Proceedings of the Subcommittee on Population Health
Issue 7 - Evidence, May 28, 2008
OTTAWA, Wednesday, May 28, 2008
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:10 p.m. to examine and report on the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chair) in the chair.
[English]
The Chair: We are missing three or four senators, who will be along when they can extract themselves from what they are currently doing. Nevertheless, we will proceed because we are duly constituted.
We are delighted to have with us today from the United Nations Association in Canada, Kathryn White, Executive Director; from the Society of Obstetricians and Gynecologists of Canada, Dr. André Lalonde, Executive Vice- president; from the Canadian Paediatric Society, Marie Adèle Davis, Executive Director; and from the Canadian Medical Association, Dr. Kathryn Bigsby, Chair of the Child Health Working Group.
We will proceed with Ms. White.
Kathryn White, Executive Director, United Nations Association in Canada: Honourable senators, on behalf of the United Nations Association in Canada, I would like to thank you for this invitation to present our work to you on the social determinants of health. I would also like to pay tribute to the work of this subcommittee, to Dr. Monique Bégin with the WHO commission and, in particular, pay a very special tribute to one of your former members who has been a keen supporter of our work and an inspiration with her advocacy for children of Canada and the world: Landon Pearson.
UNA Canada's Healthy Children, Healthy Communities project was designed to identify and explore social and community factors by which to build positive well-being and stronger, more cohesive communities. It was designed to engage young people as they have not been engaged in the past in both understanding and making recommendations on their own health. These goals have been guided by the existence of key international documents, such as the UN Convention on the Rights of the Child, A World Fit for Children and A Canada Fit for Children. By upholding the principles outlined in these documents, we went to children themselves — to young people across the country — and encouraged them to share with us their stories, voices, concerns and visions for healthy communities.
However, we did not stop there. We also surveyed child health stakeholders such as parents, community administrators and health care specialists, as well as the Canadian public, to help us better understand the social conditions which affect the lives of Canada's young people. Our research led us to publish Talking Back to Grownups in October, 2007. I thank you, chair, for helping us launch that document. It is a report that we encourage you all to read, if you have not already done so.
Since then, the team has developed resource material to continue the engagement of young people through a pan- Canadian youth network and an action toolkit for positive change. This past March, we held a national round-table exploring youth engagement, media and technology and the effects of the built environment on health.
Finally, next week we will publish our newest study, based on continued research in British Columbia, exploring the social determinants of health vis-à-vis the 2010 Winter Olympic Games.
In survey after survey, Canadians are expressing the need for addressing poverty in all its forms here at home and abroad. As a collective, we need to recognize its profound negative impacts on health, especially the health of children, whose first years will set the stage for a lifetime of health care access and consumption. In UNA Canada's Talking Back to Grownups, 74 per cent of participating adult Canadians expressed the need to end child poverty, even if it meant raising taxes. Approximately two-thirds of them told us they believe Canadian governments are putting too low a priority on child health programming.
According to our indicators on emotional well-being in children, the trends demonstrate inequalities between Caucasian, Aboriginal and ethnocultural — the UN does not like us to use ``visible minority populations'' anymore — as well as between high and low socio-economic groups. These numbers may not be new to any of us but, as we met with hundreds of children across the country, it became clearer that we can see the visible impacts of these pressures in children as early as the age of nine years. They are self-reporting these outcomes.
Other key findings demonstrate a continued stigmatization of mental and emotional health issues through significant disconnects in this basic understanding. Our research has shown that 98 per cent of adult Canadians believe that emotional well-being is just as important as physical health. However, only 7 per cent of Canadians believe that young people need to receive more information on this topic.
Let us consider what young people have told us. Our research used a number of indicators to gauge the level of emotional well-being of young people. In asking, for example, ``I worry about life'' and ``I worry about my family's health,'' respectively, 62 per cent and 40 per cent of youth agreed. The level of worry exhibited here reinforces the concern that unhealthy stress factors are a growing problem and need greater attention and resources.
Evidently, many Canadians that we spoke with outlined that there is a significant lack of mental health specialists and services, particularly in rural or remote communities. Our strategies must integrate advocacy for good mental health through strong social marketing as aggressively as we have with physical health. On this we also applaud the creation of the Mental Health Commission of Canada, led by your former colleague.
You should know that we have just touched on some of the issues covered in our three years of research, but the question is: where do we go from here? How do we begin to address some of these health issues raised by young people themselves?
The social determinants of health are about relationships, culture, an individual sense of belonging and attachment to the community and, most important, about engagement and a sense of choice or control. Good health is good citizenship. Today, we recommend the following steps forward:
A focus on emotional well-being and mental health through targeted public education and outreach, and the strengthening of communities to improve health outcomes. We call for further research into what both the built community and the social community can do to increase good health outcomes.
Community-level differences are occurring across various indicators. Further research at the community level is needed to identify these factors that contribute to young people's health, as well as community-specific solutions. We need to begin looking at neighbourhoods in which people live and work and evaluate if they are organized in such a way that allows people to lead flourishing lives.
The next item is to create integrative and cohesive health policies and practices focusing on the social determinants of health. Children's lives are shaped by three key parts of their society: parents and guardians, the school, and the community as a whole. Health policies must focus on ensuring mutually supportive roles. Parents and guardians must have the ability to play an active and positive role in the lives of their children. The school must be a place where they can grow and be empowered to take action in their own lives. The community must be a place where positive relationships and connections are formed and reinforced.
We also need to focus on vulnerable youth. The importance of placing special attention on Aboriginal, new Canadians and visible minority young Canadians cannot be overemphasized. These people consistently bear the burden of lower standards of living, poorer quality of life and unequal distribution of resources. We must understand their realities and realize that these are issues of child rights. The responsibilities, of course, lie with us.
The next item is to give a voice to children and communities, and amplify this voice as necessary. Child and citizen health empowerment is perhaps the most important role that civil society, government and the health care sector can play together. We recognize the work that is already being done by so many civil society organizations in strengthening the voice of young people, and we commend them. We also urge government to increase commitments to this area.
The Government of Canada has shown their leadership through their unswerving support of UNA-Canada HC2 initiative, Healthy Children, Healthy Communities, by encouraging our exploration for a deeper understanding of the effects of the social determinants of health on children. We must continue to do so.
The Chair: Thank you. Our next speaker is Dr. André Lalonde. The population health report will deal with the human life cycle, beginning with parenting, then moving on to maternal health, early childhood development and on through the life cycle until we reach the end of it. It is very fitting that we have Dr. Lalonde here to talk about how we achieve healthy mothers and healthy children, and how we avoid unhealthy mothers and unhealthy children.
[Translation]
Dr. André Lalonde, Executive Vice-president, Society of Obstetricians and Gynecologists of Canada: Mr. Chairman, first of all I would like to thank honorable senators for inviting me before this committee today, in particular senator Wilbert Keon and his colleagues here, who are all so dedicated to the issue of health care and specifically health care for the Canadian population.
It is a pleasure to be here today with my colleagues from the Canadian Medical Association of Canada, the Canadian Paediatric Society and the United Nations Association in Canada, to talk about this issue. We agree on many aspects of the question, specifically on the fact that a healthy childhood is the key to a healthy society.
[English]
I know you are looking for recommendations for your fourth report. The Society of Obstetricians and Gynecologists of Canada, or SOGC, is pleased to provide you with some concrete ideas about what can be done to improve child health. It will not surprise you that these recommendations will start at the very beginning because you cannot have a useful discussion about promoting and ensuring child health without talking about maternal health.
