Proceedings of the Subcommittee on Cities
Issue 5 - Evidence, June 18, 2009
OTTAWA, Thursday, June 18, 2009
The Subcommittee on Cities of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:48 a.m. to examine and report on current social issues pertaining to Canada's largest cities.
Senator Art Eggleton (Chair) in the chair.
[English]
The Chair: Welcome to the Subcommittee on Cities of the Standing Senate Committee on Social Affairs, Science and Technology. Today, we will hear from two panels of witnesses, the first one focusing on neighbours, poverty and health; and the second one focusing on disabled workers and poverty.
I welcome Senator Lang, who is substituting for Senator Martin today. Thank you for coming, and welcome.
On the first panel, we have Dr. Cory Neudorf, Chief Medical Health Officer, chair of the board of Canadian Public Health Association, and clinical assistant professor in the Department of Community Health and Epidemiology at the University of Saskatchewan, College of Medicine.
From Statistics Canada, we will hear from Russell Wilkins, Senior Analyst, Health Analysis Division; member of the Institute for Risk Research; and co-author of the study on medical health and population health impacts on reducing inequality and unavoidable deaths, and author of a study on low birth-weight babies in Canada, which also considers influences of socio-economic status.
Jillian Oderkirk, Director, Health Analysis Division, whose research interests in the past have included criminal justice, education and the correlation of income and obesity among men, joins Mr. Wilkins and Dr. Neudorf.
We also have Claire Heslop, graduate student in the joint MD-PhD program at the University of British Columbia. She has been active in research studies on socio-economic status and health outcomes. She is the lead author on the study of socio-economic status, SES, and mortality among stable heart disease patients in B.C.
Dr. Cory Neudorf, Chief Medical Health Officer, Saskatoon Health Region: Thank you for the opportunity to speak with members of the committee today on this topic. By way of background, both the city of Saskatoon and the Saskatoon Health Region have a long history of using neighbourhood-level data for planning and policy-making at the municipal level in the context of local area planning and neighbourhood profiles, and from the health region perspective, for health status reports and population health research.
I have sent the clerk a link of some of the recent reports on both our health status report and a summary of our research and policy reviews that we have done over the last couple of years. I have also sent a link to a Canadian Population Health Initiative study that we participated in to look at health impacts of poverty in 18 cities across Canada.
In our health status reports, we analyze a wide variety of data to try to develop a very comprehensive picture. I liken it to putting a puzzle together by using as wide a variety of data as possible from demographics, environment, social conditions, health behaviours and survey information. We then analyze the data, look at trends and make recommendations not only to the health system but also intersectorally in other systems to look at issues that determine health. Those recommendations are debated and discussed with community members and affected agencies. We try to use the recommendations in community planning.
We do this because often the summary data that we receive on cities does not show the nuances required to show the areas of need. In fact, over a decade ago I was spurred into doing this in more detail because of the statistics that we received from our provincial level. For example, the statistics on teen pregnancy in the Saskatoon Health Region showed as being average. I looked at it as a statistician and said, of course, it is average; we are the largest region in the province; we set the average, but what does it mean in terms of where the needs are within in our city. When we looked at a neighbourhood level, we found that there were areas in our city where teen pregnancy rates were high or higher than the supposed problem areas in the province, for example in the north or smaller rural areas. This spurred us on to do the neighbourhood-level reporting on a routine basis.
In 2006, we released a report on health disparities in Saskatoon. We reported on six neighbourhoods that had the highest percentage of families living below the low- income cut-off compared to the rest of the city and the five more affluent neighbourhoods on the other side of town. While no one was surprised to learn that health was related to poverty, people were surprised by the extent and persuasiveness of the issue across so many of the conditions. Compared to high-income neighbourhoods, the low-income residents were 1,458 per cent more likely to attempt suicide; over 3,000 per cent were likely to have hepatitis C; and 1,186 per cent were likely to be hospitalized for diabetes. The list went on and the numbers were not small but there were huge discrepancies.
The study received a great deal of local press but, before that, we felt compelled to share the data widely with community members and agencies because we did not want just another study that showed only the extent of problems. We wanted to engage in a community dialogue to look at solutions. We wanted to see how people would react. We wanted to learn what they wanted us to do about it. We wanted to see what we could do about it. We spent one year in community dialogue before we published the study. As a result, a number of immediate initiatives were announced by our municipal government and by some of the affected local agencies, and there was the start of discussions with provincial and federal colleagues as well.
This all led to a CIHR-funded more-in-depth study where we looked at some of the causes of these disparities. To jump to the punch line of the 350-page document, poverty was the highest correlation cause of the health disparities we found, when taking everything else into account. The second highest was age, the third was education, and it went on from there with some of the other determinants.
This is consistent with international research showing that either education or income tends to have the highest correlation when all of this is taken into account. There is little we can do about age but we can act upon the factors of income and education.
We then took that information and prepared a literature to ask: Where others have intervened in other jurisdictions, where have they made a difference? There are many ideas but few of them have been evaluated and fewer still have shown to be effective. We summarized that into 46 policy options that we say are evidenced-based, showing from the literature, to make a difference in other jurisdictions. We started the dialogue to determine which of those policy options might make sense in the Saskatoon or Saskatchewan context.
In the past nine months since the release of that study, our local Saskatoon regional intersectoral committee, which is a group of regional-level human service sector providers and NGOs, has been studying that report. The group has been connecting with other affected groups, such as the business sector, the religious sector, and community agencies and members, to determine which of these options they would support and whether they can come up with a community broadly supported action plan to reduce poverty in our city. They aim to have this report completed by November 2009, but many of the members said they do not want to wait for the report because as they find things that work, they want to be able to implement them. Some of that has been happening over the last few months.
We have also convened an intersectoral approach to improving Aboriginal employment in Saskatoon and are developing a coordinated housing and homelessness response among the various groups working in that area in Saskatoon.
The other document I have provided to the committee is our most recent health status report, which was published last month. It has routinely put reporting on health inequities within our city into the ongoing reporting. It is not just a special study but a part of the routine reporting that we do on the differences in health in the various sectors of our city.
From this Canadian Population Health Initiative, CPHI report, to which I referred earlier, the initiative between our urban public health network of 18 cities across Canada flowed. In that initiative, we duplicated the Saskatoon study in all 18 cities. It showed that this is a problem across Canada in all urban environments, although the highest differential between low- and high-income neighbourhoods is in the Prairie cities of Saskatoon, Regina and Winnipeg.
In summary, the most recent data has just confirmed that our poor inner city neighbourhoods in Saskatoon are younger; they have a higher percentage of registered Indian and other Aboriginals and recent immigrants; higher mortality rates for diabetes, respiratory disease and heart disease; higher rates of mental disorder, blood-borne and sexually transmitted infection; higher rates of low birth weight and teen pregnancy; and lower rates of immunization and preventive activities.
