Contents Copyright ......................................................................................................................... 11 Acknowledgements ......................................................................................................... 12 Introduction ..................................................................................................................... 15 By Kathleen O’Grady and Noralou Roos................................................................. 15 Chapter 1: Aging Population ......................................................................................... 23
Why Canada needs a national plan to address dementia and Alzheimer’s .............................................................................................. 24 By Howard Feldman and Carole Estabrooks ............................................................ 24
Le Canada a besoin d’un plan d’action national sur la démence et la maladie d’Alzheimer ............................................................................... 26 Par Howard Feldman et Carole Estabrooks .............................................................. 26
The real costs of informal caregiving in Canada.................................. 29 By Nicole F. Bernier ................................................................................................. 29
Le coût véritable des soins informels au Canada ................................. 31 Par Nicole F. Bernier ................................................................................................ 31
Why we need to think twice about adopting an Australian model of pension reform ......................................................................................... 34 By Robert L. Brown ................................................................................................. 34
Pros and cons of an expanded Canada Pension Plan .......................... 36 By Robert L. Brown .................................................................................................. 36
What do Canadians need from pension reform? ................................. 38 By Robert L. Brown .................................................................................................. 38
Dying badly in Canada............................................................................ 40 By Harvey Max Chochinov ...................................................................................... 40
When is it ok for doctors to let someone die? ....................................... 42 By Charles Wright .................................................................................................... 42
Quand est-il acceptable pour un médecin de laisser une personne mourir? ..................................................................................................... 44 Par Charles Wright .................................................................................................... 44 Chapter 2: Health Care Costs and Spending ............................................................... 47
What should be covered by our publicly funded health care system?48 By Brian W. Rotenberg............................................................................................. 48
Moving forward on health care reform................................................. 50 By Allan M. Maslove ................................................................................................ 50
An era of restraint in health care spending in Canada ....................... 52 By Livio Di Matteo ................................................................................................... 52
Une ère de compressions budgétaires dans le domaine de la santé au Canada ...................................................................................................... 54
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Par Livio Di Matteo .................................................................................................. 54
Canadians should modernize not privatize medicare .......................... 57 By Bryan Thomas and Colleen M. Flood ................................................................. 57
Modernisons le régime de santé public, au lieu de le privatiser ......... 59 Par Bryan Thomas et Colleen Flood ......................................................................... 59
How proposed user fees for health services in Quebec threaten the Canadian health system .......................................................................... 62 By Ryan Meili and Danielle Martin.......................................................................... 62
Do Canadians spend too much on taxes? .............................................. 64 By Michael C. Wolfson ............................................................................................ 64
How to eliminate MRI wait lists in the public health system – and save Alberta millions of dollars a year in the process .................................. 67 By Nick Mohtadi....................................................................................................... 67
Five challenges for bending the health care cost curve in Canada ..... 69 By Greg Marchildon and Livio Di Matteo ............................................................... 69
Cinq paris à relever avant de redresser la courbe des coûts de la santé au Canada................................................................................................. 71 Par Livio Di Matteo et Greg Marchildon .................................................................. 71
New hospital funding model is a leap of faith ....................................... 73 By Karen S. Palmer and Gordon Guyatt ................................................................... 73
Financement par activité : un saut dans l’inconnu .............................. 75 Par Karen S. Palmer et Gordon Guyatt ..................................................................... 75
The Prentice health care levy is not a cure for the Alberta health system........................................................................................................ 78 By Herb Emery ......................................................................................................... 78
Putting health care on the federal election agenda .............................. 80 By Robert McMurtry ................................................................................................ 80
Ambulance fees are an obstacle on the road to care ............................ 82 By Ryan Meili and Carolyn Nowry .......................................................................... 82
Canada has mixed wait time results in health care.............................. 84 By Robert McMurtry ................................................................................................ 84
Patient-centred health care could reduce wait times and improve the Canadian health system .......................................................................... 86 By Robert McMurtry ................................................................................................ 86
Les soins axés sur le patient pourraient réduire les temps d’attente et améliorer le système de santé au Canada ............................................. 88 Par Robert McMurtry................................................................................................ 88
