need more research to understand the complexities of knowledge translation.
The Canadian Institutes of Health Research, CIHR, define knowledge translation as an exchange, synthesis and ethically sound application of knowledge within a complex system of interactions among researchers and users to facilitate the capture of benefits of research for the Canadian population through improved health, more effective service and products, and a strengthened health care system.
As this definition implies, getting evidence into practice is a complex system of elements and interactions that includes such things as research, priority setting, knowledge creation, dissemination, uptake, application and evaluation. I have included the Health Development Agency diagram from the U.K., which talks about the evidence- into-practice cycle. You can see from this cycle that it is a complex set of interactions, and we need to understand it better.
We know that people will use research and gain knowledge if they are part of that knowledge development and the research process. The NCCDH therefore encourages funding support for researchers who include communities and neighbourhoods, front-line public health practitioners and policy-makers in the framing of the knowledge translation research that needs to be done and the interpretation of the findings. Again, Dr. Harrop's work is an excellent example of this approach.
Third, we believe that more public health intervention research is required. As several of your witnesses emphasized, Dr. Louise Potvin for example, we need to know which public health interventions work, which ones work better and under what conditions. We do not have that information right now.
We know that health inequities in Canada are socially produced, are systematic in their distribution across the population and are unfair. We need to know how best to achieve the levelling up of the health status of less privileged socio-economic groups to the level already reached by some of our more privileged counterparts. I think that includes all of us here in the room.
In summary, it is critically important to expand and enrich the population health databases and to invest in population health research and enhance the translation of knowledge addressing the socially produced inequities in health.
The NCCDH and the other five national collaborating centres are important collaborators in the knowledge translation process to place new research evidence and promising practices in the hands of public health practitioners and policy-makers. On behalf of the NCCDH, I thank you for this opportunity to make this presentation.
[Translation]
François Benoit, Scientific Director, National Collaborating Centre for Healthy Public Policy: Mr. Chairman, thank you for this invitation to take part in your very interesting work.
[English]
Healthy public policy is in the name of our collaborating centre. I will take this occasion to speak both on the option that is the topic of today and on the topic of healthy public policy and health impact assessment.
[Translation]
Healthy public policy is a key concept, a cornerstone for the application of a population health approach. It is particularly remarkable that a centre has been devoted to this issue since a program as new as that of the National Collaborating Centre's has been launched. Nor is it by chance that the Centre has been established at the Institut national de santé publique du Québec, which was selected for its public health expertise, which your report emphasized, but especially because the Centre serves as a support for the implementation of section 54 of Quebec's Public Health Act, which is the section requiring a health impact assessment of all bills and regulations submitted to the Government of Quebec.
[English]
I think you have the National Collaborating Centre Program. In the presentation we sent you, we remind you that we are one of six centres financed by the Public Health Agency of Canada. There are six topics and so six different institutions.
[Translation]
These institutions act as bridges between practitioners and public health decision-makers on the one hand and research on the other.
[English]
Four things could be said about the National Collaborating Centre Program. The collaborating centres are original in that they have been established in existing institutions building on the competencies already there. They act as a bridge between the researchers, practitioners and decision makers, but they also adopt the perspective of being the advocate of the user.
[Translation]
It should also be emphasized that this program is relatively new. In practice, we have been in operation for two years, and our centres are dedicated to knowledge translation.
[English]
This gives me occasion to comment on one of the options, knowledge translation.
[Translation]
Knowledge translation is a mandate shared by the six centres, but this is not an innovation since we rely on the work that, in the history of Canada, has marked this concept and, of course, the work of the Canadian Institutes of Health Research and the Canadian Health Services Research Foundation on knowledge translation. Ms. Beanlands has identified the translation we do. We are not the only ones working on knowledge translation, but the NCCs bring an original perspective in that each of us in our various subjects brings new ways of innovating in knowledge translation.
[English]
From the bottom up, we are informed by the user of the needs, and we are also centred on knowledge, which is not necessarily the same thing as evidence, in the sense that we are not translating the latest research on the block. We are translating and summarizing knowledge to be useful for the different targets we have.
We use interactivity.
[Translation]
Interaction assists in knowledge translation, which is important, but also in informing our work with users about what is necessary, and thus this kind of reactivity that we have established.
Our recommendation on this point, with regard to your work, is consistent with your approach; that is to say that we must support knowledge translation through a number of partners, not a single partner, but that, in this type of area, the collaborating centres should bring an original perspective.
[English]
I will broach the subject of health impact assessment. I know this is a topic you have brought forward for consideration in your report.
[Translation]
The expertise that we have developed in this area at the National Collaborating Centre for Healthy Public Policy meets a demand from users. There are currently a lot of activities at the local and regional levels in Canada, and our work has therefore focused on developing tools to support that activity. You recommend this application at the federal government level, and I submit to your attention the diagnosis made by Frankish and his colleagues.
[English]
On this question, there were challenges for implementing healthy public policy and impact assessments; political challenges, including competition among various sectors and a lack of political will; and technical challenges. I submit this is your turf and preoccupation. The technical challenge is having a structure that could support this action.
[Translation]
However, the question in the past 10 or 20 years has been: has the situation changed? Quebec's experience has generated expertise or a practice that can be queried. It has also supported the research work that has been done from this perspective and thus gives us certain perspectives that we did not have, while the health impact assessment sector at the international level has continued to develop methods and tools, which definitely puts us in a better position than we were in 20 years ago.
[English]
Dr. Ray Copes, Scientific Director, National Collaborating Centre for Environmental Health: Good afternoon. It is a pleasure to provide a presentation on behalf of the National Collaborating Centre for Environmental Health. My colleagues have explained a bit about the national collaborating centres. The time I have been scientific director of the NCCEH has been an exciting opportunity. We are new on the public health scene in Canada, and we are looking forward to making a mark. We have a unique role, and all six of us look forward to fulfilling that collaboratively.
Each centre has a different theme. The theme of NCCEH relates directly to one of the determinants of health in your paper, which is the physical environment. When we started out at the NCCEH a few years ago, we were given a relatively narrow definition of environmental health. We were encouraged to focus rather narrowly on the programs and services in environmental health delivered at the local and regional level by public health organizations across Canada. We thought that was a good definition, but a bit limiting. We negotiated and pushed back a bit to look at environmental health issues beyond current status quo in local public health units and to look at ways in which we might address environmental health issues that were having a significant impact on mortality and morbidity in the Canadian population.
Before we got started with our work plan, we picked a client or a customer group. We are there to serve the needs of environmental health professionals at the local and regional level across Canada. What we do has to meet their needs. Their priorities are our priorities. We did an environmental scan before developing our first work plan. We went across the country, coast to coast to coast, talking to environmental health practitioners and policy-makers and researchers. We did key informant interviews with over 90 such individuals in every territory and province in Canada as well as in the federal sector.
I tried to summarize what we found in that scan in one of the slides I presented you with. Not surprisingly, we found that the delivery models for environmental health services across Canada varied dramatically depending on the province or territory. That makes some sense. Prince Edward Island is not the same as Ontario and, not surprisingly, the delivery models are quite different there.