Combined, these data lead to a decrease in life expectancy in the last few years in our inner cities, which is unheard of in comparison to the rest of Canada and our other neighbourhoods, where life expectancy has been increasing for quite some time. Underlying all of this are higher concentrations of poverty, unemployment, lower levels of education, higher percentages of single-parent families, and low levels of home ownership, more substandard housing, et cetera.
However, all of this local data has resulted in much higher levels of community awareness and high levels of expressed support for the policy changes that we are proposing. We have done some local surveys to show that the public is actually supporting many of these changes. Local decision makers are motivated to act where they can and to work with their provincial and federal counterparts, because many of the policy levers reside at those levels. We are encouraged to see that the data is starting to lead to a desire for change, and some of the local agencies are already acting to try to affect some of those changes.
Russell Wilkins, Senior Analyst, Health Analysis Division, Statistics Canada: It may be easiest if you follow along. Our subject is health equity, especially with respect to neighbourhood income and avoidable mortality. However, since health equity is really a moral judgment, we will speak about differences in mortality, first by neighbourhood income, the trends from 1971 to 2001, and also by measures of individual and family income, education and other factors.
First, there is some good news. In urban Canada, from 1971 to 2001, life expectancy at birth increased by six and one-half years overall, about seven and one-half years for men and five and one-half years for women. Over that same period, the differences in life expectancy, comparing the lowest to the highest neighbourhood income quintiles, diminished by about a year — a little greater for men and a little less for women.
On page 4, you can see that in 1971, the difference in life expectancy between the highest and lowest neighbourhood income quintiles was four years, roughly six years for men and three years for women. However, by 2001 the difference was only three years, or about four years for men and two years for women, in other words, going in the direction of smaller differences.
On page 6, you can see that the differences in premature mortality between the highest and lowest neighbourhood income quintiles declined most rapidly for causes of death that are amenable to medical care. There are four groups shown. What is highlighted in red is the decline for both men and women in the differences between the highest and lowest income quintile in the causes that are amenable to medical care. That is another good-news story in many respects, which is published in a paper that we cite, including some quotations from it.
On page 8, we are changing gears. Instead of looking at neighbourhood income, if we look at family income, the differences that we see are actually greater compared to those we saw with respect to neighbourhood income quintile. If you look at the chart on page 9, the lighter bars are new data, individual-level data, information from our cohort that we followed, 11 years for mortality. The dark-blue bars are for the neighbourhood income quintile, data that we collected over a 25-year period.
Based on the new data, the inter-quintile differences, or the differences between the highest and lowest income quintiles, were 6.8 years for men and 4.3 years for women. Compared to the differences by neighbourhood income quintile for urban Canada in 1996, which is the middle of that period, this was a two-year greater disparity for men and nearly a three-year greater disparity for women. It is revealing much greater differences, particularly for women.
On the next pages, 10 and 11, the chart reveals that both educational attainment and family income were related to mortality. We calculated remaining life expectancy at age 25 for each category of educational attainment, from less than high school graduation up to university degree, and we did that within each income quintile. Within each quintile, for both men and women, you can see a gradient in life expectancy. Life expectancy increased with each increment of educational attainment.
On pages 12 and 13, we have new information — not yet published, but it should be by the fall — on the mortality of what you might call the homeless and marginally housed men and women. We examined mortality over the period 1991 to 2001, for about 15,000 men and women whose usual place of residence on census night was a shelter, commercial rooming house or hotel.
For such persons, remaining life expectancy at age 25 — that is conditional on surviving to age 25 — compared to that of the lowest income quintile, life expectancy was six years less for men and four years less for women. This is comparable to levels attained by Canada as a whole in 1921, for men, or 1961 for women; or by Cambodia and Nepal for men, or Georgia and the Dominican Republic for women, in 2006.
Here are some highlights from our findings where we looked at causes of death concerning the mortality of residents of shelters, rooming houses and hotels. Living in shelters, rooming houses and hotels was a marker for much higher mortality than would have been expected on the basis of low income alone. We do not say it was causal; it was a marker.
When we looked at medically amenable causes of death, mortality was elevated in both relative and absolute terms; and other causes of death contributing to premature mortality in this population included alcohol-, drug- and smoking-related diseases, as well as mental disorders and suicides, among other causes.
The next couple of pages are references to both the neighbourhood income studies we have done over the years and the newer studies based on the census mortality follow-up, which has the individual- and family-level data.
Claire Heslop, as an individual: Thank you, honourable senators, for the opportunity to speak to you on this topic, especially to speak following such comprehensive overviews. I feel that I can truncate a bit and try to complement those overviews with my particular study.
As we have already discussed this morning, individuals with lower socio-economic status have a higher risk for disease and they fare less well following diagnosis. However, the particular socio-economic status of a neighbourhood where people live also contributes independently to the effects of individual-level socio-economic status.
With regard to the example of cardiovascular disease, people in lower socio-economic status neighbourhoods are at a higher risk for heart attacks; they are less likely to survive to hospital; and they are more likely to die in the months and years following presentation. Data collected in Canada supports this trend, as is reported elsewhere. However, most of these studies that look at mortality focus on total mortality. Therefore, it is not clear in Canada whether disparities are due to cardiovascular disease or combinations of causes.
I feel that my study, which was published in January, complements what has already been discussed this morning because it reports on a cohort of patients. There were 1,000 patients in our initial cohort, and they were selective coronary and geography patients examined at major teaching hospitals in Vancouver. Four-hundred and eighty-five of these individuals had evidence of clinical disease and also provided home area codes as a baseline.
Their home postal codes allowed us to use customized neighbourhood-level data collected within British Columbia as a combination of Statistics Canada data as well as the Human Early Learning Partnership, HELP, initiative,. The latter mapped neighbourhoods across British Columbia based on census tracks as well as individuals reporting how neighbourhoods were actually distributed. It is very interesting customized information.
Within the cohort, there was an equal number of individuals from each of the five quintiles across the neighbourhood socio-economic indices for education — high school completion —; median neighbourhood income, or total income; as well as unemployment — proportion of individuals over 25 seeking employment.
We were able to look further at specific causes of mortality because we had a good balance across quintiles. The follow-up time for this cohort is 13 years.
Following the collection of mortality data, I surprised to find that the rates of cardiovascular mortality did not differ significantly across neighbourhood quintiles. That is when you say, "Okay, I do not have a paper."
I did look further into non-cardiovascular chronic disease mortality, which includes cases of cancer, lung disease, diabetes, renal and liver failure; they are non-acute causes of mortality. These differ significantly across neighbourhood quintiles. The rates of death for cancer, for example, increased an average of 60 per cent with each quintile of increased unemployment, and 42 per cent for each decline in neighbourhood median income. These are very drastic if you compare highest to lowest. Interestingly, no relationship for cancer was observed for neighbourhood education but it was observed for total chronic disease mortality.
The outcome for cardiovascular disease in these patients is the same across neighbourhoods. The question is where these disparities are coming from. We were adjusting for important risk factors such as age, as well as body mass index, drinking habits and smoking. These did not attenuate the relationships we observed.