Barrette's reform ignores evidence on what works ............................. 91 By Paul Lamarche, Réjean Hébert et François Béland ............................................. 91
La réforme Barrette ne tient pas la route ............................................. 94
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Par Paul Lamarche, Réjean Hébert et François Béland ............................................ 94
Why a new Health Accord needs to include better planning for health human resources ...................................................................................... 97 By Ivy Lynn Bourgeault ........................................................................................... 97
Tout nouvel Accord sur la santé devrait prévoir un mécanisme de planification des ressources humaines................................................... 99 Par Ivy Lynn Bourgeault ........................................................................................... 99
BC election represents crossroads for the future of medicine in Canada .................................................................................................... 101 By Vanessa Brcic and Ryan Meili .......................................................................... 101
Dear Health Minister – please reinstate funding for Cochrane Canada ................................................................................................................. 103 By Tom Perry and Alan Cassels ............................................................................. 103
Rétablissez le financement de Cochrane Canada, madame la ministre ................................................................................................................. 105 Par Tom Perry et Alan Cassels ............................................................................... 105
Four things you should know about the pending Charter challenge against medicare .................................................................................... 108 By Colleen M. Flood and Kathleen O’Grady ......................................................... 108
Four things we can do to improve health care in Canada ................. 110 By Joshua Tepper .................................................................................................... 110
Federal government moves to strip power from top public health scientist ................................................................................................... 112 By Colleen M. Flood and Steven J. Hoffman ......................................................... 112
Le gouvernement fédéral s’apprête à dépouiller de ses pouvoirs l’administrateur en chef de la santé publique .................................... 114 Par Collen M. Flood et Steve J. Hoffman ............................................................... 114
Should eye exams be mandatory for school-age kids?....................... 116 By Elizabeth Lee-Ford Jones and Mélanie Meloche-Holubowski ......................... 116
Canadians want patient online health care options ........................... 118 By Jennifer Zelmer ................................................................................................. 118
La population canadienne réclame des services de santé en ligne.... 120 Par Jennifer Zelmer ................................................................................................. 120
Double-failing on health ........................................................................ 122 By Joshua Tepper and Danielle Martin .................................................................. 122
Double échec dans le système de santé ................................................ 124 Par Joshua Tepper et Danielle Martin ..................................................................... 124
Rising rates of kidney failure signal need for public health strategy 126 By Allison Dart and Mariette Chartier.................................................................... 126
L’augmentation des taux d’insuffisance rénale indique la nécessité d’une stratégie en matière de santé publique ..................................... 128 4
Par Allison B. Dart et Mariette J. Chartier.............................................................. 128
Four things everyone should know about autism in Canada ............ 131 By Kathleen O’Grady ............................................................................................. 131
Quatre faits incontournables sur l’autisme au Canada ..................... 134 Par Kathleen O’Grady............................................................................................. 134
Why it’s time for a National Autism Strategy .................................... 137 By Kathleen O’Grady ............................................................................................. 137
Le temps est venu d’instaurer une stratégie nationale en matière d’autisme ................................................................................................ 140 Par Kathleen O'Grady ............................................................................................. 140 Chapter 3: Health is More Than Health Care ........................................................... 143
Why one of Canada’s big banks is calling for greater income equality ................................................................................................................. 144 By Ryan Meili ......................................................................................................... 144
Pourquoi une grande banque canadienne prône une plus grande égalité des revenus ................................................................................. 146 Par Ryan Meili ........................................................................................................ 146
Why the federal government needs to keep its promise to end incomesplitting ................................................................................................... 149 By Avram Denburg ................................................................................................. 149
Ending homelessness in Canada receives failing grade ..................... 151 By Jino Distasio ...................................................................................................... 151
How doctors can tackle the poverty of their patients without leaving the doctor’s office .................................................................................. 153 By Gary Bloch and Sharon Macdonald .................................................................. 153
Saskatoon's housing crisis is a health emergency............................... 155 By Michael Schwandt and Ryan Meili ................................................................... 155
Basic income: just what the doctor ordered ....................................... 157 By Danielle Martin and Ryan Meili........................................................................ 157
Will climate refugees in Canada finally spur action on climate change? ................................................................................................... 159 By Ryan Meili and Mahli Brindamour ................................................................... 159
What I learned as a medical student working with low-income families in Toronto ................................................................................ 161 By Lita Cameron and Elizabeth Lee-Ford Jones .................................................... 161