Mother and child are the inseparable dyad. Science now has clearly established that the health of the mother directly affects the health of her child, from preconception to prenatal, labour, delivery and post-partum. During these weeks and months a child's entire future may be decided, sometimes even before the child is born. You only have to type ``fetal origins of adult disease'' into the Google search engine and you will find countless references to scientific research in which the link between the onset of certain diseases can be linked to an adverse fetal environment: type 2 diabetes, hypertension, cardiovascular disease, asthma, et cetera.
[Translation]
Studies have been undertaken to explore the impact of factors like herbicides, PCBs, bad food habits, adverse fetal environment during the first weeks after conception, anxiety problems, on the onset of illnesses like Parkinson's disease, dementia, cancer, osteoporosis, and many birth defects.
[English]
Imagine if we could reduce the risk factors for these diseases even before a child was born. Think of the improvement to their quality of life and their productivity to society, let alone the very real, positive impact on health care budgets where we see these kinds of diseases requiring ever-increasing funding commitments.
While there are many important social determinants of health, women are in quadruple jeopardy for the most important of all of these determinants: poverty. If you are a woman, if you are a single woman, if you are an Aboriginal woman, if you are a pregnant woman, there is a very good chance you will be poor, that your pregnancy will be affected by your poverty, that your child will be poor and that your child's health will be affected by this poverty.
This is especially true for First Nations, Inuit and Métis communities. One out of every four First Nations children lives in poverty compared to one out of six Canadian children. First Nations families are three times more likely to experience poor living conditions. More than half of all First Nations citizens are unemployed. Seventy per cent of First Nations students will never complete high school, and about one in six First Nations homes are overcrowded.
Last year, the SOGC joined the campaign Make Poverty History: The First Nations Plan for Creating Opportunity, led by National Chief Phil Fontaine of the AFN, to fight child poverty in First Nations.
[Translation]
The SOCG believes that any initiative requires the engagement and participation of First Nations, Inuit and Metis communities. That is why we have been holding consultations with Aboriginal groups concerning birthing. We strongly believe that a positive birthing experience is the foundation that will allow us to improve child health.
[English]
Through its strategic direction on Aboriginal health, the SOGC has accepted this challenge of an Aboriginal birthing initiative. Over the past two years the SOGC has been seeking support for a national birthing initiative for Canada, which includes a component on Aboriginal birth. The initiative was developed in collaboration with five partners: The College of Family Physicians of Canada, the Society of Rural Physicians of Canada, the Association of Women's Health, Obstetrics and Neonatal Nurses (Canada), the Canadian Nurses Association and the Canadian Association of Midwives. The plan covers seven key actions to ensure that mothers and babies from Corner Brook to Comox to Iqaluit receive the care they need. Without going into details, here are the highlights.
First, we must listen to women and to their needs. Second, we should be working together collaboratively across professions. Third, we should gather accurate data. As you know, we have a hard time comparing our data with other countries' data since we cannot get accurate data. Fourth, create and implement national, standardized practice guidelines for every province. Fifth, develop a standardized pan-Canadian curriculum for post-secondary education, maternal and newborn health. Sixth, mandate maternity patient safety programs. Seventh, establish national oversight.
Today, the SOGC would like to make recommendations to the Senate committee. First, that the Government of Canada commit to reducing maternal and child poverty in the next five to ten years by providing pregnancy and newborn benefits as early as 20-weeks gestation, for example, rather than only through the post-partum period; guarantee early prenatal care; provide better support for day care and have a national daycare system; provide better education for young children.
Second, that the federal government adopt a national birthing initiative that includes an Aboriginal birthing component. By doing so, we would be implementing the groundbreaking recommendations of the Multidisciplinary Collaborative Primary Maternity Care Project that reported a year and a half ago to Health Canada, and the recommendations are still not implemented.
[Translation]
Third, that child health include maternal health, because when the mother is not in good health, the child will be much less likely to live a healthy and disease-free life.
[English]
Four, that mothers receive prenatal, labour and delivery support and postnatal care when they need it and that infant care always include the care of the mother. Five, that the federal government commit to bringing maternity care and childbirth back to rural, remote and Aboriginal communities so that families do not have to be separated when a due date approaches in order to be assured a safe and healthy outcome.
[Translation]
Canada must do better in child and maternal health issues. These recommendations will allow us to reach that goal.
[English]
In closing, the SOGC has undertaken a survey of our existing emergency obstetrical care capacity. For example, are there enough obstetricians in Canada to respond to emergency obstetrical care? The preliminary results, which I am now studying, suggest that the maternity care human resources situation is more urgent and critical than ever. We will see some grave problems in five to ten years. If we do not take steps now to ensure healthier mothers and babies, we are setting ourselves up for failure on many other fronts in the future. Let us not wait for the cracks in the system to become the crisis on the front pages of our newspapers.
[Translation]
I will be happy to answer any question you may have.
[English]
The Chair: Thank you very much, Dr. Lalonde, for all the time you have put into this and for your presentation.
We will now hear from Ms. Davis from the Canadian Paediatric Society.
Marie Adèle Davis, Executive Director, Canadian Paediatric Society: Thank you for the opportunity to present to your subcommittee today.
[Translation]
I am here today to represent the Canadian Paediatric Society, the professional home for more than 2,600 paediatricians, paediatric subspecialists and other child and youth health providers.
[English]
The Canadian Paediatric Society has been working on behalf of children and youth since 1922. For much of that time, our primary focus has been on what are considered medical issues: stemming the spread of infectious disease, ensuring children and youth have access to immunizations, advocating for nutritional and neonatal standards, injury prevention legislation and others.
Despite progress, these are still top priorities for CPS. In the area of injury prevention, for example, Canada has a long way to go. We rank twenty-second among 29 OECD nations in preventable childhood injuries and deaths. The CPS is a strong advocate for a national injury prevention strategy, as recommended in Kellie Leitch's recent report to the Minister of Health.
However, we know that to be successful in injury prevention and so many other aspects of child and youth health, we need to look beyond the traditional medical model. We need to look at how to improve the conditions that lead to good health. Yet, our approaches to improving health in Canada have taken on a narrow focus at times. Reducing wait times, for example, is important, but it is a short-term fix. Improving the health of Canadians means taking a longer- term and much broader view.
We know a great deal today about what makes children and youth healthy, and the most influential determinants have to do with the health and well-being of their families, their mothers, their communities and the environments in which they live. Growing up healthy means more than having access to medical services. It means having a stable family income, a nurturing home and community, a solid education, opportunities to grow and develop, and so much more.
The Canadian Paediatric Society, along with the Canadian Medical Association and the College of Family Physicians of Canada, articulated much of this in Canada's Child and Youth Health Charter, which was launched last year after consultation with leading experts and organizations. Unfortunately, to date, the federal government has not indicated a willingness to formally support or endorse this charter.
Canada has not fared well in international comparisons of child health and well-being. One recent report from UNICEF shows Canada ranking twelfth of 21 wealthy countries on overall child well-being. Despite technology and the minds to deliver the best health care in the world, Canadian children are not doing as well as they could be. Why? In part, we feel there is a lack of sustained political will and commitment to make children and youth a priority. Canada also falls short in creating the conditions that nurture good health, as my colleagues indicated. Nearly 20 years after a motion to end child poverty by the year 2000 passed unanimously in the House of Commons, the rate of child poverty has not changed.
The need for leadership is crucial. That is why the Canadian Paediatric Society is calling for a federal commissioner for children and youth, an independent voice that will ensure the views and needs of children and youth are considered in all relevant national public policy decisions. A commissioner would ensure that the federal government is accountable to young Canadians. This was recommended by your colleagues in the Standing Senate Committee on Human Rights.