We found important cross-cutting lessons as well that relate to the issues paper you asked us to read. We found in environmental health that there is very little monitoring, surveillance or tracking of environmental risk factors or exposures in Canada. To some extent, internationally Canada lags rather than leads in this area, and that causes me respectfully to question whether we do have good information on all the determinants of health for the Canadian population. In the environmental area, we are somewhat lacking.
There is also scant citeable evidence that many people delivering environmental health programs can provide as justification for their programs. That is not to say that the programs are not achieving objectives or are not worthwhile, but if you challenge people to provide a citation of scientific evidence, not much could be put forward.
We also found that there is relatively little evaluation of services and programs in environmental health. That speaks to another option you have under your first issue. Should we be looking at evaluating interventions and outcomes? Much of what we are doing, if evaluated, would show that it is effective. Probably some of what we are doing is not effective, however. We would like to do more of what works and perhaps not do as much of what does not work. There is real value in focusing on some intervention research in environmental health and trying to motivate what is physical environment.
I have been in this field for a number of years. It is important to recognize that as well as being a determinant of health, environment includes the natural environment, which is what many people think of when they see British Columbia travel posters, and also the human environment, which in many respects is more important because that is the environment we are in right now. Very good research indicates that the typical Canadian spends over 85 per cent of their time indoors, breathing indoor air, exposed to an indoor environment. Exposures indoors are generally underappreciated and under-researched, and perhaps to some extent they are, I do not want to say under-regulated, but perhaps they do not attract as much attention from government agencies as they should.
In some parts of the country, environmental health programs include injury reduction. I urge folks to consider whether that important set of health outcomes should be included in environment or not.
As someone with training in medicine and toxicology, I tend to focus on biological, chemical and physical agents and how they can interact with the body and produce death or illness. It is important to think about the physical environment and its indirect effects on human health. A lot of interesting research is looking at how the buildings in which we live, work and go to school can affect our activities and exposure. Do these buildings offer us the opportunity to exercise and have fresh air?
The neighbourhoods and communities we live in can influence our eating habits. If we live in neighbourhoods where the only food or the nearest food is fast food as opposed to vegetables, fruit and fresh produce, then that can have a subtle effect on our dietary choices. If our neighbourhoods are not conducive to taking exercise, this can affect our choices on physical activity. The way we lay these neighbourhoods and communities out and the reliance on private vehicles as opposed to public transit, walking or cycling can be a powerful influence of the physical environment on major public health issues such as obesity and lack of physical activity.
I have presented a bit of information on World Health Organization, WHO, estimates of the environmental burden of disease. I do not want to get into this in great detail because we do not have time. However, if there is interest or more questions on that, I can try to answer them.
I would like to comment on one Canadian estimate of preventable deaths due to air pollution in eight major cities. I would point out that it is no coincidence that we have a specific estimate of mortality from air pollution in Canada. Why is that? If I try to think of nationwide information systems or databases on environmental exposures for Canadians, the only one I can think of is the National Air Pollution Surveillance, NAPS, database which takes results of common air pollutants in Canadian cities and puts them into a national database. That has been used by Health Canada scientists to do research on the relationships between common air pollutants in Canadian cities and a whole variety of health outcomes, largely cardiorespiratory in nature but looking at mortality, hospitalizations and physician office visits. That database, which is probably our best or only one in the environmental sector, has generated a lot of incredibly useful information. It has led to the estimate we have that 8 per cent of all preventable deaths are due to air pollution in eight major cities.
We are asked to think about health disparities. It is interesting that the figure for those preventable deaths is only 5 per cent in Vancouver and 10 per cent in Toronto-Hamilton. There is a disparity there. We are not used to thinking of Toronto as disadvantaged, but depending on the levels of air pollution we have in our cities, there are unequal risks being experienced by Canadians. I would suggest that for many other environmental factors there are disparities as well in the health risks faced by Canadians.
With respect to drinking water systems, we do not have a national database on what is in Canadian drinking water. The NCCEH is conducting a project that is trying to put together retrospectively a complete compilation of cases of water-borne illness in Canada. It is interesting that we have to do that retrospectively. Why is there not a complete reporting system? We do have some reporting, but we need to look at ways of improving the completeness and effectiveness of this reporting system.
We have heard about water supplies in First Nations communities, and these do not always meet acceptable standards. That may be very true, but I would suggest the real disparity here is not so much about First Nations versus non-First Nations but probably relates more to large water systems and small water systems. Across Canada, there is little concern about a Walkerton kind of event occurring in Toronto or Edmonton or Vancouver. However, there is a great deal of concern about how well we are able to operate water systems and to treat water in many smaller communities both on and off reserves.
With the physical environment as my focus, I suggest that we cannot look at those determinants in isolation. There is a figure in a discussion paper that carves up a pie into neat portions. My training in epidemiology would suggest that you cannot apportion or attribute out determinants of health into mutually exclusive categories.
An exact percentage will always be wrong no matter how we try. We are looking at a range, and I suggest that because we have relatively poor information on environmental factors, 10 per cent is probably an underestimate for environment. A WHO estimate, again incomplete, suggests that 13 per cent might be a better figure, but we do not want to quibble over percentages. The important things to look at are not only determinants in isolation but also the interaction of determinants and the fact that some of the socio-economic relationship between poor health outcomes is probably explained through differences in environmental exposures for less advantaged Canadians. Mechanisms are important because it is only through them that we are able to think about interventions and the steps we can take to remediate, rectify and reduce some of these disparities. Environmental factors are amenable to that kind of assessment.
We need better information, which speaks to the first option you have put forward. I wonder whether we need a Canadian institute for environmental information along the lines of the Canadian Institute for Health Information, CIHI? Often there is a great deal of federal and provincial data but there is not always good trust between the levels of government. Sometimes a model of an agency outside the federal-provincial-territorial framework can be helpful. We need to focus on mechanisms and develop policies and practices that look at the interaction of these health determinants. As well, we need to look at how we can build our physical environment and how that can affect things like obesity and diet. We need to integrate actions at federal, provincial and local levels and, above all, we need a better evaluation of outcomes. Let us find out what truly works. I appreciate the opportunity to address the committee and I look forward to questions.
Margo Greenwood, Scientific Director, National Collaborating Centre for Aboriginal Health: Good afternoon, honourable senators. As a Cree woman, indigenous scholar, mother of three, and academic leader or scientific director of the National Collaborating Centre for Aboriginal Health at the University of Northern British Columbia, I am both personally and professionally invested in the questions concerning population health policies in Canada, in particular as they are informed by social determinants of health.
It is a privilege and an honour to come before the committee today to offer some thoughts on behalf of the National Collaborating Centre for Aboriginal Health. The mandate of the NCCAH is unique in the NCC program in its focus on the population. Our mandate is to support Aboriginal communities across Canada in realizing their health goals. The centre uses a coordinated, holistic and comprehensive approach to the inclusion of Aboriginal peoples, research and indigenous knowledge in a public health system that is respectful and responsive to First Nations, Inuit and Metis peoples and all Canadians. I will focus my comments on issue 1 of the committee's issues and options paper, but I will address some aspects of other issues contained in the document as well.