Arrested for Sleeping? .......................................................................... 163 By Jino Distasio ...................................................................................................... 163
Extreme weather events hit most vulnerable...................................... 165 By Jino Distasio ...................................................................................................... 165
Is it finally time for a Guaranteed Annual Income? .......................... 167 By Noralou Roos and Evelyn Forget ...................................................................... 167
Serions-nous enfin mûrs pour le revenu annuel garanti? ................. 169 5
Par Noralou Roos et Evelyn Forget ........................................................................ 169
Many of the most complex needs of my patients stem from poverty and not disease alone ............................................................................. 172 By Laura Stymiest with Elizabeth Lee Ford Jones ................................................. 172
What I didn’t learn in medical school ................................................. 175 By Vivian Tam with Elizabeth Lee-Ford Jones ...................................................... 175
Setting the conditions for good long-term health ............................... 177 By Chris Harper ...................................................................................................... 177
How to make the social determinants of health matter ..................... 180 By Ryan Meili ......................................................................................................... 180
Growing gap poses a health risk to all ................................................ 185 By Ryan Meili ......................................................................................................... 185
Five things we know about economic inequality – and why we need to act ............................................................................................................ 187 By Carolyn Shimmin .............................................................................................. 187
Cinq faits incontournables sur le rapport entre santé et pauvreté au Canada .................................................................................................... 192 Par Carolyn Shimmin.............................................................................................. 192
Why does Canada do so poorly on children’s health rankings? ...... 195 By Nicole Letourneau ............................................................................................. 195
Pourquoi le Canada fait-il mauvaise figure en matière de santé infantile? ................................................................................................. 197 Par Nicole Letourneau ............................................................................................ 197
Canada needs to rethink approach to early childhood development200 By Nicole Letourneau and Justin Joschko .............................................................. 200
Le Canada doit repenser son approche en matière de petite enfance ................................................................................................................. 202 Par Nicole Letourneau et Justin Joschko ................................................................ 202
We need a radical new approach for kids in care .............................. 205 By Marni Brownell and Neeta McMurtry .............................................................. 205
Canada has too many kids in care – and the situation is not improving ................................................................................................................. 207 By Marni Brownell and Neeta McMurtry .............................................................. 207
Le nombre d’enfants placés en structures d’accueil au Canada est trop élevé ................................................................................................ 210 Par Marni Brownell et Neeta McMurtry................................................................. 210
Alcohol use in pregnancy part of a complex set of issues .................. 213 By Chelsea Ruth ..................................................................................................... 213
Missed opportunities ............................................................................. 215 By Fiona Kouyoumdjian with Stephen Hwang ...................................................... 215
Is it fair to make a public appeal for a live organ donor? ................. 217
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By Jennifer Chandler .............................................................................................. 217
Three things the federal government can do to improve the Registered Disability Savings Plan.......................................................................... 219 By Kathleen O’Grady ............................................................................................. 219
Trois mesures que peut prendre le fédéral pour améliorer le régime enregistré d’épargne-invalidité ............................................................ 222 Par Kathleen O’Grady............................................................................................. 222
It shouldn’t matter where you go to school, but for kids with diabetes, it does ...................................................................................................... 225 By Jan Hux.............................................................................................................. 225
Rethinking diabetes ............................................................................... 227 By Jan Hux.............................................................................................................. 227
Repenser le diabète ................................................................................ 229 Par Jan Hux ............................................................................................................. 229
Learning to walk .................................................................................... 232 By James Wilson..................................................................................................... 232
Apprendre à marcher ........................................................................... 234 Par James Wilson .................................................................................................... 234
Social change: at the heart of medicine ............................................... 236 By Ryan Meili ......................................................................................................... 236
Canadian researchers call on fellow scientists to be more vocal in the media ....................................................................................................... 242 By Mélanie Meloche-Holubowski .......................................................................... 242
Des chercheurs canadiens sollicitent une plus grande présence dans les médias de leurs pairs ....................................................................... 245 Par Mélanie Meloche-Holubowski ......................................................................... 245