The federal government has received clear direction on many children's health issues, thanks to the report from Dr. Leitch. She has indicated that injury prevention, preventing childhood obesity and improving mental health should be top priorities. We support her recommendations wholeheartedly. However, we are disturbed that the federal government has still not responded publicly to her report. We encourage them to work with child and youth advocates to ensure that the recommendations in the report take shape in the coming months and years.
Still, even in Dr. Leitch's report, explicit mention of the broad determinants of health appears as an appendix; this despite knowing that in order to make progress on issues such as obesity and mental health it is critical to look at children's families, social environments, education and much more.
Four years ago, the federal government signed on to A Canada Fit For Children, which underlined the need for a broader lens on child and youth health. Yet, past and current governments alike have instead taken a more narrow view. We look forward to your report encouraging them to take a broader view. We know what is needed to improve the health and well-being of children and youth. What we need now is political will and immediate action.
As a representative of an organization of pediatricians, I also need to make you aware, as Dr. Lalonde did, of the serious human resource shortages we are facing. When children and youth come into contact with the health care system, they need timely access to the range of professionals who support their growth and development, promote health and safety, and provide quality care for acute and chronic problems. However, there are fewer and fewer pediatricians to share the workload, and more children with complex medical issues.
Pediatricians are integral to child and youth health care in Canada. Not only do they provide clinical care but they are also actively working to improve the communities in which children live. Fewer pediatricians means fewer advocates working to improve the broad determinants of health for children and youth.
This is not an issue that has resonated with Canada's provincial and territorial governments. They are not developing human resource strategies that respond to the needs of children and youth. The CPS 2007 status report on public policy revealed that no province or territory currently has a pediatric human resource plan.
[Translation]
Children and youth must have access to the best heath care services we can provide. Wherever they live, whatever their parents's incomes or the colour of their skin, they are entitled to the best health care possible, and our role is to help them do that.
[English]
The Chair: Thank you, Ms. Davis.
Dr. Kathryn Bigsby, Chair, Child Health Working Group, Canadian Medical Association: On behalf of the Canadian Medical Association, I thank you for the opportunity to be here today and I commend the subcommittee for focusing on the critical issue of child health.
My presentation today will focus on three areas. The first is what the Canadian Medical Association has done, and plans to do, in the area of children's health; the second is why the Canadian Medical Association has chosen to focus on the early years as a priority; and the third is recommendations for the subcommittee and for government for action in the area of children's health.
Physicians see the adverse effects of poor child health all too often, and as a pediatrician I see it every day in my work. We strongly believe that all children should have access to the best possible start in life. That healthy start includes opportunities to grow and develop in a safe and supportive environment with access to health services, as needed.
The CMA has been proud to be a partner in the Child Health Initiative, an alliance between the CMA, the Canadian Paediatric Society and the College of Family Physicians of Canada that has pressed for improvements in child health and the development of child health goals.
The CHI held the Child Health Summit last year where it developed the Canada's Child and Youth Health Charter based on three principles: A safe and secure environment, good health and development and a full range of health resources available to all. The charter states that all children should have things such as clean water, air and soil, protection from injury and exploitation, and prenatal and maternal care for the best possible health at birth.
Further, the charter recognizes the need for proper nutrition for proper growth and long-term health, early learning opportunities and high-quality care at home and in the community, and basic health care including immunizations, drugs, mental and dental health.
Delegates at the summit also endorsed the Child Health Declaration and the Child Health Challenge, a call to action to make the charter a reality. Going forward, the Canadian Medical Association will invest considerable time and effort to develop policy targeting children from birth to 5 years of age. To that end, the CMA will host the Child Health Expert Consultation and Strategy Session on June 5 and June 6, 2008. The purpose of this consultation is to create a discussion paper, first, to identify how the Canadian Medical Association can help their members — physicians — and improve the health of children under 5 years of age and, second, to identify the key determinants of early child health, identify goals and recommend ways to achieve optimal health outcomes for children under 5 years of age.
This paper will inform a round-table discussion of child health experts in the fall this year, where we hope to produce a final report on the key determinants of children's health for those early years. We then hope to be invited to come before the subcommittee once again to present this report and to discuss our conclusions and recommendations.
The Canadian Medical Association is focusing on the period from birth to 5 years of age because it is a critical time for children and also a time when the physicians of Canada are, perhaps, in their best position to make a difference. Recent human development research suggests that the period from conception to age 6 has the most important influence of any time in the life-cycle on brain development.
As well, we are all aware that Canada could be, and should be, performing better in comparison to other OECD nations in a number of key areas such as infant mortality, injury and child poverty. We also know that most early screening for hereditary or congenital disease must take place between the ages of 0 and 5 in order to provide effective intervention. Development of brain and biological pathways in the prenatal period and in the early years affects physical and mental health in adult life. Physicians are well positioned to identify and optimize certain conditions for healthy growth and development. They can identify and prescribe effective interventions following many adverse childhood experiences in order to improve health outcomes for the child as he or she grows into adulthood.
The CMA believes that there are a number of things government could be doing today in the area of children's health. First, Canada should not be at the bottom of the list of developed countries when it comes to spending as a percentage of GDP on early childhood programs. Investing in early development is essential for an optimal start to life and a physically, mentally and socially healthy childhood and adulthood.
Second, we need to improve our surveillance capability to better monitor changes in children's health because we cannot manage what we cannot measure. That is why the CMA recommends creation of an annual report card on child health in Canada.
Third, nearly one child in six lives in poverty in Canada. This can impact a child's growth and development, his or her physical or mental health and, ultimately, the ability to succeed as a teenager and adult. Governments can and must do more.
Finally, there are a number of recommendations within the recently released Dr. Leitch report in areas such as injury prevention, environmental vulnerabilities, nutrition, Aboriginal and mental health. The Canadian Medical Association strongly supports these recommendations and urges this subcommittee to consider them.
However, if there are two recommendations within the Dr. Leitch report that the Canadian Medical Association believes government could and must act upon immediately, they are the creation of a National Office of Child Health and a pan-Canadian child health strategy.
In conclusion, the Canadian Medical Association strongly supports the subcommittee's work and your focus on child health. If you have questions that I cannot answer, I will be very happy to take them to our expert advisory group, which will be meeting next week. I would also be pleased to speak further on my own experiences, particularly with respect to Foetal Alcohol Spectrum Disorder and any opportunities to deviate from the script.
We hope to return to see you this fall with specific recommendations to address specific child health determinants, especially those affecting children from birth to the age of 5.
Canada can and should be among the leading nations on earth in terms of children's health status. Our children deserve no less.
The Chair: Thank you. I believe I am a signatory to your charter. We are also committed to having you back in the fall; there is no question about it. I am sorry I will be out of town, holding other hearings, and cannot be at your round-table. I feel badly about that but I am following the matter closely and will have other people monitoring it.
There will be a number of senators wanting to question you. I do not want to take too much of your time. It is very interesting to try to grapple with the great Canadian mosaic when it comes to social services and health care. I will be speaking to that somewhat this week at the Canadian Public Health Association 2008 Annual Conference in Halifax. I will not say anything about it now because I would like to hear from you.
We are not far from our final recommendations. Having been through a number of health studies — the last one being the mental health report — the big problem in the system in Canada is people falling off the cliff at various stages of the life cycle.
It is very interesting in regard to mental health when you try to hold hearings with Aboriginals about their terrible suicide problem. I recall one young male saying to me: ``I had a lot of support in place when I was growing up, but when I became a young adult male, there was nothing; people fundamentally said to me, ``Now you are on your own.'' It is not fun being a young adult male in an Aboriginal community because their whole way of life has changed.