In answer to what might be done to improve the information available on health disparities among First Nations, Inuit and Metis people, my thoughts are as follows: There is a distinct need for data specific to First Nations, Inuit and Metis peoples and for data that are national, regional and community based. Combining these distinct groups together under the term «Aboriginal» does not yield the meaningful evidence necessary to inform health approaches, policies and interventions, in particular at the community levels.
In their work, Dr. Charlotte Loppie and Dr. Fred Wein found that health surveys are critiqued for not comprehensively including all Aboriginal groups, yet when the groups are included, there are often survey methodologies and inaccuracies that make the data not comparable. Dr. Janet Smylie work on vital statistics registration surveillance in infant child health data also raises the need for specific and accurate information that distinguishes amongst Aboriginal peoples. How do we identify? In fact, as Smiley observes, we still do not have infant mortality rates being produced nationally or provincially. As well, we do not have provincial and territorial data that meet international or even national standards.
As for health indicators, there continues to be a need for the inclusion of specific First Nations, Inuit and Metis indicators addressing the underlying social determinants of health, such as self-determination, culture and the intergenerational effects of assimilation policies evidenced through residential schools and dislocation. The Assembly of First Nations' holistic approach to indicators that they developed in March 2006 and the UN Permanent Forum on Indigenous Issues identify a number of indicators that can address linkages between health and social determinants. Indicators concerning language, for instance, can determine how many people in a community speak an indigenous language, the number of related programs that exist and how many children are learning indigenous languages. Languages are key to children's identifying with communities and cultures.
Developing a comprehensive Aboriginal-specific health strategy for addressing health disparities is critical to the health and well-being of Aboriginal peoples. An individual program approach to prevention and treatment of ill health does not adequately address Aboriginal health needs. As well, it is not consistent with Aboriginal holistic views of health. Often in our communities, we hear people talk about holistic health and all of those things that impact our well- being. As was written in the Senate subcommittee document, the federal government has a unique opportunity to engage Aboriginal leaders in the development of an approach that would respect Aboriginal concepts of health and improve the focus, the organization and the delivery of governmental services. This would mean engaging with Aboriginal political leaders, leaders in health research, community stakeholders, members and related non- governmental organizations and entities. This approach would not only demand coordination of governmental programs and services but would also require building upon the strengths of existing entities, such as the national collaborating centres, the National Aboriginal Health Organization, NAHO, and the Institute of Aboriginal People's Health in CIHR. Some of those entities exist.
One might also look to ground-breaking examples, such as the Tripartite First Nations Health Plan, an agreement signed between Canada, British Columbia and the British Columbia First Nations Leadership Council. This agreement ensures that First Nations are fully involved in decision making regarding the health of their peoples. Aboriginal groups have also developed comprehensive frameworks for public health. In 2006, the AFN developed a public health framework for improving the health of the people in our communities. The Inuit are developing their framework, and the Metis have also developed a similar document. In addition, the government could provide high-level support to Aboriginal leadership undertaking First Nations, Inuit and Metis health assessments through existing mechanisms, such as the First Nations Regional Longitudinal Health Survey.
In short, we have high-level agreements that can help us to guide implementation strategies; and we have some examples. We have models of shared governance to draw upon. We have capacity as well as public health frameworks developed by Aboriginal people. We have mechanisms upon which to build a comprehensive and coordinated plan for the Aboriginal health and well-being of Canada.
Finally, I will close with my thoughts on population health research and knowledge translation. There is an ongoing need for adequate support for innovative, community-based research that ascertains policy program and service interventions, ones that work and ones that do not work as well. I think we heard that from Ms. Beanlands earlier. Since 2000, the federal government has supported development of NAHO and the NCCAH, which are engaged to various degrees in research and knowledge translation. These organizations can help develop a concerted national Aboriginal health research agenda with strong collaborative partnerships, with the strength and linkages between government, research institutions, communities and organizations.
One of the highlights of our own NCCAH work was an inaugural forum in February 2008 on the indigenous social determinants of health. This forum for the first time brought together representatives from many and varied sectors, including government departments across the country, to explore indigenous social determinants of health in their broader context. We are also nearing completion of a comparative inventory of Aboriginal health policies that are in place at the national, provincial and territorial levels. This is a tool that we have developed for researchers and policy- makers and is hopefully useful to community members as well. We have a number of activities going on that support the population health agenda.
In closing, when it comes to addressing this complex multi-faceted and interconnected issue of social determinates of Aboriginal health and well-being, I would urge you to consider starting with children. Almost half the Aboriginal population consists of children aged 24 and under. It would seem sensible at an early age to deal with the health consequences that we see manifested in adulthood. It is in our children where so many social determinants, including poverty, culture, education, employment, language and self-determination, all intersect.
I thank you for the opportunity to present my thoughts on behalf of the NCCAH.
The Chair: Thank you very much. A number of senators want to question you, and I would like to begin.
We are reaching the point where we are working with a structural framework for our final report on the recommendations. You are here to help us wire it, so to speak. The information system will be of vital importance as this whole movement unfolds for the tracking of progress and the identification of needs and the identification of change and so forth.
We are working towards identifying what we need at the highest level of the federal government. We are working towards what we need on the ground. We selected at the beginning two areas to target so that we could implement our recommendations from top to bottom. These two areas are Aboriginal health and maternal, child and adolescent development and so forth.
I was pleased, Ms. Greenwood, that you repeated something I heard during the mental health hearings from the native communities, and that is that there are problems with the children and there are problems with the mothers and with the older children, particularly the young adults, who feel disenfranchised. We cannot leave them out.
Here is what I would like you all to address, if you can, starting with Ms. Beanlands and going in the order of your presentations. We have a tremendous number of good things in place, many of which were mentioned, through CIHR and the new Public Health Agency, a new atmosphere of cooperation federally and provincially through public health and through CIHI's population health initiative, and the Statistics Canada information system, which they are prepared to adapt. We have had them before us and talked to them about it. It is my belief that we really have to concentrate on community to make this meaningful, because the system, way up there at the top, cannot give you the information you need to translate into the kinds of communities you talked about, Ms. Beanlands.
What resources do you think we must embrace to give us the ability to establish what information we have now? We have plenty of information now to take some action, but how then to build on that information and to measure the progress we are making, whether it be on environment, air pollution, or the correction of poverty, or through the solution to drinking water nationwide?
Ms. Beanlands: I shall start. I know my colleagues will help me out here.
The question is a provocative and important one. We have a lot of information. We have to make a good assessment of what it is that we have and also do an evaluation of how accurate that information is. We have to look at what we should keep and maybe what we should not use.
There will be several challenges, including the definitions on which the data was collected. What does the data really mean? Does it mean what we think it means? Do we all have the same understanding of the label that the data was given when it was collected?
There is another challenge in the data we have. I believe we have good data on education, but what does that mean in terms of the social determinants of health? Is education the same as literacy? Is education the same as health literacy? How do we unpack those concepts?
We know that social networks are important, but we have no information in this country that can be compared between communities.