Five things every Canadian should know about obesity ................... 248 By Carolyn Shimmin .............................................................................................. 248
Cinq faits pour mieux comprendre le phénomène d’obésité au Canada ................................................................................................................. 250 Par Carolyn Shimmin.............................................................................................. 250
Most Canadians don’t understand food nutrition labels .................. 252 By John Millar and Mélanie Meloche-Holubowski................................................ 252
La majorité des Canadiens ne comprennent pas le contenu des étiquettes nutritionnelles....................................................................... 254 Par John Millar et Mélanie Meloche-Holubowski .................................................. 254 Chapter 4: Pharmaceutical Policy ............................................................................... 257 Toward a True Health Accord............................................................................... 258 By Ryan Meili ......................................................................................................... 258
Ontario spends more than $11 billion a year on prescription drugs 260 By Steve Morgan .................................................................................................... 260
Compulsory insurance does not create affordable access to prescription drugs ................................................................................. 262
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By Steve Morgan .................................................................................................... 262
L’assurance obligatoire ne favorise pas un accès abordable aux médicaments d’ordonnance .................................................................. 264 Par Steve Morgan .................................................................................................... 264
Pharmacare is for kids too .................................................................... 267 By Avram Denburg and Steve Morgan .................................................................. 267
Getting a grip on the risks of vaccination ........................................... 269 By Brian W. Rotenberg........................................................................................... 269
Bien saisir les risques de la vaccination............................................... 271 Par Brian W. Rotenberg .......................................................................................... 271
Are we finally in a health election campaign? .................................... 273 By Ryan Meili ......................................................................................................... 273
Catastrophic pharmacare is a catastrophe ......................................... 275 By Steve Morgan .................................................................................................... 275
Canada’s chance to catch up on drug safety for children ................. 277 By Terry P. Klassen and Martin Offringa ............................................................... 277
Antibiotics – overprescribed and under-effective .............................. 279 By Brian W. Rotenberg........................................................................................... 279
The other drug problem in Canada’s cities ........................................ 281 By Steve Morgan .................................................................................................... 281
Pharmacare is good for business.......................................................... 283 By Steve Morgan and Danielle Martin ................................................................... 283
Why we should think twice before we institutionalize national pharmacare ............................................................................................ 286 By Alan Cassels ...................................................................................................... 286
Provincial Health Ministers right to push for national pharmacare program – but what kind? .................................................................... 288 By Marc-André Gagnon ......................................................................................... 288
Why employers in Canada waste $5 billion a year on inefficient drug coverage .................................................................................................. 291 By Alan Cassels, Sean O’Brady and Marc-Andre Gagnon .................................... 291
L’inefficacité de l’assurance-médicaments privée coûte 5 milliards chaque année aux entreprises............................................................... 294 Par Alan Cassels et Sean O'Brady .......................................................................... 294
Is it finally time for a national drug plan? .......................................... 296 By Livio Di Matteo ................................................................................................. 296
Four things needed to make pharmacare work for Canadians ........ 298 By Steve Morgan .................................................................................................... 298
Are we medicalizing healthy people? .................................................. 300 By John Frank ........................................................................................................ 300
Why I decided to get the flu vaccine for myself and my children .... 302
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By S. Michelle Driedger ......................................................................................... 302
Qu’est-ce qui m’a incitée à nous faire vacciner, moi et mes enfants, contre la grippe ...................................................................................... 304 Par S. Michelle Driedger......................................................................................... 304
Saskatchewan has the highest rates of HIV in the country ............... 307 By Julio Montaner and Ryan Meili ......................................................................... 307
We have built a sickness care system rather than a health system .. 309 By André Picard ...................................................................................................... 309
Un système de santé orienté vers la maladie plutôt que la santé et conçu en fonction des médecins et non des patients ........................... 312 Par André Picard ..................................................................................................... 312 Chapter 5: Mental Health ............................................................................................ 315
Older adults living with mental illness need specialized housing and supports to avoid homelessness ............................................................ 316 By Pat Cashion and Lee Tunstall ............................................................................ 316
Five ways we can reduce suicides in Canada ...................................... 318 By Jitender Sareen and Cara Katz .......................................................................... 318