It is also not likely that environmental toxins or air pollutants actually act in a linear fashion across neighbourhoods. It seemed more likely to us that a combination of factors from care access to healthy lifestyle opportunities and psycho-social stress were playing a major role.
We feel that we found that patients with lower socio-economic status neighbourhoods had poorer health. Even with treatments in major care centres, which seemed to be equalizing the care for initial presentation of cardiovascular disease, these patients had multiple health conditions and health disadvantages, which compromised their survival.
The magnitude of the effects I observed were greater than for the expected risk factors for cardiovascular or chronic disease mortality, and also for blood or genetic bio-markers, which I was studying as well. This is an issue of not only access to care but major health disparity. I am happy to have been given the chance to talk today.
Senator Segal: I will just give you my conclusion from the work that you have done, but also tell you there are other possible conclusions. I would invite you to give a view. One conclusion, which would not be mine, is that bad health outcomes are a result of many different factors: Education, birth weight, parenting, physical fitness, neighbourhoods and poverty. If we are to have a coherent policy, we must address all of them in some way — federal, provincial, municipal or non-governmental organizations.
That is one view. It is held by many distinguished people, many of whom are physicians themselves and have had a broad range of practice.
I will give you my view, and I do not know if it is correct but it is what I conclude from your work: The one salient predictor of crushing health outcomes is poverty. Out of all the other predictors, poverty is core. Accept for a moment that health care is largely — at the clinical delivery level — a provincial jurisdiction, and municipal organization and community development is largely a mix of private, not-for-profit, provincial and municipal jurisdictions and that the only lever we have really aside from transfer payments to the provinces is essentially income security.
If we had to make a decision in the context of diminished resources, your information would say to us: "Work on the income security side; get people's incomes up so that fewer people are living below the poverty line, in whatever way." There might be a thousand different ways of doing it. However, that is what I would conclude from the work you have done if you want to have Canadians live longer, more productive lives.
While there are diseases that are produced because people are too wealthy and do not work physically hard enough, those are not as significant. The medical system deals with them relatively well in terms of leverage the federal government has as those diseases and outcomes, which are tied to holes in the income security system, which leaves — depending on the community — 14 per cent to 15 per cent of our fellow Canadians living below the poverty line.
You may disagree, but that is a theory I have come up with from what I have read and you have presented. Would you please share your thoughts on those comments?
Dr. Neudorf: On the whole, I agree with you. The research we have done has certainly pointed to the fact that, of all the various interconnected issues that determine individuals' health, it seems that both individual- and neighbourhood- level income is the largest predictor.
When I presented that information to various stakeholders, the issue that was thrown back is that it is not as simple as throwing money at the issue. I counter, saying it may not be sufficient but it is a necessary first step.
I look at it more like a foundational element. If you deal with the income inequality issues, which is a root cause or cause of the causes which then allows people the ability to deal with education issues, employment concerns, housing issues and, ultimately, issues like food, security and other things.
We are promoting an all-of-government approach and the ability for these various policies to interconnect. However, we feel the root cause that will assist in that complex interplay of policies resulting in improved health status is dealing with the poverty issue.
Jillian Oderkirk, Director, Health Analysis Division, Statistics Canada: I would just like to add or reflect back onto page 11 of Mr. Wilkins' presentation. We still see the gradient in mortality and life expectancy by income. However, education makes a huge difference to this issue. Therefore, at every income quintile, there is a clear gradient related to how much education people have received.
Senator Segal: As poor people drop out from the system.
Ms. Oderkirk: You are asking about which comes first or second which I cannot tell you. However, there are other drivers underneath what we observe with income and clearly, education is one of those drivers.
In other work we have done looking at socio-economic contribution in the area of mental health and stress, anxiety and depression, we are able to see that stressors people experience who are living in a low-income situation make an additional contribution to the onset of those related health problems.
You cannot really disentangle it. Is it the income or the stressors that people experience, some of which are financial stressors? There are also relationship and other stressors that people are experiencing. It is a complex issue.
Ms. Heslop: I would like to echo that it is a major component; the psychological and biological stressors act on multiple pathways, not just by encouraging coping behaviours but also by directly impacting disease processes.
What Senator Segal was talking about regarding adjusting income might also address the disparity, which is a major factor in how communities interact. This is along the lines of the materialist argument, which suggests that income disparity contributes to disparities in interests of communities, which may lead to erosion of social investment and diminished opportunities for disadvantaged neighbourhoods.
I am hoping that thinking along those lines might lead to solutions.
Senator Dyck: My question relates to gender. From looking at some of the data on the Statistics Canada website, I know that women tend to have higher levels of educational attainment than men. They also tend to have lower incomes; and they used to have a longer lifespan, although it looks like that is starting to decrease over time.
Within any of the data that you collected, Dr. Neudorf, did you notice any effect of gender? If so, was that effect greater within specific populations, particularly within the Aboriginal population, because the difference in educational levels between Aboriginal men and Aboriginal women is much greater than it is in the non-Aboriginal population? Did you see anything related to gender within your study?
Dr. Neudorf: One of the limitations of our study is the size of our population, obviously. Not dealing with national data, but dealing with local data, often the power was not sufficient to show some of the things that have been shown at a national level.
We did see some gender differences in some of the selected medical conditions, although it was far less of a driver than many of the other issues. Once we got into where we would expect to see more of the gender differences — for example, in low-income and Aboriginal peoples — that is where the numbers got very small for us and it was difficult to show.
Senator Dyck: I think your study showed that being Aboriginal was not a significant factor — that the income level was the most important factor.
Dr. Neudorf: Yes. It should be an obvious thing, but not a lot of studies have been done on this. We felt it was important to disentangle that issue, especially for the Prairie cities where there is an overrepresentation of the First Nation and Metis populations in the low-income neighbourhoods.
We wanted to find out if there are some intrinsic differences to health outcomes by being Aboriginal, or are these fully accounted for with other causes? For most the issues we looked at, the overrepresentation of being Aboriginal either disappears completely — in some cases, it actually reverses direction — or, in some cases, is reduced to a very small percentage once you take into account the other social determinants.
Senator Dyck: I believe you said that the Saskatoon study was replicated in 18 other cities across Canada. Did that include Prince Albert?
Dr. Neudorf: No, it did not include Prince Albert. It was duplicated in the 18 cities of the Urban Public Health Network, which is pretty much cities of 200,000-plus. We could not duplicate the study completely because not all the data is available at a national level. We used those indicators that could be replicated in each of those 18 cities, and used a slightly different methodology. Instead of looking at local neighbourhood, we looked at smaller areas of dissemination areas, which is the smallest level that you can look at with the Statistics Canada data.
It showed a consistent pattern across all the 18 cities. However, the difference of higher disparity in some cities is very apparent, especially in Saskatoon, Regina and Winnipeg, which are the cities with the highest First Nations population in those inner cities.
Part of the issue we were getting at was trying to see what some of those drivers are. We feel that much of it is represented by the fact that in those cities, there is a higher concentration of poverty within selected neighbourhoods, which amplifies the disparity.