Another challenge is that we need a framework upon which to collect the information. I would submit that perhaps the determinants of health could provide such a framework. They are comprehensive, interrelated and, I believe, could help change the paradigm for how we think about health. Health services are important and are one of the determinants of health, but they are only one of 12 that you have listed in your report. Where do they stack up? How much money are we now spending on that one determinant when we compare it to the other determinants?
We need to have an information system that does a number of things, including measuring those determinants in a way that can be compared across the country. Data needs to be collected at the community level, because once we have it at the community level we can roll it up into regional, provincial and national levels; but when we collect data the other way around, it is hard to roll it down from pan-Canadian to provincial, to territorial, to regional, to community levels.
It is important that the communities be involved in identifying what is important to collect. I know that is a shift in thinking. We do not necessarily do that now, but I believe that will be an important consideration.
We need to have people understand the importance of data, have them feel that they can control their data and have them give us accurate data. That is another whole dimension of the information we collect.
[Translation]
Mr. Benoit: I think we can refer to some of the lessons given at user meetings.
[English]
The user meeting on the environmental scan that we did at the beginning of the NCC program informed us, and we will continue to do that. A key message we heard is that people want to have a one-stop shop, and that relates to policy and other things.
We were also told that there are some good chunks of information about policy program indicators, but they are stuck in silos and in different parts of the country. We want to bridge them, again referring to the bridge function of the national collaborating centre.
Finally, most important for policy, and it could apply to data as well, is that we need to have a way to make sure that people have the tools so that they can contextualize how it applies to them and how can they apply that to their community level or their actions.
Dr. Copes: That is an excellent question, and it is important that we not lose sight of the community or local relevance of what we are trying to do. When I think about CIHI, and I mentioned possibly a Canadian institute for environmental information, it is a big macro system that feeds the policy-makers. It will not have the impact it should.
Some of the CIHI reports I have seen that create local interest are on different hospital outcomes in different parts of the country. People ask questions. Sometimes those reports may have more hidden in them than what meets the eye.
Along the environmental side, there is an interest in environmental issues across the country. There is not much information, and in many of the local issues I have dealt with, folks are far too fearful, in many respects, than they should be about the environment, and that is a negative impact. Kids stay inside. We are worried about air pollution and all sorts of risks out there from the environment when we should be viewing the environment in more of a First Nations' type of framework as a source of sustenance and nourishment for all of us, and we have lost some of that.
How can we take a big information system, or information, and relate it to the community level? Perhaps we can use benchmarks or indicators for things like your local water system. How much do Canadians know about where their water comes from? How does their particular drinking water source, in objective terms, compare with appropriate benchmarks, such as other communities in their province and across Canada, adjusting for size and making for true comparability?
Can we generate information that will inform or put in context many of the important environmental factors, stimulate questioning and, perhaps more important, bring about appropriate action where there are disparities or where one community looks like it is not as well off as another community? We can do that with the information systems I would envisage in environmental health.
Returning to maternal and child health, parents are particularly concerned about children, and we have some fears and challenges about Canada's youngest Canadians. We also have some incredible success stories. It amazes me the amount of media attention we still get about childhood lead exposures. Lead exposure reduction is a huge public health success story, and if we compare the lead exposures to children in my kids' generation to mine or my parents', we have made huge progress, but many other exposures have gone up. Information on Canada's youngest Canadians can provide us with information, almost like the canary in the coal mine, such as the following: Where are these exposures coming from? How quickly are we exposed? What are the sources? How can we intervene specifically through something like Health Canada's banning of BPA in baby bottles or other targeted interventions that are likely to have an effect and address those exposures that are going up, rather than worrying about exposures that have come down dramatically in the last half century? We should probably channel a lot of that interest and effort into dealing with emerging and new problems, which we can only pick up through an information system and monitoring and tracking of exposures that we are not yet doing in this country. We could take that on a consistent basis nationally and roll it out or have report cards and reports that could be relevant at a community level, too.
Ms. Greenwood: At this time, we have some specific indicators, but we need a lot of research and greater understanding of indicators of help that would be specific to Aboriginal populations. We have got some building to do there.
Also, as I said earlier, there is work to do just collecting basic information and vital statistics. It happens in some places, but it is not consistent, so we cannot really look at Aboriginals compared to other people.
We have some relationships and some entities that we can build upon. Some places and pieces are doing things well. At the community level, a number of examples of data collection work very well in those communities, and we need to bring those forth and give them voice so that we can all know about them and add that to our information. We have that building to do.
In terms of capacity, I think about human resources as well, not just infrastructure capacity and the mechanism of doing it. How do we build capacity in Aboriginal communities to collect, know and analyze this data and to facilitate those interfaces with the provinces, the territories and nationally? If we are talking about the community level up, a lot of building and infrastructure has to happen. However, we have relationships and examples.
To go back to a comment I made earlier, it struck me that you said in your document that sectors other than health have the greatest potential to improve or worsen population health and well-being and to reduce health disparities. That is really poignant to me because in the communities, we think about holistic health. If I was talking with elders we would probably talk about holism, about holistic health. They would probably not have the same concept as we do about population health, but holistic health would be that piece. I think about all those other pieces that we have lots of statistics on beyond the health sector, for example education and employment, and how we bring those together.
Earlier a mentioned a meeting that we hosted here; we invited Aboriginal organizations with a national mandate. Of the 56 such organizations in the country, 49 were represented at the meeting, and they told us that they had never been together in the same room to talk about this. Yet we all carried the same vision for our children, families and communities and for our health and well-being.
I was struck by that comment, and I think that holistic health from an Aboriginal perspective reaches down to when we are looking at indicators and back up again. In your document, you also talked about vertical and horizontal movement. We can see that holistically and circularly, too.
The Chair: I have another important question for you, but I have to let the other senators go first.
Senator Cochrane: Dr. Copes, you indicated that our neighbourhoods and our communities can influence our eating, our physical activity and our social interactions. Have you examined options for how to design communities that promote health? Can you think of any models where healthy eating, physical activity and social engagement have been achieved?
Dr. Copes: A colleague of mine, Dr. Larry Frank, who has recently come to Canada from the U.S., has done a lot of research mostly on walkability and the influence of community design on physical activity. There is certainly good research literature there. Many of his papers would address the physical activity part of the environment.
There is also emerging literature on proximity to fast food outlets versus other sources of food. I am not as familiar with that literature, but it would also support the view that if you live or work within say 500 metres of fast food outlets, you are less likely to consume fresh fruits and vegetables than you are if those are available nearby.
There is a market in the lobby of a government building in Victoria. Although I think that is a wonderful intervention, we are again falling into the pattern of putting in something new — in this case a farmer's market — but we are not evaluating what kind of a change it will have on the diets of people who work in that building. The irony is that we are putting in innovations and interventions but we are failing to ask how much of a difference they might make.
Similarly, with respect to social engagement, some emerging literature looks at how close together houses are built and whether there is an opportunity for interaction in front yards or everything is set back and the development is oriented to private space in backyards. The question is whether this promotes or prevents the engagement of people on the same block and the extent that we feel part of a neighbourhood or community. There is some research, but I fear we are stumbling around and not evaluating many of these things as rigorously and frequently as we should. I think this is a wonderful area for research and also for improving the health of Canadians on some of the big issues that face us.