One of the reasons that we wanted your testimony at the beginning was to get the beginning right. That is terribly important, starting with what Dr. Lalonde has said. We can back it up further than that. We visited Cuba. The counselling on parenting there was incredible, I thought. People were counselled about when they might become a parent and how to be an ideal parent. Given that context, and trying to work with the great Canadian health and social service mosaic, I believe, before the mental health report was released, I would have undertaken this study first. I was the Vice-Chair for that report. I felt it was essential for subsequent reports. However, there was tremendous pressure from the mental health community to complete the mental health report.
Nonetheless, we need to have a whole-of-government approach. However, no one wants to hear about that at any level of government. I have talked to people I trust at various levels of government about this issue. I think we need to recommend it anyway. It will occur in the United States after the election. A whole-of-government approach to population health will be advocated from the White House.
I would like to hear each of you comment on how we can convince federal, provincial, civic and community governments and organizations to take a whole-of- government approach to population health from preconception to the terminal state.
Dr. Bigsby: I was interested in what you were saying because I think it is absolutely true that we know there is a problem. However, we have seen many failures.
You described the situation of a young Aboriginal man feeling like he has been dumped. I argue that while there were supports in place, they were probably not the right supports. We need to change our approach to this sort of situation. The interventions need to be child-centred and family-focused. If all we do is offer superficial interventions, it is about child care and baby-sitting, and not about early childhood development.
Earlier, I was talking about young children developing neural connections that make them into people who can think and problem-solve later in life. Along the way, we need to provide their parents with skills to help them take that child through the teenage years into adulthood. Those pieces have been missing. If we had a government office dedicated to child health, that could be a place where the success stories such as the programs I described can be systematically evaluated. Then there is an opportunity to disseminate that information broadly to communities across the country.
There are many well meaning people who will take your money and build something. We want them to build the right thing. There have been many failures along the way that can be very discouraging. However, they will not continue to be failures if we do it right in the future.
The Chair: I discussed this subject with a powerful provincial minister whom I trust very much. He said that this is mostly provincial jurisdiction, and there is no point in talking about the federal role.
We must have an arrangement whereby our needs and expectations can be part of the plan. How do you respond to that?
Dr. Bigsby: I would argue that the provincial funders also want to spend their money wisely. They may be uncertain how to do that.
I think the federal government has a role to play in setting national health goals and standards. I am not a politician, but I appreciate the pushback when you tell people what to do and then send them off to do it themselves.
If we have people in Ottawa whose job is to sift through this information and to champion research in the area, we can send it back to the funders and tell them they will get bang for their buck if they do it this way. I think that has a chance to be well received.
Dr. Lalonde: We always hear people talking about interventions. The Wait Time Alliance was all about interventions. If we are talking about population health, we have to talk about the parenting skills that we discussed. It is not popular to talk about the mother.
Why is the mother important in Canadian life? We only have to look back in history at the progress made in this country. Much of this progress was made by mothers who really are the important factor in raising children. It is not me as a doctor that is important. It is what support I can provide to mothers.
The phrase ``population health'' scares people. They do not know what it means. It is very abstract. Population health means how to remain healthy. We have not done that promotion. A few years ago, we had an exercise program that was not maintained. That was part of population health, to keep healthy and fit.
When we did campaigns against smoking showing pictures of lung cancer, it did not go anywhere. When we showed young people that they cannot run, or ride their bike as fast, or play soccer as long as other children their age, then they started to relate to the campaign because they understood it.
Population health must start with the fundamentals of preventive medicine. Canada used to be number one. To return to that state, we need to look at the bad word of ``poverty.'' We need to find out why women are poor throughout the life cycle. If you take an Aboriginal woman, a young woman who is pregnant or an older woman, they are more likely poor. They are much poorer than us men.
We need to dissect that into messages to all Canadians promoting better life skills. I know about the experience of Cuba and I think it is wonderful. When someone is pregnant, everyone is happy and they run to that person.
As a gynecologist, I used to say to friends, let us see what happens six weeks after you have a baby when the baby is crying all night and you cannot reach anyone. Where is that other person that should be with you in guiding you in parenting?
Ms. Davis: I will go back to your first question about how to convince people that we need to take a whole-of- government approach. We need to wake people up to what will happen if we do not take a whole-of-government approach. I am here representing a group of pediatricians, so I hesitate to talk about economics and the future viability of the country. However, if we do not start to improve the broad determinants of health for our children and youth, it will ultimately have a huge impact on our economy. Children will not be finishing school or going on to post-secondary education and taking on the roles in our economy that we would want for our economy to grow.
I cannot believe I am saying this because I never liked economics very much when I was doing my MBA. James Heckman, who won the Nobel Prize in about 2005, was the keynote speaker at the American Academy of Pediatrics meeting. He showed various economic graphs that he had ``dumbed down'' enough for the pediatricians in the audience to understand, showing that if we do not start to take care of our children and youth in the broadest definition, the long-term success of the economy will suffer. In his case, he was speaking about the United States.
We also need to break down silos and to talk about the success stories where we have achieved that. The most evident one for children is between health and education. We have examples from all over Canada where they have put health back into the school system. They are small, so they do not get discussed very much.
One is in Cape Breton where they have introduced teen clinics in the high school. Within three years, they cut their teen pregnancy rate by 50 per cent. Most children go to school at least part of the time. Therefore, it is a wonderful platform through which to reach children and youth and to talk to them where they are comfortable in their own language.
On your second point about FPT, or federal/provincial/territorial jurisdiction, and the provinces saying that this is their jurisdiction, there are examples, albeit few, of where having national strategies actually led to better health across the board. The most relevant one for me is the national immunization strategy. All of the people who are interested in infectious disease get together and set standards. They do not tell the provinces what to do; they give the provinces the information they need to make wise decisions about immunization. In the five years since that strategy has been announced, we have seen much better free-of-charge national coverage of the vaccines that are recommended to prevent infectious disease in children and youth.
Ms. White: You will note that in my report I mentioned that fully 74 per cent of participating adult Canadians expressed the need to end child poverty, even if it meant raising taxes.
One thing of which UNA-Canada is very conscious in our research is asking the questions. Politicians necessarily have short attention spans because of the election cycle. In other research we have said the same thing. We have made a point of telling politicians that our focus is, for example, on support among Canadians of the UN, and therefore UN health agencies. That support is stronger among women and stronger in certain regions of the country that are important in terms of the next election cycle, and so on. There is a need for pragmatism.
You asked how we can sell this initiative. We need to do exactly what you have done today with this subcommittee; that is, bring people together. People who work solely with paediatricians do not work with civil society organizations like UNA-Canada, which is also doing research and bringing people together.
One of the key parts of the work we did, and why the report is called Talking Back to Grownups, is that we actually received the voice. We are going to leave with you a submission from young people whom we invited to speak to you as well. It is important that politicians listen to that, because of course they feed into the electorate. This is citizen engagement, and in selling whole-of-government we must recognize that other voices are talking across the FPT silos.
The Chair: Thank you. A real success story currently is how the Public Health Agency of Canada has been able to work with the provinces and branch out. They have nodes and sub-nodes, and so forth.
Senator Trenholme Counsell is particularly interested in early childhood development and will be doing a report on that. Our report, as I said, is dealing with the human life cycle, but we recognize the upfront importance of parenting, childhood and early childhood development.
Senator Trenholme Counsell: Welcome, and thank you for all of your presentations. They are very validating.
Dr. Bigsby, I will be happy to be part of your consultation process next week with the CMA and other fellow associations. Thank you for the invitation.