Senator Dyck: The percentage of the population in Prince Albert that is Aboriginal is 30-some odd per cent. The income disparity would maybe not be as great as it is in Saskatoon, as a guess — I do not really know. It would be interesting to find out.
Dr. Neudorf: We have worked on a methodology to allow us to do the same type of study in smaller cities and rural areas. We are working with the provincial government now in Saskatchewan to try to take what we have done and apply it at a provincial level, using the data systems that we have developed.
Mr. Wilkins: We have a study that is to be published in September, in Health Reports — about the mortality of Metis Canadian and Registered Indian adults. It is a comparison, using the same data set we looked at for income and education. It does not get the younger people, where there is very high mortality, but it does take in the adult mortality and gender differences.
Generally, in the relationship between mortality of the two sexes, there are much greater differences in the lower socio-economic groups than in the higher groups. That really means that what you are seeing are more or less gender differences, rather than sex differences so much. In the higher socio-economic groups, if they are smaller, there is nothing physiologically different about the people in the other groups. There clearly is a relationship between the gender disparities and the socio-economic disparities, at least with respect to the hard numbers on mortality.
Senator Lang: I find the conversation interesting in that I am from the Yukon and a smaller community. I can see that we face many of the same problems that these big cities face — maybe in a smaller number, but the problems are very similar.
Just as a note, I am new to this place and it is the first time I have ever walked to work in my life, which is quite an experience. I am 25 minutes away from the Hill and I walk up Rideau Street every day and every night. I am amazed at the poverty, at the socio-economic differences of the people that I see. I see smoking, obesity — all the things that we really do not want to see in our society — every morning and every night. As a newcomer, I find it quite shocking.
That being said, following up on what Senator Segal indicated, poverty is the underlying problem in part. There are other issues, as the other witness pointed out.
Dr. Neudorf referred to policies that Saskatoon was looking at implementing; perhaps other cities are looking at them as well. My concern is that both the government and the taxpayer can just throw in more money, feel good about it, and think that everything will take care of itself. However, are we looking at the situations that these people face by trying to put incentives in place to encourage them to go out and educate themselves so that they are more aware of what is available? That is, do we have incentives to ensure that their children go to school, and so on? For example, if we take the income security system and say, "Here is the base level. However, if you do certain things, you will get more money," there will be an incentive to do more. It is like an indirect or direct pay cheque. You will be paid when you do certain things.
Is that premise being built into some of these policy options to encourage these people to get out on their own?
Dr. Neudorf: In the policy option study that we did, we confined ourselves to looking at policies where they have reviewed the results of the initiative and have shown it to have a positive impact. A few studies showed that, in addition to an underlying policy, providing an incentive toward that policy did make a difference with some of the education and employment initiatives, for example.
In our discussions with business sector interests, as we have shared these policy options, there has been a certain amount of support for that approach. For some of the other areas, like in some of the basic income support areas or in health service interventions, there has not been shown to be much of a difference. In fact, we found disincentives. There are so many environmental factors stacked up against an individual in poorer neighbourhoods that it becomes difficult to make healthy choices because of the infrastructure, not because of personal choice problems.
We have looked at smoking, for example. In our high-income neighbourhoods, it is 17 per cent; in low-income neighbourhoods, it is 40 per cent. When we look at where you can buy tobacco, where it is advertised, we find that the focus on inner city neighbourhoods is huge. They advertise in far more concentration, the availability is higher and the modeling of who else smokes around them, for example, is more prevalent. All those issues combine to make a healthy choice far more difficult for that population. Similarly, access to exercise facilities, price and access barriers, where the facilities are located, transportation problems and the stresses of a very multifactor, multi-problem family combine to make a healthy exercise choice much more difficult. Until we deal with some of those root issues, incentives alone would not work in those circumstances or at least not as well.
We found that our population-based approaches, where incentives were put in place, preferentially work on middle- and high-income groups more than on low- income groups and they further increase the disparity where we have tried with health behaviours.
Senator Lang: You said there were 46 policy options. Your group has gone ahead with a number of these options and has begun implementation. Can you give us an example of two options that you are proceeding with that you think will make a difference?
Dr. Neudorf: From a local level, we work with our municipal government on some of the housing interventions, for example, where we saw a deficit in affordable housing. There was a desire to have more infrastructures in place and after we announced the results of the study, the city doubled its affordable housing budget. There was also a desire to look at some of the land allocated for affordable housing for new development. Those were some municipal decisions.
At the provincial level, we advocated a change in the lower limit tax exemption and raising some of the social assistance payments. These were acted upon in the months following our study.
Within the local purview, health services, for example, we have shown that provision of more primary care and interdisciplinary health services from a school-based setting improves not only the health of the children attending those schools but also their school performance and their ability to stay in school. We have reallocated about $1 million worth of health services into some of our low-income schools because of that study and are now working with the government to try to replicate that in more of our inner city schools.
Out of the policy options, some of them are more within the purview of a municipal government or regional sector. We have acted upon some of those and on others, where there is a need for provincial or federal involvement, we have been advocating for those changes.
Senator Cordy: When we read in the paper and listen to the news, we hear about higher life expectancy, we hear about our seniors being healthier and more active now. We do hear about obesity of young people, but, by and large, the news we hear is that life is getting better for everyone.
As Dr. Neudorf said, when you break it down and look at neighbourhoods the statistics are shocking. It is shocking to learn that where we have people in shelters, rooming houses and hotels their life expectancy is comparable to 1921 for men and to 1961 for women or comparable to countries like Georgia, the Dominican Republic and Cambodia. That message is not getting out to the public. I think we have to talk about the costs of poverty to our society. We have to get the information to the people.
We have heard about some excellent programs that are happening across the country. They seem to be happening in areas where people understand the costs of poverty to a city, or a neighbourhood, or our country.
How do we get people to understand the costs of poverty? We hear people using the system; we hear all those old stereotypical things that are not true. We seem to give people living in poverty enough to make them live a little better, but still in poverty instead of giving them springboards to get out of poverty.
The areas where we have heard about the good things happening are areas where business communities, faith communities and community groups have gotten together and said, "We have to do something." How do we get that message out to Canadians, namely, we should be concerned about the cost of poverty. I am talking about how much better it would be if we could alleviate the poverty. I am talking about how much better life would be for these people to come out of poverty.
Dr. Neudorf: One of the first issues we found is that this data has been out there in sterile statistical forms for a long time, but getting the information out on a specific community to people who live in that community was the first step. For whatever reason, there is this perception that it may be true elsewhere but it is not true here. Even if it is Canadian data, it is too depersonalized. We found getting local neighbourhood-level data to be extremely important in whatever format that local group understands local geography. For us, it is local neighbourhoods that we have used in planning.
The second issue we found was in publicizing it and starting to create community dialogue. People can relate to and understand what neighbourhood they are talking about, but do they get a picture of who the people are and what this means? Therefore, personalizing it with stories of people who have actually been through it breaks down the stereotypes that these are just people who do not want to look for work or who have made these decisions themselves. Of course, some individuals fall into those categories, but the reality for the vast majority is that it is just life happening to them. We can do better.