My colleague mentioned the topic of food in schools. Some provinces are undertaking to get junk food out of schools. There you have more of a captive audience. Again, are we evaluating that and documenting the extent of the effect, or are we simply implementing the change and not doing the before and after comparison?
Ms. Beanlands: I think it is inconsistent, and I encourage the support of these evaluations wherever possible, because they are extremely important.
Dr. Copes: What works and what does not.
Senator Cochrane: We need these models and we need to go out and promote the effectiveness of what people are doing.
Dr. Copes: Yes. I am sorry; I should have mentioned that Dr. Larry Frank has mapped communities in Vancouver, Atlanta and I believe Victoria looking at walkability, high walkability areas, low walkability areas and the difference in layout among those neighbourhoods. That research provides good guidance or a model, if you will, for governments involved in land use planning and developing new neighbourhoods.
Senator Cochrane: According to what you are saying, then, this has not been applied; it is just an idea. Is that right?
Dr. Copes: Local government folks, at least in Vancouver, the area I am most familiar with, are aware of Dr. Frank's work and are looking at its practical applications for a community. There is still a real need to get the results of this research out and to make it available to the policy-making and practice community. That is a job that the NCCs collectively have to tackle.
Senator Cochrane: Mr. Chair, we should obtain that information and have an opportunity to read it and divulge it.
The Chair: Dr. Copes, before you depart, perhaps you could leave that source with the clerk.
Dr. Copes: Yes.
Senator Cochrane: It would be interesting reading. At what point do you think we should move from research to action in order to actually establish priorities and measuring tools and to put all the research and theories into action?
Mr. Benoit: That question is at the heart of many of our discussions. As all public health actors do, we have a commitment to using evidence in our work and not improvising. At what level do you have this kind of evidence available? Should we continue until there is sufficient evidence?
One answer could be to make available to people a continuum of research such as the walkability studies of various areas. The Sudbury & District Health Unit has brought forward such a program. The assessments and information must be documented and assimilated in order to see what level of evaluation exists. We should make available the information that such programs exist and add the level of evidence supporting them. You have a choice to make.
In a sense, this speaks to another request from public health actors. Canada seems to be a country of scans. If we want to develop a program, we do a scan. The time spent doing that is time spent away from the activity. If those things are available as information with the assessment or evidence involved, then you can make an informed decision.
Senator Cochrane: Would anyone else like to respond to that?
Dr. Copes: It is an excellent question. In public health, we have best practices. I am a real skeptic, but how do we know a practice is the best? We need to recognize that often the perfect is the enemy of the good, and what we should be looking at in a more rigorous and consistent manner is "promising practice.''
What is coming out of new research findings that has application to front-line public health work? How can we shorten the time from research to action, at least on a pilot basis? Let us come back to this evaluation. Let us explicitly put things in as pilots promising practice. Let us evaluate if it works. If it does, let us transmit success stories. If not, let us scratch our heads, go back to the drawing board, realize that one did not make it and move on to something that looks promising.
Ms. Beanlands: To build on my two colleagues' answers, I think it is important to share what does not work so that people do not continually do the same thing just because it seems like a good idea.
I really like "promising practices.'' I think that is the direction we need to go. I also think that we need to stop being a country of demonstration projects. We need to move on to something more sustained so that we can actually build on what we begin and build on the good things, the things that are working. Let go of the things that do not work. Rather than stop and start all over again, continue building.
The same thing will not work everywhere. We must be open to adaptation and adjustment. We take the good things, try them and figure out how to make them work in that particular circumstance with that particular community or population.
Ms. Greenwood: I agree with all that my colleagues have said. I am reminded, Dr. Copes, when you talk about promising practices, about a concept that we see in communities, namely, that we learn from each other. It is like horizontal learning. I will speak from the perspective of early childhood, which is my background. We will try something in our child care centre. It will work, and then we are excited about the different activities we do with the parents and the children. We will share that with the community down the road with us.
A lot of horizontal learning goes on as well. We could build some of those networks. If we are talking about the community level, we can build on those concepts or constructs of horizontal learning and the promising practices. I know there is a place for scientific evidence, but a lot of knowledge out there is not contained in that term. I think all of us share that in our communities and with each other. We should think about that as we try to roll out something very large.
The Chair: Senator Trenholme Counsell has a special interest in early child development. I suspect she is not asking about seniors.
Senator Trenholme Counsell: This has been a most stimulating presentation. I wanted to congratulate you, Ms. Greenwood, on your comment about beginning with children; as the chair said, I certainly agree with that.
Before I ask a question, I want to put a word in about the fact that you have used networks and horizontal working together and dissemination of information. I absolutely agree with you on that. It is important and it is a philosophy that I feel attached to.
I also wanted to congratulate Ms. Beanlands on mentioning the sex-disaggregated data. That is a mouthful. You have to stop and think what this is about. Is it about data or about sex? I read in the medical journals and in quite a few different places that there is a difference in how women are treated, be it hip surgery, knee surgery or for heart disease. Some of this is probably our own fault because we do not complain enough and we think we cannot leave home or take time to be looked after. That is a fact. I wanted to compliment both of you on that.
I was amazed to read that this is the first time your organizations have come together to think about health determinants, health programs, and so on. That should be underlined. I hope this first time will lead to many more.
I have read and listened and heard that in 2004 the national collaborating centres were set up by the Canadian Public Health Agency of Canada. That was when the health agency was formed. It must have happened more or less at the same time.
Dr. Copes: Yes; the announcement.
Senator Trenholme Counsell: That is a start. I want to understand the structure. There are four NCC: determinants of health, aboriginal health, environmental health, and healthy public policy. Presumably, you collaborate and bring together a lot of information. I assume you report to the Public Health Agency of Canada and then that agency reports to the Minister of Health. Do you have any possibility of making things happen?
The words you have said here today make me realize that you know what needs to happen. You have been explicit or prescriptive in a number of respects. How do you feel your collaboration results in knowledge going up through government and then something happening?
Ms. Beanlands: I will start and my colleagues will finish. There are actually six national collaborating centres. The National Collaborating Centre for Methods and tools, NCCMT, is at McMaster University. The National Collaborating Centre for Infectious Diseases, NCCID, is at the University of Manitoba. The six of us work closely together.
Can we effect real change? I believe we can. We are at arm's length from the federal-provincial-territorial collaborations that happen across the nation. Our mandate is to work with public health practitioners and policy- makers. Therefore, it is our responsibility to engage our colleagues in public health practice and in making public health policy and to provide them with the latest evidence in a way that is meaningful.
When I was coming here today, I realized that probably much of what I was saying was jargon. I expected that you might question me and ask me to really tell you what I was talking about. When I go back to my centre, I will suggest that we provide something a bit more understandable to provide you specific examples or stories that you can take away and use when talking with your government colleagues.
Thank you for the invitation to appear here today. Our coming here is part of how we can influence change. I believe that your report will be very important. I think the WHO Commission on Social Determinants of Health, to be released in September, will be another important opportunity to start the dialogue. Although the WHO commission looked at the social determinants of health, it really speaks to all determinants of health, and all six centres have a role to play.