Ms. White, you said that we can see visible impacts of these pressures in children as early as nine years of age, referring to poverty and socio-economic conditions on health and emotional well-being. I practised for a long time as a family doctor, and I saw these changes as early as age one, and certainly as early as ages two or three. That is what led me to go into issues of early childhood when I left family practice, because I thought that was where the greatest difference could be made. Someone may have observed that at age nine, but these things are apparent much earlier.
I did not hear any of you give figures on infant mortality in Canada. Could we have the latest figures on that? On infant mortality and perinatal deaths, do we have figures for our Aboriginal population or just for Canada as a whole, and what is our present rating? I direct that question to Dr. Lalonde.
Dr. Lalonde, you recommend a national system of daycare and early childhood education. As Senator Keon said, I have been working on this with my colleagues for over a year. I become more and more convinced that we cannot have a national system. We can have national standards, vision and leadership, but to have a national system in this country with ten provinces and three territories is very difficult. Yet, you have recommended this. I would like to hear your conviction on that.
There are so many different ways in which child care programs, early childhood education, parenting programs and all of these programs are delivered. It is not a simple system. Dr. Fraser Mustard has used the word ``network,'' but we need quality national standards and vision that will be applicable to all. I would like to hear a debate on system versus non-system.
Dr. Lalonde: OECD statistics show that on infant mortality, perinatal mortality and maternal mortality, the three mortalities on which they report, Canada is doing badly. We have fallen down. In the late 1980s and early 1990s, we were first or second in the world, and we are now twentieth to twenty-fifth in the developed world.
Unfortunately, because in Canada we ``sanitize'' our data, we do not report on the origin of people. We do not know if it is Inuit, First Nations, new immigrants or immigrants from India. We cannot collect national statistics on that anymore. We do not report on that and it is not written on the top of the chart anymore. That is a concern, because people in public health cannot zero in on a community that is having a big problem.
As another example, I met yesterday with someone from the Canadian Perinatal Surveillance System. They still cannot use the data from Ontario for maternal mortality. Yesterday we landed on Mars, yet we cannot report statistics from Toronto and Timmins to Ottawa. We need a strong recommendation that data must be available. Canadian citizens demand that, even if some provinces do not like it. If they do not like it, they can go internationally and show how bad their rates are. It is a shame that we cannot have a maternal mortality report in Canada because of lack of statistics from one or more provinces.
In the latest statistics on perinatal mortality, Manitoba was missing. What is going on? We only have 230 hospitals in Canada and they are all computerized. By February 1, we should have all the statistics on that. There is no reason not to have them.
Second, on the national system of daycare, I may have gone further than I meant to. I meant that there must be guidelines. We have a good system in Quebec, where I happen to have children who have children in daycare. They can afford it. They are thinking of moving to Ontario to work. They told me ``If we move to Ontario, it will cost a fortune, probably using a single salary to put two children in daycare.'' I do not think that is good for a rich country like Canada.
Third, the standards we reported are exactly like Ms. Davis and the CMA mentioned. We have worked with midwives, nurses, GPs and rural physicians. They all agree we should have one curriculum for maternal health in Canada. Why do we need 15 curricula? We are only 38 million people. Countries of 80 or 100 million people have one curriculum. We can have one curriculum; one guideline. It is the same people working. If you are on a committee of the CMA or Canadian Paediatric Society, we are the same people. Our committees have people from Alberta, to Comox, to Quebec; everywhere. A gall-bladder in Comox and a gall-bladder in Atlantic Canada is still a gall-bladder.
Let us get some national standards, then the provinces and local hospitals can pick that up. These committees look at their situation. They may have to change the guidelines because they have a particular situation. However, at least you have given them a framework. When we are talking about federal-provincial and health, we are talking about national frameworks.
The news is not all that bad. The Society of Obstetricians and Gynecologists of Canada succeeded in selling the idea of a national program on risk management for maternity care to the province of Quebec. Minister Couillard signed on, as did all of the hospitals who do obstetrics in Quebec. They are protective of their jurisdiction. However, when we explain to them that there is a program constructed with physicians from Quebec, B.C. and everywhere else in Canada, they see that that can be good for their citizens. If we make the point and show that it is cost-effective, I think we have a chance to get this adopted.
Ms. Davis: I would agree that a national vision around standards and expectations is needed. National immunization strategy is exactly the format we followed.
In terms of your work on early childhood education — and I will not take time to share that with you today — in November of this year, CPS will be releasing the third edition of a book called Well Beings which is a guide on how to run a healthy daycare. It used to only deal with infectious disease and injury prevention. In my remarks, I said that that is what we used to spend a lot of our time on. This edition will deal with mental health, social well-being and some of the challenges that children from different ethnic backgrounds might face. I would be happy to follow up with you and share the work we have done there.
Dr. Bigsby: I will comment on that, as well. When I read about plans to try to move forward with a national daycare/child care program, what strikes me about what I see published is that I do not think people understand daycare in the same way. I have a brother who is a surgeon. To him, daycare means a place where people who do not care about their kids can dump them off. He will not subsidize that for the people down the road.
That is not what we are talking about. We are talking about broad determinants of health. There are people out there who would like to be working but cannot, because they cannot afford to put their children in daycare. Some of the children that I see in my practice who are neediest with respect to daycare have young single moms who are at home. I am desperate to get them into daycare because their moms need a break, the children need a richer environment and it is an opportunity for that parent to interact on a daily basis with someone who knows all about normal child development and can be a real support to that parent. This is about a child-centred, family-focused service, integrated with early childhood education. It is not just about babysitting.
Ms. White: I do not know about gall-bladders, so I will not comment on that. However, it seems to me we also have an obligation — and I know we take it seriously — to actually speak to the provinces and territories, as well as to the centres, when we have findings. I think that is a part of encouraging them to share norms; in other words, to see that a national system comes from their participation.
Senator Trenholme Counsell, I also wanted to mention to you that I agree wholeheartedly that we see the effects of the social determinants of health in newborns and pre-natal babies. What is new here is that children as young as 9 are self-reporting their awareness of the social determinants of health; the negative impacts of poverty, of their colour, and so on, and their own health.
The Chair: Dr. Bigsby, I want to tell your brother that surgeons should be careful, because they frequently do not express themselves properly. I made the mistake at one of our previous hearings in saying something similar to what your brother just said: That daycare should not be a place for dumping children so mothers can go to work, or something to that effect. It did not go over well.
[Translation]
Senator Pépin: Dr. Lalonde already answered the question I wanted to ask, about the fact that, between 1990 and 2005, Canada has gone from 6th to 25th place in the world concerning infant mortality rate.
We now know there is another problem. An article published this week says that women are going to the United States to deliver their babies, women from British Columbia and even Ontario. I knew that nurses and physicians were leaving Canada, but now it seems that expectant mothers decide to go to the States to have their babies.
In your fourth recommendation, you say, and I quote in English:
[English]
Mothers receives prenatal care, labour, delivery support and post-natal care when they need it. You also say that infant care includes the care of the mother.
[Translation]
When you said earlier that Quebec was about to deliver obstetrical care to almost all regions in the province, were you alluding to this program? I know that the SOGC is trying to set up a whole-of-government initiative, but is it through this approach?
Dr. Lalonde: Not really. There are huge problems in big cities like Montreal and Toronto, and women are having difficulties finding a physician early in their pregnancy. We now know how important genetic screening can be, and they cannot have a genetic consultation beyond 20 weeks.
The Quebec program is based on risk management, which allows nurses, midwives and physicians to work as a team. They study all possible complications and rebuild the obstetric care unit in order to prevent complications.