The third is to start engaging Canadians in a discussion about our underlying values. The vast majority of Canadians see this situation as fundamentally unfair. When we surveyed people, saying that it is not acceptable and asked them what degree of disparity they are prepared to live with, most said very little or none.
While engaging in those community dialogues, we try to put the issue to Canadians as to where the cost of poverty hits them personally, either in the context of it could be a member of their family or how it affects their local business. We ask if we cannot appeal to strictly ethical moral grounds, what it will do to future economic prosperity if we keep this up versus contributing to the solution now.
The key, we found, as we looked at this locally as well as at Sir Michael Marmot's report from the WHO commission, is that we need a combined effect of political will and community-level support in order to create the change.
Senator Cordy: I think people will say they have the political will. In 1989, the motion that passed in the Year of the Child to alleviate child poverty, which is really family poverty, passed unanimously, but it was not followed up with outcomes of how to achieve this.
If we are looking at it from the federal perspective, and assuming that the public will would be there, what is the first thing we should do?
Dr. Neudorf: One issue that I see is people do not have an understanding of how the total cost affects them. All they see is that an extra program means increased taxes, as opposed to seeing that there is an overall cost to society and that it may be cheaper for society overall, and, in many cases, for you personally, to pay more here in order to pay less there. In so doing, as a society, not only would it improve our health status and deal with things more equitably and fairly, it would also be more cost effective to the system.
Canada is starting to get involved with some studies to try to get at those underlying costs more comprehensively. I know one is being worked on now nationally that maybe Statistics Canada can talk about.
In the meantime, we have tried to focus on the evaluation of those interventions where they have focused on a housing initiative, for example, but shown how that has decreased costs of things like the prison system, the health care system and social services, so that the initiative has paid for itself. That type of evidence needs to get out to the public so that the support is there.
Senator Cordy: People need to understand the other costs in the sense of if it goes up here, it may go way down somewhere else.
Dr. Neudorf: That is right.
Ms. Oderkirk: To follow up on Dr. Neudorf's remarks, a wealth of data within Statistics Canada can be brought together to help elucidate the different health outcomes and costs by different levels of income. We are working with the Public Health Agency and the Canadian Population Health Initiative and other partners to see how we might be able to bring data together to help inform this issue more effectively than we have been able to do until now.
Ms. Heslop: With respect to making people more aware and engaged, it would be helpful to discuss disparity rather than just point out that "this is a poor neighbourhood" and "this is a not poor neighbourhood." With all these gradients, we are doing an excellent job of characterizing for Canadians, I hope, through the media, that they live in a neighbourhood with a degree of privilege and a degree of disparity. One example I can think that could improve health would be to find a way to address degrees of disparity in the doctor's office, perhaps, or when seeing patients. A quick screening tool might be a useful idea in that context. I realize it may not be in the mandate of this subcommittee, but thinking about how Canadians could understand their own degree of disparity might engage them further in improving health outcomes for everyone.
Dr. Neudorf: That is a very good point. In fact, we have dealt with this issue by talking with the public, and the vast majority of the public lives in a gradient other than the top decile. Using the gradient issue, you can show that every gradient is affected by inequity, that there is always this difference and that the group just above you has better health status. It makes it personal for people that way. Everyone is affected, not just the poorest of the poor.
The Chair: A sister committee of this subcommittee has just completed a report on population health, and the chair of that subcommittee is next on the list, and that is Senator Keon from Ontario.
Senator Keon: I will not address a question to you, Dr. Neudorf, because I have been in constant touch with you, but I want to thank you for your recent letter of support for our report and for everything you contributed along the way while we were writing it.
I want to raise the Cuban paradox because I totally agree we must eradicate poverty in this country, whether it is rural or in the large cities. When you come to tie poverty to health, it is a complex subject. That is why I studied in- depth the Cuban paradox. The average Cuban has an income one fourth of our LICO, and they have the same health indices as we have. Why is that? It is because they are organized, and they have 92 healthy communities that serve a population of 10 million people and everything is organized at the community level. Their whole emphasis is on early childhood development, education, the integration of health, education, sport, social services and so forth at the community level where they know exactly what they are doing and how to do it.
That is why with your help, Dr. Neudorf, we are recommending the community approach, with the appropriate information system to nail down this subject.
I do not want to distract everyone; this report on cities has to concentrate on the elimination of poverty in cities. There is no question about that, and I do not want to distract us to a health agenda, so the discussion here should focus on how we can eliminate poverty in the cities. It is easy to tie it to health; there is no question about it. However, it would be useful if you all could address how we can eradicate poverty in the cities. It is a very important issue for this subcommittee.
The Chair: Whoever has the answer gets a prize. This is the solution we are looking for. Who wants to weigh in on this question?
Dr. Neudorf: This is a very complex issue, and not just in cities. However, where it plays out and how it plays out in cities, I think, is where this committee is focusing.
The paradox issue is more about equity than it is about income. The disparity inherent there, and where priorities are placed in terms of investment in social and health programming, is what results in the paradox, as you are well aware. In the Canadian context, without fundamentally changing Canadian society, how do you translate that?
I think there is still a way for us to get a different balance of income security and some of the other social and human service programming to achieve better equity in this nation so that we can approach that type of success as well. We do have other examples from Nordic countries that have made that choice and had very good outcomes.
For us, looking at the way we have structured our cities is very important. We want to avoid ghettoization and further increases in the disparities that are in place between neighbourhoods and sectors.
We have been working very closely with our partners in the Federation of Canadian Municipalities and with the city planners around different ways of planning future neighbourhoods and revitalizing existing neighbourhoods. We are looking at changes to infrastructure, changes to the way in which neighbourhoods are structured that will move us toward equity, sustainable cities and away from the trends that we have seen south of the border, where ghettoization has led to further problems.
It is more than about money, in that case. It is about the way we plan cities and the way in which we deliver some of the infrastructure services.
However, when it comes to the social programs and how we support individuals in those neighbourhoods to attain better life circumstances, that is where the programs and policies from the federal and provincial governments are important. I think they do feed together. That is why, even in your report, you look at an all-of-government approach — the fact that policies that are tied together need to be very strong between the sectors at a given level, but also across the different levels of government.
Senator Pépin: I have to admit that when I was working with Senator Keon, my question was what should we do? I find that very interesting, listening to you, because we look at it in our report.
When you speak about the way the city plans should be changed, how would you organize that change? I am thinking about the place where we live now; how would you organize a city plan? How would you do that?
Dr. Neudorf: The city planners have long advocated for changes where within a given neighbourhood, there is a balance or a mix of different levels of income and housing; and an appropriate mix of design for promoting active transportation for local business so people can find it easier to walk to work and not rely more on the increasing suburbanization and low-density cities. That is oversimplifying things, but that is what we are talking about with the planners.