The Canadian Public Health Association is meeting in Halifax in June. That is usually a large gathering of public health practitioners and policy-makers. The NCCs have worked hard together to put on at least three if not four pre- conference workshops where we want to engage public health practitioners. My experience is that public health practitioners and policy-makers are eager for this information and that we have a responsibility to provide them with the evidence and with the promising practices.
So far here we have not mentioned the business case. In our work plans for the next year is to start looking at the business case to actually make these investments.
Dr. Copes: Although we were announced in 2004, we are a bit newer than that, because the first of us did not get going with our first operational year until 2006.
We are all at arm's length from the Public Health Agency of Canada, and we like it that way. We do not have a formal reporting relationship up to the federal government. We do want to make a difference. We want to make things happen. Our belief is that we can probably do that most effectively by working through front-line public health organizations across the country nationally. We are told by the Public Health Agency of Canada that we cannot retreat into provincial frameworks. That is good advice. We accept that what the NCCs do must be of national significance.
We are unique in our arm's length relationship from the agency. We have been told that in our environmental scan that provides us with credibility because we have a national mandate but we are not part of government and people will listen to us. We are seen as being independent and not having a particular axe to grind.
We have also received advice that we should tell people «what is» rather than «what should be.» When we provide evidence to practitioners, they want us to tell them what is, what works and what does not, but they do not want us to tell them what they should do. That is not an NCC's mandate or job. It is the right of the people in public health across the country to either adopt or act or not, depending on their particular circumstances and their accountabilities. Those accountabilities are not to us. Their accountabilities go elsewhere in the system.
By and large, I think we heard good advice when we went across the country.
Senator Trenholme Counsell: It is reassuring that you are reporting to your colleagues across the country and giving them substantial information on which they can develop their own programs and take action. You have that freedom and liberty to transmit. You bring together knowledge, but you also transmit it.
Dr. Copes: Absolutely. In our environmental health scan, we heard an incredible amount of enthusiasm; people were telling us that there is a real need for this. No one else is trying to provide support to front-line environmental health practitioners across Canada. The NCCs are unique, and the people we spoke to told us they are glad we are here.
No one else is doing it. There is information for the public and information for large provincial and federal government departments. However, the folks on the front lines were left wondering who was there to back them up and provide knowledge for them. There was almost a vacuum there, and we are happy to fill that vacuum. We got a warm response right across the country. We are here to do some good.
Senator Brown: I know you are gathering very important information. I wonder if anyone is looking down the road to how we can deliver modern health care to small communities. How do we duplicate modern hospitals and all of the technologies they have such as brain scans, MRIs and laser surgery? How could we ever deliver that into small communities in the North or, for that matter, in rural Canada?
I am told 85 per cent of Canadians live within 200 miles of the American border. We have a vast country, all the way to the Arctic Circle. What are the practical applications of all the knowledge we have? How do we deliver modern eyesight care, dental and emergency services? What could we look at — mobile hospitals or something like that? It boggles my mind to think about it. I wonder if you have looked down the road to see where we are progressing with rural Canada.
Dr. Copes: Our work is more on the preventive and public health side, which I think has some of the same challenges. For example, how do you equalize or eliminate the disparities in knowledge resources between large, well- funded public health organizations and those in rural and small-town Canada?
Many jurisdictions are trying to bring practitioners to patients rather than moving patients to practitioners on a rotating basis. If we can bring information and summarize for practitioners right across Canada, that is efficiency. For example, why would each health unit want to look up the effects of a particular drinking water treatment if the NCC can do it and make those results available to everyone across the country? That is more efficient than trying to duplicate work.
I will address technology. Just as there are huge changes in medical diagnostic and therapeutic technologies — which I deal with wearing my medical hat — on the public health side, there is remote sensing and technology we can use to do real-time monitoring of drinking water systems for chlorine residual — which was missing in Walkerton — and turbidity. All of that can be measured in real-time and the information can be sent to larger centres. All this technology on the environmental health side will reduce risks where those risks are greatest. If we look for these promising new technologies, we can bring many of the advantages of state-of-the-art expertise and safety to smaller communities.
However, we will not eliminate geography. I see how they run environmental health services in Iqaluit; they have a completely different world to live with and deal with than we do in Southern Canada. That speaks to the diversity of this country and the need for some flexibility, as Ms. Beanlands mentioned; one size does not fit all. There may be one set of goals that we are trying to achieve, but how we go about doing that will, of necessity, be different in communities that have permafrost as compared to communities that have buried water and sewer pipes.
The Chair: I have an interesting supplemental to that. On a couple of occasions I have asked the head of the Public Health Agency of Canada how the agency sees public health integrated with the community health and social services facilities.
[Translation]
Mr. Benoit: That question is indeed highly relevant and recalls the diversity of organizations in the various provinces. In some cases, you are probably alluding to Ontario's situation, where the RLSSs are everywhere. The role of the municipalities is very important in public health, but is not necessarily there in care delivery. In some provinces, a number of departments are working on that.
[English]
One of our earlier works was to map the different functions of public health across Canada. Four to six of us published a structural profile of what is done, where and by whom. It showed the diversities, and we had to adapt our work to those diversities. No one had done that previously.
Ms. Beanlands: I do not pretend to have the answer to that excellent question. However, I think we all need to take up that challenge.
My sense is that if we start working at the community level and listen to the community, some answers will emerge. My experience in public health is that communities can frequently find their own solutions. Sometimes the practitioners have to move aside, take down the silos and let go of some of the turf and listen to the communities.
That is why I like the idea of community needs assessments based on the social determinants of health. You need to look at the community as a whole and to look at the whole family and the school population as a whole, as part of the community and as part of the cultural community to which they belong, whether physically present or at arm's length. Once we start to do that, some of the answers will become clearer.
Dr. Copes: I had better be careful because, as I mentioned, there is a huge array of different service delivery models. We often focus on structures, and structures can become silos, which is not a good thing. We want to look at a functional integration of these services.
I will draw from another point in your discussion paper. There is a need for targets and for everyone to have a clear understanding of the problem and the goal. If you have different structures and different organizations, there needs to be a shared understanding of what the target is. The more precisely those are articulated and the more we put numbers around them, the more likely it is that we drive action. If we can have shared targets between the acute care sector, the public health and the social sector, we are far more likely to drive action. Ironically, some of these targets may serve an integrative function for some of these entities.
I am familiar with the model we have in British Columbia and I am a big proponent of integrating across preventive, acute and continuing care in health. That works, but we cannot lose sight of the social side. Sometime we still have challenges integrating, but goals, targets and having everyone share those is one good integrative measure.
The Chair: Interestingly, I think our First Nations are leading the way, because they have organizations in place that deal with everything, from water to roads to houses, poverty, social assistance and health. Those are the models necessary to effectively ramp up the low health disparities in a community.
Ms. Greenwood, do you want to respond? I am sorry, honourable senators; I am holding some of you up.