The program is a real success right now. Quebec and Alberta have signed in. Other provinces have not followed suit yet, but we continue to engage them.
My recommendation here is that we have guarantees for surgeries but we need guarantees for prenatal care as well. Any woman should be guaranteed access to a physician, a midwife or a gynecologist within 2 to 4 weeks. Presently, it is not the case throughout Canada.
[English]
Ms. Davis: I will answer your question about the shortage of particular doctors. It is a multi-faceted issue; it is not as simple as saying that there are not as many people training. You need to look at the population health of women of child-bearing years. Dr. Lalonde can say more about this than I can. Many women are waiting to have their children later. That means that there is a higher risk of having a multiple birth or of having a premature birth. Therefore, they need the perinatologists on Dr. Lalonde's side and the neonatologists on our side. People are looking at various technologies to help them get pregnant. That increases the risk of twins, triplets or of the children being born early.
Although the birth rate in Canada has been relatively stable over the last few years, if you look at the health of newborns, it has become much more complicated. Children survive today that even ten years ago, probably, the system would not even have tried to help. That is one of the major reasons why our neonatal units are so busy. Often, when you hear of women having to go to the United States or another town to have their children, it is not only because there is a shortage of obstetricians; it is because there is no space in the neonatal units.
Dr. Bigsby: This is an example of how we missed the boat in planning. We have all been very concerned, and rightly so, about the greying of our population. We did not see this coming.
In my own small province where I practiced neonatology, when we redeveloped our neonatal unit about 12 years ago, the government gave us estimates on the need. Our number of beds was cut back. In a brilliant move about 12 months ago, with a lot of pressure from us, the number of beds was increased. It took a lot of convincing to get people in the Department of Health to appreciate that this phenomenon was real, and that it was happening across the country. That occurred because we did not plan well. It goes back to the need for a pan-Canadian strategy.
The Chair: We are doing many things in the Senate currently that interface with each other. Senator Eggleton and I agreed to a strategy where he would head a subcommittee on cities and I would head a subcommittee on population health. We had tremendous crossover in the deliberations, but the two reports very much need each other to be successful.
Senator Eggleton: The cities study that is under way now deals with poverty, housing and homelessness, which is germane to this question as well. I appreciate your input. It will have a double effect.
I had a question, but Dr. Keon asked it. This will be more of a comment, but you are welcome to further expand upon the response you gave to him. Senator Keon raised the whole-of-government approach that is a great difficulty at the federal and provincial levels. We operate in silos. Population health and social determinants cross many boundaries in those silos. That is difficult to do in the system of government that we have. As Dr. Bigsby has said, you are not the politicians; we are, and we have to sort that out. However, we may need your help to assist us in that because it will take pressure to overcome those silos.
There have been ways of doing it. Tony Blair did it on issues of poverty and, I think, child care came into it as well in the U.K. The Chancellor of the Exchequer at the time, who is now the Prime Minister, had the overall responsibility, which was good because he was the person with the money.
The other challenge is provincial versus federal responsibilities. Your recommendations today are excellent. I like them all, but they are heavy on federal responsibility. I do not personally object to that, but some people do. There are different views around this issue and some want us to stick closer to the constitutional division of authority. Indeed, we have some agreements with the provinces and we need to be careful when we start moving into their territory.
I like the idea of national strategies. That is quite possible, but national systems may not go over well with everyone. Part and parcel of whatever we do here lets us take federal leadership and develop strategies, but there will need to be collaboration with the provinces and territories to produce a result. Again, your support and help in that regard could be very important, particularly if we are to create national standards. National standards will not be achieved by the federal government alone. It will have to collaborate with the provincial and territorial governments.***
The other comment I would make is that child care is a very important part of this, but I prefer to call it early learning, or early childhood development. For many people, child care or daycare is a parental responsibility. However, most people understand that education is part of societal responsibility. I think that is a good emphasis to take with respect to early learning.
Have you any more thoughts about how we overcome these great divides, both within government and between governments? That will become a key part of what we have to sort out.
Dr. Lalonde: The example that I used for the National Birthing Initiative and the Strategy for Risk Management was accepted because it came from physicians from all provinces. I do not think it would have succeeded if we had sent someone from Health Canada to the Quebec government and told them to implement this new initiative on risk management. They clearly saw from the beginning that we were representing physicians, nurses and midwives from across Canada, and if it worked in other provinces, why could it not work there?
We are looking at how to distribute human resources in the field of health. Guelph, Ontario now has a great need. Obstetric services will fall through the cracks. They need to determine what combination of midwives, family physicians, gynecologists, neonatologists and pediatriciansare needed to keep that facility running.
We need to look at new ways of delivering this message. The provinces do not seem to have it on their radar screen. If we come in with a multidisciplinary team and we have a few of these examples, such as those from Saskatchewan, Guelph or Trois Rivières, the provincial governments will eventually fund these initiatives.
We are not looking for $300 million to do this. This is to deliver care. Not one cent of our project on the birthing strategy is to deliver care. It has to do with the strategy, the models and the implementation in a few communities. Then we need to get the provincial governments on board.
I was told by the deputy ministers in Ontario and Manitoba that they are interested. They have so much pressure on the delivery of care in their provinces that looking at other strategies may not be on their radar. We have the chance to do that. It is important for the Senate to take leadership here. I think people will listen to you.
Ms. Davis: I think it is important, when you speak about the federal-provincial-territorial equation, to not forget the intergovernmental organizations. As Dr. Lalonde has said, we can play that in-between role. Much of what both our organizations do is to create standards. In our case, it is for the care of children and youth. When the provinces get those standards from the Canadian Paediatric Society, they are likely to implement them because they know we are a group of honest pediatricians. If they came from the federal government, there may be more resistance.
The Public Health Agency of Canada is starting to incorporate us, but the more that groups like those of us represented here today can be incorporated, the easier the conversations will be.
Ms. White: I would like to speak to both Senator Keon's and Senator Eggleton's comments and applaud you for working together, including on the built environment.
We worked on a pan-Canadian project called Youth of Today, City of Tomorrow that fed into the World Urban Forum in Vancouver. Increasingly, we are working with provinces and territories and have sometimes been perplexed at how enthusiastic our federal partners have been with this support — and of course I am seeing more of that here in your presentation.
I have had concerns about this situation in terms of social cohesion. Of course, when we are taking made-in-Canada solutions to the global commons, sometimes I wonder if one Canadian voice is heard, never mind getting 13 or 14 Canadian voices heard.
Having said that, there is great enthusiasm, and I know we are working closely. I am about to meet with both the Western and Eastern provinces. There is great support and partnership, including funding support. The concern is integrating all of this; in other words, how to identify leadership. That is one of the issues we see across the country. You mentioned Tony Blair. I know the Ontario government is currently looking at an integrated strategy to attack poverty. They have asked us to present a series of projects that we have done on different age groups, et cetera. As exhausting as it is for civil society organizations like the United Nations Association in Canada, it is important, as I have heard from you, to have those bilaterals with the provinces and territories as well as here, with you.
Senator Brown: I wish to thank the witnesses. You are all obviously very professional people. One of our problems with the collection of statistics is the protection of privacy. Perhaps statistics could be collected with a double or triple coding system, using codes for ethnicity or place of residence. Only the health care system would have the key so that it could know to whom, exactly, the statistics relate.
Canada is the second largest country in the world and about 80 per cent of our people live within 200 miles of our southern border. I have learned from witnesses before this committee that much of our poverty and many of our problem areas are in our smaller communities.
That leads me to ask three simple questions. How many more doctors and health care workers do we need? How do we get them to practise in areas outside our major cities and to stay there? How does government either encourage these changes or move to try to enforce them?