In new neighbourhoods, we are trying to promote that type of development. Also, as we go back and do local area planning within the city in some of the older neighbourhoods, how do we change or improve those neighbourhoods so that they look more like that ideal neighbourhood? Zoning changes might be necessary, along with changes to transportation systems and even to neighbourhood design.
On the work that is done as well with neighbourhood revitalization, we are going to be releasing a study soon that looks at the impact of densification on health status. In fact, there seems to be greater disparity with cities that are more distributed. If you can look at revitalizing those inner city neighbourhoods with a higher residential population and making these changes to neighbourhoods, it reduces the disparities as well. Those are the types of things we are discussing.
The Chair: I will finish off with a couple of questions. First, I am looking at this chart on page 13 and the descriptive information on page 12 of the Statistics Canada presentation. I assume when you say that those in the shelters, rooming houses and hotels' category are comparable to 1921 for men and 1961 for women in Canada, as compared to these other countries, you are talking about the general population as opposed to comparable in terms of shelters, et cetera. It probably is not comparable at all in those cases because the vast number of people would just be homeless in those countries.
Is there any variance among the major cities in Canada in terms of these statistics? Did you find much the same in different cities?
Mr. Wilkins: Based on the census mortality study, we have not looked at the local levels — although we followed 2.7 million people for 11 years, with 260,000 deaths. At least for the larger cities, we could look at that. It just has not been done yet.
With the neighbourhood-level data that I quoted earlier from 1971 to 2001, we did some of that. I think those are the sorts of statistics that Dr. Neudorf was reporting, where it is generally a similar picture from city to city, but there are areas where there are greater disparities.
We would be more certain about what is driving those disparities, looking at the individual level follow-up from the census mortality study. I think it would be beneficial to replicate some of the life-expectancy differences and mortality differences across the major cities, using that data set.
In mixed neighbourhoods, sometimes, if the poor areas have many immigrants that are known to have lower mortality, that makes it harder to see the true extent of the differences for those who were born in Canada, for example. It is difficult to do with the neighbourhood-level data, but it is more straightforward on the individual-level data. Where we know the place of birth and period of immigration, we can look separately at these to see what is going on in a sense that could help to understand more.
The Chair: Thank you very much to all four of you for your contribution to our issues.
We are continuing our session of this meeting of the Subcommittee on Cities of the Standing Senate Committee on Social Affairs, Science and Technology. Our second panel will deal with the issue of disabled workers in poverty.
We have two witnesses before us who I will now introduce. Darrell Powell is a National Advocate for disabled Canadian workers and their families; and Dr. Lisa Doupe established the Prevention Wellness Rehabilitation Health Consultants in 1989 to champion her belief that rehabilitation should be institutionalized in public policy and in the policies of the private sector, such as employers and insurers.
Darrell Powell, National Advocate — Mental Health and Disability for Disabled Workers Canada, as an individual: Thank you very much for the invitation to come here. I think these committees have been doing incredible work and, from my perspective, disabled workers and the disparities they face generally are not accepted into health and social issues dialogues and discussions. Any opportunity to join in such discussions is greatly appreciated by the demographic across Canada.
I see some familiar faces from having testified before the Senate committee on mental health. When that occurred, it created an incredible dialogue across the country about the mental health problems acquired by disabled workers or workers who sustain an injury in their occupation and suffer a subsequent disability.
It has triggered a lot of dialogue and allowed me to advocate and educate people in the government, health sectors and different groups across the country to create and push that dialogue forward.
I am sorry I do not have speaking notes today. I will quickly go through a rundown on things and I will keep track of what I feel you are looking for in the way of evidence, as well as what you would like to look at in more detail. I will then submit that information shortly after this hearing.
Speaking about poverty and what happens with disabled workers and their families is a devastating situation. The poverty is extreme and there is a perception about workers compensation across the country. Yes, we have all heard the stories and we have heard how bad things are — or most people have — but we tend to think of it as a problem that takes care of itself. If not, then it is a jurisdiction that is unto its own and so, therefore, we are excluded from dialogues and from us actually understanding what these people are facing once they have a subsequent disability.
How does this affect the community in the cities where the bulk of the population of Canada tends to be? However, it is not exclusively a city-dominated issue. I have lived up the coast in many small communities and they are a microcosm. As an example, in a small community of 1,200 such as Texada Island, if five miners sustain severe injuries in the limestone mines, the entire community witnesses the process from injury to poverty. The community witnesses the injured workers trying to establish the claim, trying to receive treatment in an expedited fashion — which does not happen any more, and then witnesses the onset of poverty.
Especially if the injured have children and a spouse, there are very specific issues related to who is connected and how that translates out into the community. Women have criteria and differentials with what they experience when the main income earner is permanently or severely disabled. Whether they are the ones who are disabled or not, the effects on women are huge because of the roles that they play in the family and in society, and really needs to be looked at in that way.
I have been trying to include and get women representatives from the demographic to come forward. In the past, it has been perceived as a male issue in terms of the so-called injured worker from the steel mill or whatever.
Identification is the first principle of looking at this type of situation. It is important to get the proper identification and then get an idea of the scope and size of this demographic. Then you look at the differentials between people who are affected and what this boils down to in the equation of poverty in the major centres where the bulk of people end up. Whether they live there or not, they sort of end up there, whether they are seeking medical treatment or seeking financial help through benefits, et cetera.
When the Workers' Compensation Board does not accept a claim, it is offloaded to other social benefit systems. This is much more severe than what we realize. There is a table of offsets whereby they take our prime benefit in Canada, the Canada Pension Plan Disability Benefit, and send it directly to the employer to offset their costs. I have mentioned this on a previous occasion before the Senate Social Affairs Committee when it studied mental health. They are pushing more onto the public system than the Canadian community realizes, in large part due to the social marketing by the board and the way that they refer to themselves that is not even close to the truth. The off-loading has been severe.
I think I will stop here because that needs to be looked at in the future, especially during this economic crisis. In my experience since 2005, when I started out to be an educator about and creator of a dialogue on mental health. I ended up being an individual and a national advocate. Certainly, even though the jurisdictions have a stranglehold on things, it has morphed into a repetitive situation across the country to the point where we have a national dilemma.
We have to look at the role of the Workers' Compensation Board across Canada and its responsibility to Canada's working families in dealing with disability, expediting medical diagnosis and treatment while maintaining a necessary income. The wage loss replacement amount used to be 75 per cent of a worker's gross pay, which usually equated a worker's net take-home pay. That needs to be reinstated and maintained, not off-loaded.
Currently, a person needs to have the full diagnosis before WCB will allow him or her to establish a claim. In a no- fault system, we should not be required to deal with things like that. The public system is loath to deal with it, and cannot and will not handle it in order to expedite a diagnosis. Therefore, the worker is caught in this position of litigation of reduced income or flat-out poverty on the heels of a physical disability.