Ms. Greenwood: I think you have said it. We have models. Again, I am reminded of children and families and our fundamental units that comprise our communities. We do not separate the well-being of our child out into parcelled pieces, but all the pieces, social and health, however we define them, are part of that child's or that family's well-being. Models that bring all of those pieces together in an integrated fashion will be most effective; we cannot do just one thing.
That said, there are critical things we have to look at, and we will probably target areas to start with, but we need to do that within a larger holistic framework. That is how people think and how we live our lives. We do not cut them up into pieces. It is who we are as humanity, and that is important. Integration and holism are good.
[Translation]
Senator Pépin: Someone answered the question I wanted to ask. I hand the floor over to another senator.
[English]
The Chair: Senator Pépin was a nurse before going into politics and was in elected politics before she came to the Senate. She is vice-chair of this committee.
I am sorry; I do not know who stole your question. I hope it was not me.
I must tell you that Senator Fairbairn has a tremendous interest in literacy, so I do not know whether she will come from there or not, but she always finds a way to get to it.
Senator Fairbairn: Thank you very much. It has been tremendously interesting and indeed exciting to listen to you. I am from Lethbridge in Southern Alberta, and I came back to Ottawa this week after spending a great deal of time on the Blood Reserve, which is not very far from Lethbridge. I had the incredible honour of being an honorary chieftain of the tribe. Sadly, I was there for the departure of one of their absolutely outstanding and wonderful elders.
What you are doing sounds terrific and forward-looking. You understand that only when you get to the roots of the life of our Aboriginal people can you bring them together to follow in the path that you wish we could take, particularly in terms of health and children.
Driving to the funeral, I was struck by how much the reserve has changed since I was last there. Instead of vast places with little homes here and there, we saw a town, Standoff, and a medical centre. There are a home for seniors, a number of schools and a college that is attached to the University of Lethbridge.
At the funeral, the whole feeling of the community was not just a sad day. They were saying farewell to an incredible person. The children were out in droves, and they were in such a good spirit of mind.
I read about how your inaugural forum in February brought together for the first time representatives from many and varied sectors across the country, including government departments, to explore indigenous health in its broadest context. When you reach out, how do you do it? You are obviously doing it well.
Do you go yourself or with one or two others right to the people? There are two areas, one in the cities and the towns but the other out on the land where the heart and the drum still beat. Are you now in a position where you can go into those communities and have the communities come out and listen to you and follow what you are saying? Has there been a large jump in this over the last while as you have been working so hard?
Ms. Greenwood: Are you asking me that from the NCCAH's perspective? I am actually a Cree from Alberta. My family is on the Ermineskin First Nation in Hobbema, so we are close in territory to your story.
I am not sure I can answer how. I do know I go to groups with great humility. When we envisioned this forum, many of the participants expressed to us that this was one of the first opportunities they had ever had. That is the reason it is written this way. When we sent those invitations, we knew there was commitment in our communities, in people and in governments to the health and well-being of our children. This was an opportunity that brought us together to talk about that and about our shared responsibility in achieving that goal and what gifts each person could bring to that vision.
I thought about that as I was thinking about the document, and I will come back to the point. In the document, it talks about who should take the leadership. I think there are multiple leaders. I go in humility because I do not go as the leader: I am the facilitator. There are people who know way more than I do. I can give you names and sources of where to go, but I am not the expert. The people in the communities, the researchers, my colleagues — they are the experts. I play the role of bringing us together. I go with the value of not being the expert so that those leaders can come and bring voice. In the original writing of the mandate for the NCCAH, we talk about bringing voice to community, bringing those forums so that those leaders and knowledge holders can come together and speak those solutions and identify those diverse strategies. We are diverse, and we need that flexibility, but we are holistic in our vision of what we need in the community.
Does that in part answer your question?
Senator Fairbairn: Yes, it does, and the fact that you are here is extremely important. Here in the nation's capital, we have to know this. It is still a huge challenge to bring together, but I would say from listening to you that something very good is happening so that doors are opening. It is not about our going in and telling them what to do. The way you have put your words together, it sounds like you are going into communities that are opening doors, and they are grateful and encouraged that you are coming and that you want to do them the honour of showing them what will get them beyond the situation that has existed in the past. This is one of the most uplifting pieces of information I have heard for a long time. I am very pleased to hear it and wish you all the best.
Ms. Greenwood: Thank you. Embedded right in the name of the NCC program is our commitment to collaborating with other folks, our commitment to partnership. We have done that with each other. I always like to say that I play with everyone in the sandbox because since I am population-based all of those things are important to me. From the community level, we reach out to other national partners. We have formal agreements. We are just signing formal agreements with the National Aboriginal Health Organization and the Institute of Aboriginal Peoples' Health. There are partnerships at various levels. I work with the B.C. government and the First Nations Leadership Council. I work with communities. Multiple partnerships and collaborations occur, and my colleagues could speak to the long list they have as well. I think I can say on behalf of us all that we are really committed to that.
Senator Fairbairn: Thank you very much. It is important for us to hear this.
The Chair: Ms. Beanlands, you raised the need for a business case. If we are to move the agenda in the population health initiative towards the correction of health inequities in Canada, we need a business case. This has come up before when we have had financial experts in front of us. The general consensus is that there is a business case but that to lay it out in the terms that a business case usually takes is particularly difficult. Could I have your thoughts on how that might be achieved?
Ms. Beanlands: I think you are right on two counts. It is difficult and it will be a challenge to lay it out, but I think it is absolutely critical. I do not have the answer. In our work plans this year, the NCCDH is proposing that we look at what evidence we have in the business case, what is missing, and how to fill the gap. We may well need some specific, targeted research. At this point, I do not have an answer.
Public health practitioners at the regional level in the districts and the communities are telling us that there is a lot of evidence to support early child development, which is one of our major areas of focus. Like Ms. Greenwood, we believe it is critical to start there. There is a real opportunity to demonstrate the interaction of the social determinants with early childhood, particularly in looking at the crosscutting theme of gender. We can look at women and gender equity and put that together with employment and working conditions, and we can see how it affects the family, how it impacts early child development and the nurturing environments in which children live.
People have said, "But we need the business case. We know the evidence, but give us the business case that will help us put the policy forward such that action will be taken by those who are in decision-making positions and have control of the money.'' We have agreed that we will step up to the plate and see what we can contribute. We will not have the whole answer, but we are quite prepared to look at what is there, what the gaps are, and then work with our colleagues and partners to figure out the next steps.
Mr. Benoit: Another way to look at this is to ask whether it is a business case we need, or a case for business. We are speaking about what you alluded to in your report, the inter-sectoral activity that must take place in all of those subjects. We were conducting workshops in Toronto and Vancouver, and the public health actors were telling us that they have begun acting but need to scale it up, and to do that they said they need a business case.
It is the structure or a way to communicate to other actors and engage everyone around that, and that is an important part of your report. We need to have this communicated to other sectors so that there is a unified action on this.
Dr. Copes: I agree. We have work to do on developing a business case. One problem is information deficiency. As a country, we are very rich in health outcome data and information on utilization of health care services. Of the determinants to health, I would suggest that we are probably most deficient on environment as a determinant of health. We have better data for socio-economic factors. We lack good information on how the broad associations between social determinants and health outcomes work mechanistically and how we can intervene. If we had demonstrated pilots that worked, we could readily build a business case for scaling them up and implementing them more widely.