Dr. Bigsby: That sounds like a question for me. We struggle with this problem a lot. We have a health human resource problem in our country and, as you say, it is not just in absolute numbers. There is a huge distribution issue. In some parts of the country, there is not much of a problem at all.
Not long ago there was a concerted cutback in the production of health care workers, and I can speak to doctors in particular. We are feeling it now, and we will not be able to solve this problem soon.
We also realize that there have been planning mistakes made in our medical schools. Medical schools were not thinking about why our country was training doctors, and what kind of work they would need to do. They did not design curricula that were conducive to having doctors choose family medicine and rural family medicine. That is in the process of changing now, but there is a time lag between the changes being conceptualized and implemented, and then seeing the effect at the other end.
You were talking not only about doctors but about all kinds of health care professionals, and I am glad you did because sometimes when we are looking at solutions, we will say that maybe there is an alternate care provider who will do that work. The information tells us that they are just as likely to want to practise in an urban centre as is a doctor.
There are things we can do to make practice in rural and remote settings quite exciting. I am speaking as someone who did two years of rural family practice. That was one of the best times in my professional life. I really enjoyed it.
Some provinces have entertained return-of-service contracts, such as the military does. We thought that that was probably not the best way to go about it, because you want people practising in places where they are happy to practise, and I think there are other ways we can go about doing that.
I appreciate that I am not providing concrete answers, but the problem exists on many levels. Again, we are in deep difficulty now because of bad decisions made a generation ago, in doctor terms, and things are slowly turning around.
I live in a relatively rural area. The whole of Prince Edward Island can be considered rural. The medical students who come to our province love it. We are hoping to be able to encourage more of that.
Access to medical care is just one small piece of this puzzle. We want to see a healthy population that does not need quite so much medical care. We really believe that it is worth investing in the little ones.
Ms. Davis: I cannot tell you the number of pediatricians that we need. We made a proposal to the federal government three or four years ago to try to figure that out and, unfortunately, it was not funded. You cannot look at the number of pediatricians needed in a vacuum, because it takes a team of health care professionals to care for children and youth.
My members are spending the majority of their time on mental health. What we call community general pediatricians are spending 30 to 50 per cent of their time on kids with some kind of mental health issue. As an example, perhaps they are not going to school because of anxiety. Pediatricians can provide that care, but if there were more school-based psychologists or social workers, they could share the work in a team environment.
It is very important to the future of child and youth health care that we look at the team environment. Governments can facilitate different types of health professionals working together for children and youth.
We also look at different remuneration models. Especially in those jurisdictions where it is still fee-for-service, it is very difficult to look at innovative ways of providing child and youth health care. In Manitoba, for example, where it is salaried or some other remuneration model, pediatricians from Winnipeg go on a regular basis to the small- to mid- sized communities that serve Aboriginal children and youth, and they provide ongoing care via tele-medicine. It may not be possible to justify having a pediatrician in Thompson, Manitoba, but by using different methods of remuneration they get pediatricians there regularly. In that way, the physician knows the child, and can provide better health care remotely.
We must go for teams, and we must look at models of compensating different types of health professionals that encourage them, even if only temporarily, to get out of the large academic centres and into schools, the communities or more distant remote areas.
Dr. Lalonde: I have a comment on poverty. I think it occurs not only in small cities, such as in Ottawa, for example. I hear in Ottawa, the Aboriginal or First Nations make up less than 10 per cent of the population but make up over 70 per cent of the homeless. We know about poverty in Toronto, Montreal and Vancouver. It is everywhere. It is not limited to particular regions.
How many more doctors do we need? My colleague stated that, years ago, nobody ever dared asked specialty societies in Canada to try to answer that question. We had famous economists from Vancouver who told us in the late 1980s — I was there, and I was fighting mad — that we had too many doctors in Canada. I knew that that was not true.
I will give you an example why these people have it wrong. First, they do not talk to the people in the field. There are over 1,650 gynecologists/obstetricians in Canada. If you divide the population by 1,600, we know who is doing obstetrics. There are only 1,000 doing obstetrics because some are in administration, some are in research, infertility, cancer, et cetera. If the bean counters do not have the right statistics, they do not come up with the right answers.
We are doing surveys now. I cannot give you the exact number but I can tell you that we need to use different models, such as paediatrics is looking at. We need to make better use of midwives and nurses. We must get out of these silos.
We need to have teams. We need to say that in specific areas there are, perhaps, 2,000 deliveries. Therefore, we have so many kids to take care of; what is the team? Perhaps it is four nurse practitioners, two doctors, one paediatrician, et cetera. We need to look at that kind of thing.
Our provincial systems are extremely rigid. It is fee for service, and if you try to go outside that model, it can take five or 10 years to get funding for a good idea in connection with trying to care for Canadians.
Second is rural practice. B.C. and Ontario with their rural medical school is the answer. I was born in a farming area of Ontario. When I was in medical school, if they had said I would get $10,000 a year for each year spent in a rural area, I would have been the first one to sign up. We were in debt over our heads and nobody cared. We had to borrow.
There are systems to encourage young people. We are hearing more and more students are coming out of medical school with large debts. In Toronto, it is $30,000 or $35,000 a year. It is a scandal to go to medical school. I would not have been able to afford medical school at the University of Toronto, coming from a farm.
Third, enforcing is not the idea; the idea is finding incentives. When I was practicing in Montreal, I was surprised when talking to a friend of mine. He said, ``We are working in James Bay. We have this big project.'' This was back in the 1970s. I said, ``You must have a hard time finding engineers.'' No, they did not have a hard time. They had the people to work there. They had incentives and, therefore, electricians, doctors, surgeons — whatever they needed — went because there were incentives.
Working on incentives and encouraging people from communities is critical. We have a big program — and I think the CMA has been promoting this — for Aboriginal medical students. These are some of the positive things we can do to change that human resourcing. I would put forward a plea by us that, when they discuss human resources, we be at the table.
The Chair: Thank you. Senator Fairbairn is next. Everyone around this table is interested in something. Senator Fairbairn, I have to tell you, has been interested in literacy for a very long time. She is interested in literacy through the life cycle.
One of the most interesting hearings I ever sat through was a hearing about adult literacy and how some of them were able to become literate. I am not sure if that is relevant, but I wanted to tell you where she is coming from.
Senator Fairbairn: It has been truly wonderful listening to you. As the good doctor noted, for many years I was very much involved with the National Literacy Secretariat and the work it did across the country.
So much has been said today about the importance, first, of working together, getting in on the ground, getting into the areas where people live and where all these very difficult and, in some cases, very uplifting things are made a reality if you are working together. If you are working together, not just here and there, but everywhere across the country, it can make a huge difference. The kind of work that you are doing, the way you are doing it and the notion of having a pan-Canadian procedure across the nation is absolutely terrific. I am sure it will work for you.
I think warmly — and sadly — about how the National Literacy Secretariat — a very small group of about 22 people — hung like an umbrella across the entire country, in every province and territory. It was not just in the upper levels of education but right smack down where the babies were born, and on and on. You will find colleagues in this room from Newfoundland and from Prince Edward Island who were involved in all of this, as well.
The things that you are doing are being done in the manner that you know what it is you are doing and you know where you are going. The question is around the tools needed to get there. I think you are doing a great job. Your enthusiasm is absolutely wonderful. It can be felt in the room.
I noticed recently that, although we do not have the same effort nationally that existed previously, all of the provinces and territories have banded together again. They are working on a pan-Canadian learning program together. It is those kinds of connecting links that make it possible for you, with the skills that you have, to get them on the run for the people who need them the most.