This is very different from the Employment Insurance program. According to testimony at a Senate committee looking into the EI, only 34 per cent of women were actually obtaining benefits and only 38 per cent of men were obtaining EI, while they maintain a huge surplus of more than $50 billion, I believe. The systems in place have to be more than a simple exercise in fiscal prudence. They must serve the people, especially during this economic crisis. We have a serious problem with all of the financial off-loading.
I will mention something that I witnessed in Vancouver. I went to a meeting of the Greater Vancouver Regional District. Senator Campbell was there. They talked about the division of powers, about having a voice and about the funding given to the cities. Representatives from each district spoke. I sat there as an observer and spoke to many people after the meeting. Vancouver has the infrastructure and the city is wonderfully gentrified where I live in Cole Harbour, where potholes are not the problem. The issue spoken to unwittingly by all of the districts was the social determinants of health. It was something to witness. With everything that is happening these days, their biggest problem was the off-loading of services for the cities to deal with, while not authorizing any say in how the money is spent. Yet, they are seeing the social determinants of health and the barriers to health and income stability, et cetera, bubbling up through the drains. The worries were palpable.
We have a problem with the way that information is collected. If a Workplace Safety and Insurance Board, WSIB application is rejected, the information will come up in other social program areas that have been off-loaded, and you have to find it there. The statistics from the compensation boards have to be taken with a grain of salt. To understand how bad it is, you have to talk to the community and intermingle with the groups and individuals in the health sector who will tell you how bad it truly is. Poverty affects the family, which affects the community, which affects the population. We are at a pivotal turning point in Canada. We must take action on this issue.
Dr. Lisa Doupe, Consultant, PWR Health Consultants Inc.: Thank you for inviting me here today. I am honoured to speak before you. I welcome your interest in workers and poverty. A recent survey by Street Health in Toronto called, Failing the Homeless, identified that none of the participants who were homeless and who had WSIB benefits were able to maintain ongoing benefits. Some participants lost their benefits because they could not provide the medical reports. WSIB did not help to ensure that the participants had another source of income before cutting off their WSIB benefits.
My focus today is to inform you of another system that has emerged from the World Health Organization called the International Classification of Functioning, Disability and Health. The present system we utilize to manage our disability issues is based on an 1980 version of defining disability called, the International Classification of Impairments, Disabilities, and Handicaps.
I would like to make sure that senators are aware of this new model and the new definition. This new model has been implemented in the European Union and expanded to all 26 countries and the various departments. It changes from looking only at the person's dysfunction of an organ to looking at the mismatch between the person's physical and mental abilities to his or her environment, which includes the social environment.
I have been working with Dr. Carolyn Bennett and I asked her to look at where we stood in implementing this in Canada. She was able to get Parliament to do some research on it and the report came back to Dr. Bennett that Canada had a bottom-up approach to the implementation of this new system versus a top-down approach. That will fail us in the long run in that it will not meet our commitments to the World Health Organization and will not serve the needs of people with disabilities, whether they are on compensation or other insurance programs. I wanted to alert you to that new system.
I am a community physician and my background has been working in occupational medicine, both for major manufacturing as well as in community health centres. I am now working as a GP psychotherapist and I see very complex cases. Those are the only kinds of cases I deal with. Lack of coordination of the social determinants of health is one of the barriers for me to return people to function.
My patients do not talk necessarily about their health complaints, and I am always shocked. They talk about their need to function and return to work. That is what they say: I want to function; I want to work. They understand better than any of us the issue of poverty and how it links to ill health. I come here also as a representative expressing their needs to have people understand that relationship.
We in the health professions function in a complete tangle of programs and services of which there is little understanding by my health colleagues. There is little cooperation between the other health professionals in the community. This in itself causes delay.
The combative process is often because of the insurance need to manage numbers, whether it is cost or number of claims, then in the lack of this coordination and collaborative process, creates extraordinary delays in the actual processing of people's treatments and claims. The process in itself becomes an additional barrier to well-being and recovery.
I have done work both with the medical association and with my own colleagues to ensure that the changing definition of "medicine" includes "return to function" or "return to work." This was formalized in 1997 with regard to the Canadian Medical Association, at which point I was able to work with the federal government — HRDC at that time — with the assistant deputy minister Julyan Reid. We established a roundtable. We were able to get consensus of 16 stakeholders. We started a group of eight with the first roundtable and, by the end, all 16 sectors agreed on the principles of any disability program, if we were to envision it at that point.
It was interesting because, at that time, all the principles that were identified by the 16 groups of stakeholders were similar to the ICF. It is interesting that you can actually get agreement on the issue when you have something that is fundamentally right.
I urge this committee to look at the ICF.
I might add one more comment. There is an opportunity to look at the compensation systems. There was a report by Morneau Sobeco for the Ontario Workers' Compensation Board because they had an evaluation of their experience rating. The report ends with four options, with the purview to review it because of the underlying inefficiencies of it.
One of the options is to look at a world-class system. I see this is as an opportunity for the ICF to be integrated as one of the options to be considered, not only for the compensation system, but also for other insurance systems.
The Chair: I will ask a small question to start with. What does ICF stand for?
Dr. Doupe: The acronym stands for the International Classification of Functioning, Disability and Health. I have created some folders. One side is about the roundtable and the other side is an overview of the ICF.
The Chair: Leave that with us, please.
Dr. Doupe: There is much more information because they are much more developed and had expansion recently on the ICF. I am sorry for not explaining it.
The Chair: That is all right. There are many acronyms.
Dr. Doupe: I refer you to the experts who are working over there. One of them is an Ontarian from Queen's University: Dr. Bickenbach. The other is another physician by the name of Matilda Leonardo, from Italy. She chairs this project on behalf of Europe. I suggest that is a good place to start.
The Chair: Before turning the floor to my colleagues for questions, let me ask you both a question. Much of what you said relates to workers' compensation and that, of course, is under provincial jurisdiction. We are here as a federal entity. However, many people also end up coming into the federal sphere when you get to the Canada Pension Plan.
I think you are saying that many people are falling in the cracks and not getting sufficient income to survive.
I will take you back to the workers' compensation level first. Is it a problem that not enough people are being qualified? Is there too much red tape? Are too many people being turned down, or is it a question that, when the workers' compensation runs out, many people who go to CPP, but do not receive as much income, falling even further below the poverty line?
Trace that for me a little, so I can understand what is happening there.
Dr. Doupe: Injuries and illnesses will occur, but one of the biggest problems is the lack of integration between the workplace and the health care professionals in the community. The timeliness and appropriateness of health care, and the coordination, are factors.
Often, the coordination of the injury or illness is also traced back to the workplace, so you must have good communication in the workplace. That means understanding people in the workplace, as well as the culture and the work processes.
The Chair: Is that relevant to the follow-up in dealing with the injury from a medical standpoint, or is it relevant to having to fill out forms to be able to get some income?
Dr. Doupe: I think it is critical in terms of the treatment and rehabilitation.
The Chair: Okay.
Mr. Powell: Workers compensation has changed dramatically since 2000, especially in British Columbia, which is leading the compensation systems and is homogenizing it to this new stylized version of compensation, which is predominantly focused to benefit the employer and the corporate sector.