We will have to look at piloting some of those promising practices as an investment in research and development in public health. We have to hold folks accountable for setting targets, for making a commitment to deliver and for evaluating those promising practices, those pilots, in a meaningful manner. We have to pick successes and implement those based on the additional information we get for a business case. If pilots do not pan out, let us try something else. We do not want to do what does not work; we want to do what does work. It is all about making a difference.
The Chair: You talked about early childhood development. We will be emphasizing early childhood development in our report, but we will begin with parenting. We will cover maternal health and early childhood development. I am not sure how we will frame that, but later we will cover adolescent development. It appears that sometimes no matter what a great start the child has had, they can really fall off the wagon in adolescence because of community, peer pressure, and so on.
Do you think that is the right scope, or should we just concentrate on early childhood development?
Ms. Beanlands: I think that the holistic approach as you have described it is important. You are on the right track. It is important to look at the interventions. I think parenting is absolutely critical. In the NCCDH we hope to look at the parenting practices, programs and interventions that we do have and that have been evaluated and share them with public health practitioners across the country.
With adolescents, we know that preconception is important. It is as important as prenatal care. We need to move forward on preconception. We know that addresses the adolescent population, whether they choose to or whether they happen to become pregnant at that time. Their adolescent years are important in terms of the foundation for healthy babies.
I feel that you cannot look at just one piece, one determinant; you must look at the whole thing, which means the whole child, the whole lifespan, the whole family, the whole community and all the cultural implications and the social environment.
Senator Fairbairn: Mr. Chair, having listened to this, I think it might be interesting for you to talk about what you and others who were with you in Cuba learned about literacy and what they were doing in Cuba as compared to here.
The Chair: As Senator Cook and Senator Pépin can tell you, it was a real eye-opener. That country looked reality straight in the eye and said, "We cannot afford a sophisticated health care system like they have in the U.S. or in Canada or in Western Europe. What can we do about a healthy population?'' They decided to work on a population health basis. The functional unit is their polyclinic, which fundamentally is a health unit. Right beside the polyclinic are the daycare centres, the early childhood education centres and the grandparent education centres to teach them how to parent when the parents are not there, and so on. Their whole investment is on a population health basis. That is, keep the population healthy and we will deal with illness as best we can when it comes along, but we simply cannot invest the resources that much of the Western world is. Guess what? Their indexes are as good as ours.
[Translation]
Senator Pépin: They have absolutely no illiterates. When a woman is pregnant, the doctor immediately goes to see her. If she lives in the regions, they travel to see her twice a month. When she delivers, the monitor takes charge of the child and family, and, when the children are old enough, they go to the day care. It is really surprising. They do not have our money or resources, and there are no illiterates. There are grandparent clinic services to teach parents how to be parents. I must say that that was a good lesson in humility and that we learned a lot.
[English]
The Chair: Senator Cook, do you want to comment, or have we said it all?
Senator Cook: You said it all. It was very enlightening.
Ms. Greenwood, you talked about the intergenerational effects of assimilation policies evidenced through residential schools and dislocation. How long will it take? I ask as a senator but also as a member of the United Church that has struggled with this for a long time. Will there be an end? What are your strategies?
Ms. Greenwood: I cannot answer your question, but I can share a story. I did not attend residential school but my father and my family did, my aunts and uncles. I now have three sons aged 30, 24 and 11. I know from experience about residential schools and I have learned about residential schools from being in the community and also in my education. When I talked with my friends about those, we would have a certain kind of discussion, a certain understanding. When I talk with my older sons about this, they have a very different understanding than I do and a different passion than I do. It changes as the generations move away. That is what I am saying. I am much closer to it than my sons are, so they have different issues with it. Theirs are not the same as mine. Perspective changes over time. There must be the health and healing strategies that we see. I think perspective will change with every generation; I see it in my own family. I have learned lessons. I knew what it was to grow up in my family and I knew what family violence was. I knew all those things. I was a generation of change. My sons will be a generation of change and their sons will be a generation of change.
I do know that many people suffer. We need to heal. We need those health and healing strategies and we need to identify those for ourselves. I cannot say that it will happen in a certain number of years; I can only speak about my own experience.
Senator Cook: Would you say what is happening is a positive experience? How do you see healing? Does it come from within or does it come from other factors? I hear a lot about healing and reconciliation. Have we dared to put meaning to those words and implement them into programs? I believe it is still a big issue for our First Nations people.
Ms. Greenwood: Personally, I think healing is very individual, but it is also a collective thing. We all have to heal — all peoples — because we all experienced this in our history together. My family may have experienced it differently than other families, but there is healing to be done by all people. It is a hard and complex question that you ask because it is a very personal question as well.
Senator Cook: Yes. For me, I need to heal too, in order to understand.
Ms. Greenwood: Yes. I think we will heal and we will do it together. It will change. I believe that. I see it in my own family.
Senator Cook: I want to thank you for sharing something that is very personal and deep.
The Chair: I want to ask one last question. How are you linking with the CIHI initiative on population health, or are you linking with it? Do you think this could be a coordinating body for the tremendous pools of data that exist in Statistics Canada or elsewhere?
We have to find a way to commit to some advice.
Mr. Benoit: We are indeed collaborating with the Canadian Population Health Initiative, CPHI, on social determinants work. We also collaborated on evaluating a project they did with the Urban Public Health Network on the disparities and inequalities in health in 19 cities across Canada. We work with them on several things.
CPHI commissions work on healthy public policy. This is common ground we share with them. If you look at the different projects they commission and that are underway, they work beyond information and data gathering. It is relevant, but they are not acting to gather data to create policy; rather they are trying to answer the need for policy and informing existing data. For the most part, they are also aptly using outside resources. This speaks to data information knowledge. There needs to be a common background to develop a framework to analyze the data. This is beyond simply gathering data.
Dr. Copes: We have some interaction with Statistics Canada. As you know, they do many different types of surveys, including the current Canadian Health Measures Survey, which will get into some markers of exposure to environmental contaminants.
Before talking to Statistics Canada, I was puzzled about why Canada was relatively far behind other countries in some of this work. I have attended a number of expert panel workshops with Statistics Canada. They are the arm of the federal government that does survey work, and a lot of what we need is survey work.
I was impressed with the integrated thinking of the Statistics Canada people. They realize the need in a determinants of health model to look at how we do periodic surveys, tracking socio-economic determinants, the health care system, and at long last trying to integrate more physical or environmental measures.
We had good discussions on how we explore the interaction between socio-economic status and physical environment. We looked at ways we can add components to different surveys Health Canada does to help us identify how these things work and get beyond broad and powerful, high level associations. Those associations do not necessarily lead us to interventions that will make a difference or fix the problems and reduce disparities.
We certainly see ourselves working with Statistics Canada. The question is how this information would get integrated with other information sources on social and environmental determinants. I think a model like CIHI is needed in the environmental health area as well.
The Chair: Thank you all very much.
The committee adjourned.