I cannot tell you how much I have enjoyed your presentations. I almost gave a round of applause on many occasions as you spoke, because you will be doing something very special for our country. I thank you for that.
The Chair: Thank you, Senator Fairbairn. Senator Cochrane is from Newfoundland.
There are two areas where I have seen population health models that really work. One is Cuba, and it works because of the polyclinics that deal with every human citizen, including prenatal counselling to grandparent counselling, to help raise grandchildren, et cetera. It is because of the network of these clinics that every Cuban citizen has a doctor and a member of the health care team. Their numbers are phenomenon for a poor country. Their maternal health is the same as ours, as is their infant mortality. Their health outcomes are fantastic. They have the polyclinics and they deal with the life cycle. You know the old saying ``It takes a village to raise a child.'' They believe it takes a community to do so and to move that child through life in a healthy fashion.
The closest thing to that in Canada is found in Newfoundland. Senator Cochrane is from Newfoundland. They have the best information system in the country for population health. They can show you a map of Newfoundland that is a series of dots from yellow to red that indicate the health status of Newfoundland in each area, whether by postal code, community, town, et cetera.
I have no idea what Senator Cochrane is intending to ask you, but I can tell you she is an authority.
Senator Cochrane: We have made quite a few advances, mainly due to some of our dedicated public servants. They have been phenomenal. We have a strategy under way whereby we can designate, even in a small region, a particular item to that community.
It may be worth your while, especially for the Canadian Medical Association, to review this process because it is a phenomenal program. We know Prince Edward Island is about to implement it after having done a review, and Nova Scotia and British Columbia have made inquiries into the program.
Dr. Lalonde, I understand what you are saying. We need a team approach. We must get rid of these silos. That is not what Canada is about. We must share. If anything in this world is effective, let us publish it, put it out there and tell the world about it. This is where I am coming from.
Tell us about this national immunization strategy. It was a positive strategy. I am looking for positive things. I am not looking for the negative. I want the positive things to be out there in the media and in all the newspapers, with all the hospitals, doctors, et cetera involved in this process. Positive things are being accomplished and we can accomplish more than we are now.
Ms. Davis: A few factors have led to its success. From the outset, it has been carried out in partnership with the federal-provincial-territorial governments as well as the NGOs. For the most part, we have had equal footing. We set out goals for where we wanted Canadian children and youth to be regarding immunization. We have said we want 95 per cent of Canadian infants to have their whooping cough vaccine by a specific time.
Then it was left up to the provinces and territories to figure out how to deliver the program. We all agreed on the goals. They looked to groups such as the Canadian Paediatric Society to set the standards to educate the physicians. We also do public education, for example, to create tools for when a physician raised immunization with a family, there would be a reliable tool from the Canadian Paediatric Society that a doctor or nurse could use in their conversation.
It was also helpful that the federal government set aside a pot of $300 million to be accessed by the provinces as they saw fit to initiate programs in four new immunizations that have been recommended in the past 10 years.
The success was in setting the goals nationally for everyone involved — funders, government and health care workers. Then each jurisdiction was able to determine the best way for them to deliver the program.
Senator Cochrane: It has been a success and produced savings as well. What about your teen clinics? I understand that has been positive as well.
Ms. Davis: It is very positive. I use the example of Cape Breton, where we have active members. A couple of afternoons a week, a nurse is in the high school so the students can casually go and ask for advice on birth control, for example. It is done in a way that the students do not feel barriers to accessing care.
They also have pediatricians in Cape Breton involved. Therefore, if the nurses see a young person who is not doing as well as one might hope, the child can see the pediatrician in the school, from what I understand.
It is bringing health care to a vulnerable population. I would suggest that youth are a vulnerable population. They are expected to deal with a lot these days. Instead of expecting them to go to health care, which we know they are not good at doing, we are bringing health care to them.
Another model, though not dealing with teenagers, is at the University of Prince Edward Island. There is one family physician I know who specializes on male health issues. He goes into the residences and sets up a room. People can go chat with him. It is health care taken to the populations that need it as opposed to waiting for them to come to us.
Senator Cochrane: You are part as the Canadian Medical Association. Have you portrayed this great strategy to other provinces?
Ms. Davis: I am with the Canadian Paediatric Society. Where we can, we do. We encourage best practices to be modeled. Part of the challenge is that there are many best practices that we do not necessarily know about.
At our annual conferences and through other forums, we try to encourage people to write about these best practices and to disseminate them.
Senator Cochrane: That is exactly my beef. The best practices are not publicized. Other provinces, doctors, families and mothers are probably not aware.
Dr. Bigsby: I will speak to that as well from the point of view of the silos. The Canadian Medical Association has invested heavily into looking inward at the problems with the system that creates barriers to people obtaining health care. Silos are definitely one of those problems.
I found it helpful to look at this situation from the perspective that if someone comes looking for help, they do not know how the system works. Every door they knock on should be the right door. They should not have to figure out where they need to go.
This particular metaphor was brought to my attention. I work with the Aboriginal Women's Association on fetal alcohol. If you are a young mother, you think something is wrong with your child and it occurs to you that you were drinking during pregnancy. How do you raise that with someone? How do you get a yes or no answer to the question in the back of your mind, whether your baby is affected? You may talk to someone who does not have the information, and they may falsely reassure you because they do not know where to send you. That should not be happening. It is a hard question for a mother to ask.
We need to create a system that will guide a person to go to the place where they need to go in order to get the help that they need.
Ms. White: When it comes to Newfoundland and Labrador, increasingly there is more diversity on the island. There has been incredible social cohesion and I would say that that is one of the reasons for the fantastic community support. It will be interesting to see how this is introduced and how these new Canadians are integrated as well.
For the project Healthy Children, Healthy Communities, we have developed tool kits for the community in terms of best practices. We found peer-to-peer education to be remarkably helpful.
We have developed a tool kit on HIV/AIDS called It Is Time to Act. Our research was astounding in showing the ignorance of young people. These were basically our best and brightest because they were part of our Model UN. The ignorance around birth control generally versus barrier birth control in preventing HIV/AIDS was startling. We gave them the kind of information they needed and told them they could become a peer-to-peer mentor and talk to other people in their community. The peer-to-peer approach is very important.
Likewise, we have developed a model for Healthy Children, Healthy Communities. It will actually take youth- serving agencies like ours in the informal, non-formal and formal education sector with ways to engage young people, to hear young people's voices about their own health, their own issues, and to take action, including how they can bring their voices to circumstances like this or to agencies like CMA or other NGOs. How do we raise their skills enough to tell their stories, which need to be heard? This is happening and it is quite positive. In fact, we have been happy to work in Newfoundland on these issues as well.
The Chair: I want to ask you all a favour. You presented some bad statistics on population health, but the most damning statistic that has come out recently is that we are thirtieth of 30 developed nations in efficiency for our health care delivery system and 23rd of 30 in the overall health of our citizens.
I have been convinced for at least 10 years that we will not overcome this situation until we can achieve a whole-of- government approach to population health, from womb to tomb — in fact beyond womb; from parenting to death. One-shot initiatives will not get the job done.
I have spoken to quite a few people about this matter, and I will raise it publicly for the first time at the public health meeting in Halifax next week. I have spoken privately to people with vested interests. I am absolutely convinced, and will have to be unconvinced, that nothing else will get the job done for us.
I would like all of you to think about how we can sell federal, provincial, and community governments on an all-of- government approach to population health, from womb to tomb, and how we can develop the kind of community system that we saw in Cuba of polyclinics, where everyone is involved in the well-being of the community.
Thank you, and good night.
The committee adjourned.