What they will accept is different and the tools that they use to measure health and disability are for the most part, quite unconstitutional. I refer senators to a case one month ago: Plesner v. British Columbia Hydro and Power Authority. It was an issue of mental stress, which is post-traumatic stress disorder, PTSD. It is an issue very similar for returning soldiers who suffer PTSD and disabled workers. They face the same standards and methods of measuring health and disability in order to have their claim established.
This has become quite tight as to what they will accept as a claim. Over 50 per cent of people in Ontario and in B.C. are not even filing for a claim, especially those who are immigrants or who have language barriers. They are not going near it because it is too much of a problem and they are too scared of it; they will not do it.
The Chair: PTSD people, in particular.
Mr. Powell: I am just referring to workers in general, but the PTSD is an example. Now we have a precedent-setting decision that will affect the prime language of workers' compensation, which was changed in 2002. It is only accepting an injury and subsequent disability that is derived from exactly the workplace incident. It was too narrow. The fact that they did not take into account complex PTSD — or chronic, which it used to be called — is a very good example, because they would only accept mental stress from an incident happening specifically in the workplace.
The Chair: Does that mean most of them are being turned down?
Mr. Powell: Yes.
The Chair: People are finding themselves unable to work without the revenue they need to survive so they are into poverty.
Dr. Doupe: It is worse than that. It sets up a culture of conflict and combativeness. Not only are they trying to recover, they are now trying to fight the system that, if they are an immigrant, they do not understand. They do not know how to navigate it and they do not have any resources to facilitate that navigation.
Mr. Powell: I want to go back to compensation, because most people think it is a problem that takes care of itself. When we are talking about a disability or a social policy or we have committees here and there, generally it is not included in the dialogue. I have been working very hard to ensure we are accepted into the discussions of people with disabilities, as an example.
With workers' compensation, they are not accepting claims, period. It is a staggering rate of denial on claims. The medical criteria and arguments that they use to deny a claim are astounding. I do not have any kind of medical training, except for the 20 years' experience I have with my disabilities in having to navigate the health system.
The Chair: That involves B.C. Do you have people in your organization that would say it is similar in other provinces?
Mr. Powell: Exactly. In Ontario, we have another problem with the early return to work programs or LMRs. Here we have a system where your true level of disability or function is not assessed. They are literally making an assessment on you — which will be your pension assessment, too — based on a functional impairment at the time. However, they are sending you back early before you plateau, so we have the working wounded going to work.
We have people not reporting — up to 50 per cent, which is significant. We have the denial of claims that are hung up in litigious medical evidence battles with the board that stagger the imagination, all of it leading to a mental health injury. Mental health is not integrated. Therefore, an ordinary worker in Canada — which I consider I am, coming from the shipyards — does not stand a chance at fighting this. It is not like the old compensation system, sir; it is not what was devised originally.
If you go back to the original 1914-1919 agreement in Ontario, it is actually quite interesting to see that the principles they had surrounding health and disability measurement were remarkably good. They were based on people's differentials; one broken leg on one person may be totally different on another person, who might only have one limb.
They have been trying to create a system where everyone gets the same and remove the differentials. However, the biggest thing that causes the poverty — we could maybe get into it, if you want to explore that area as to how much it is and how wide it is — is where you are immediately into claim denial. You cannot get the true level of disability established because it is not a no-fault system anymore, and they do not expedite tests in order to diagnose people and to properly assess the damage from the actual injury.
The Chair: I will have to stop you there because we are running out of time.
Senator Cordy: Dr. Doupe, you talked about Canada having a bottom-up approach rather than a top-down approach. Could you explain that a bit? I think you said it is doomed to failure; it will not work well. Could you explain what it is and how perhaps we should change it?
Dr. Doupe: What is happening is that occupational therapists and some researchers are doing research projects on it and training their professionals. It is only going through very small groups.
The physicians who often have the responsibility — although it is now a shared responsibility — are not aware of this system. They are not aware of the new and changing terms and, therefore, not aware of the importance of the social determinants of health and the importance of the environment. If you start off with a wrong system, you get the wrong answer. That is my concern.
In Europe, the Prime Minister of Italy, who was the President of the World Health Organization, took control and said they would implement the whole system in Italy. From there, it went to the rest of the European Union.
Senator Cordy: They started at the bottom.
Dr. Doupe: No, at the top and then it went down, whereas we are just bubbling up with little research projects rather than the directive coming from the top down.
Senator Cordy: We need a national will, is that what you are saying?
Dr. Doupe: Yes, a national will.
The Chair: I am afraid we have run out of time because we got a little behind schedule. If you have anything else to say — and I sense you do, Mr. Powell — can I ask you to put it in writing, please, and send it to us? I would love for us to keep going on this dialogue longer, but unfortunately we are past our designated time for adjournment.
Mr. Powell: Can I make one statement?
The Chair: Yes, one statement.
Mr. Powell: I appreciate the pressure that everyone is under. There are many issues to cover. We did not come here today expecting to solve the problems or even identify the state of the crisis.
I want you to trust me long enough to understand that I have had my fingers out into the community and have spoken to a great many people and we are in a crisis. The unfunded liabilities in the provinces, in the accident funds, have been wiped out by the attempts of unconstitutional legislation, which has been struck down continually in the courts.
In B.C., $900 million in the accident fund sounds great, but it has now been reduced and reduced because the courts and the tribunal have overturned the decisions as being unconstitutional. They have had to pay back $400 million here and $200 million there, et cetera. Since 2002, this is what it has evolved into.
This situation with WCB in Canada has morphed. It never started out as a national program; it morphed into a national program. The powers and the prerogative right of law that they have was certainly not given to them for this intent — to look for exclusions from the Charter.
The case I just mentioned is going to be really significant for those who are on the Senate committee on mental health because they will remember back to the talks on compensation. I will be sending this for everyone. I could not afford to print it up. It is part of a brief that I am preparing for the Mental Health Commission, which is where we are going after this meeting.
It is significant, because in the U.S, the prime language of their compensation system was imported word for word in 2002, and it was struck down in precedent in Nevada, based on a mental health claim.
We are paying for the off-loading to society already. They are in serious trouble across this country with the system, and I know that they have been at the Senate Banking Committee several times and have been told to deal with their own unfunded liabilities and that they would not be given social program status.
I want to this to be a start because we never intended to cover anything, and I am smart enough to know the limitations. However, I ask you to seriously consider, with your wisdom, taking this back to the standing committee. We need to look at striking up an appropriate committee to look at these very comprehensive conditions and issues to do with disparities in law and health. We must look at the service and effective workers' compensation schemes in Canada.
That is what I think we need to do, just as EI did. It has never been done.
The Chair: Thank you very much. As I say, feel free submit something in writing to us to expand further on this subject.
We will adjourn this segment of the meeting, and we have a small in camera session, which should take about three to four minutes.
(The committee continued in camera.)