Cinq propositions pour réduire le taux de suicide au Canada ......... 321 Par Jitender Sareen et Cara Katz ............................................................................. 321
Many patients with chronic health conditions also have mental health issues that go undiagnosed and untreated .......................................... 324 By Sanjeev Sockalingam and Paul Kurdyak .......................................................... 324
Canada needs improved access to mental health care services ........ 326 By Paul Kurdyak and Sanjeev Sockalingam .......................................................... 326
Le Canada néglige les personnes souffrant de maladie mentale ...... 328 Par Paul Kurdyak et Sanjeev Sockalingam ............................................................. 328 Chapter 6: Comparing Canadian and American Health Systems ........................... 330
Why Canadian hospitals outperform U.S. hospitals .......................... 331 By Steffie Woolhandler and David Himmelstein ................................................... 331
Why this U.S. doctor is moving to Canada ......................................... 333 By Emily S. Queenan .............................................................................................. 333
The Canadian doctor who prescribes income to treat poverty ......... 336 By Trudy Lieberman ............................................................................................... 336
The Canadian baby boom years are different from the U.S. ............ 338 By Robert L. Brown ................................................................................................ 338
Il ne faut pas confondre le baby-boom canadien et celui des États-Unis ................................................................................................................. 340 Par Robert L. Brown ............................................................................................... 340 About the Editors .......................................................................................................... 342 Appendix A .................................................................................................................... 345
Write a Snappy OpEd ........................................................................... 345 To Change Minds, and Maybe Even Behaviours ............................... 345 9
Appendix B .................................................................................................................... 347
2011 - 2015 published Op-Eds analyzed by media category, December 30, 2015 ................................................................................................... 347 Appendix C .................................................................................................................... 351
Number of Op-Eds, by where published ............................................. 351
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Copyright 1st edition with content from December 2014 to December 2015. License to Republish: Our commentaries, podcasts and videos are provided under the terms of a Creative Commons Attribution No-Derivatives license. This license allows for free redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author and EvidenceNetwork.ca. EvidenceNetwork.ca supports the use of evidence when reporting on health and health policy in the mainstream media. Specific points of view represented here are the individual author’s and not those of EvidenceNetwork.ca. Let us know how we’re doing:
[email protected]. Edited by: Noralou Roos, Kathleen O’Grady, Eileen Boriskewich, Mélanie MelocheHolubowski, Carolyn Shimmin, Kristy Wittmeier and Nanci Armstrong. Cover photo and image provided with permission from the artist and photographer. “Blue & White Sea,” Paper Sculpture by Peter Gentenaar. Photo by Pat Gentenaar Torley. Website: www.gentenaar-torley.nl. Cover and pull quotes designed by Eileen Affleck/Folio Design. All other images were purchased through iStockphoto.com and Dollar Photo Club Developed in Canada. ISBN 978-0-9916971-9-9
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Acknowledgements It takes a tightly knit team of regular contributors, interns, research assistants, editors, academic expert advisors and journalists to make EvidenceNetwork.ca possible, in dayto-day operations, and in the production of this eBook, the fourth in our annual series. In other words, there are many people to thank. We are indebted to our independent media advisory committee who provide general guidance on our priorities and approach, and who act as a general sounding board for all that we do. Their time is valuable so we appreciate that they’ve donated some of it to our project. Our gratitude is extended to Gillian Steward, Journalist, Toronto Star and PartTime Faculty, Mount Royal University; Ann Rauhala, Associate Professor, Ryerson University’s School of Journalism; Steve Buist, Investigative Reporter and Feature Writer, Hamilton Spectator; Dean Broughton, Chief News Editor, Vancouver Sun; Tom Blackwell, Senior National Reporter, National Post; new member, Cecil Rosner, Managing Editor, CBC and Adjunct Professor, University of Winnipeg; and out-going member, Janice Neil, Associate Chair, Ryerson School of Journalism. A special thanks goes to Mary Agnes Welch who sat on the Committee from its inception until recently, when she departed from her job at the Winnipeg Free Press. She has had a remarkable career in public policy journalism, and her thoughtful and passionate reporting, and her support of Evidence Network, are greatly appreciated and will be missed. . We also have more than 80 academic experts to thank – from across the country and internationally – who field media interviews, author original material for publication in the mainstream press and participate in videos and podcasts, among other projects. Their expertise, presented in a non-partisan manner with a balanced take on evidence at the forefront, is the backbone of Evidence Network. We’d also like to thank our newly added Panel of International Journalists, which includes Rita Araujo from Portugal; Amelia Beltramini from Italy; Trudy Lieberman from the United States – who came up with the idea for the panel and orchestrated its creation – Shaun Lintern and John Lister from the United Kingdom; Ray Moynihan from Australia; Ivan Oransky from the U.S.; André Picard from Quebec; and Rinke van den Brink from the Netherlands. These top-notch health policy journalists from around the world have offered to act as a resource for fellow journalists and health experts trying to understand health systems across borders. We’d also like to thank our Evidence Network team for their on-going dedication and hard work making health policy matter by getting more health policy evidence into the mainstream media. Thanks to Website Editor and Administrator, Eileen Boriskewich; our Research Assistant, Nanci Armstrong; our Podcast and Social Media Editor, Mélanie Meloche-Holubowski; our colleagues from the George and Fay Yee Centre for Healthcare Innovation, Carolyn Shimmin, Knowledge Translation Coordinator, Kristy Wittmeier, Director of Knowledge Translation and Patrick Faucher, Knowledge 12
Translation Media Specialist, who also work on the Evidence Network project when they are able. We’d also like to thank our Regular Contributors, Neeta Das McMurtry, Trudy Lieberman, Ann Silversides and Lee Tunstall. And our newest journalist intern, Dane Wanniarachige. Colleagues who worked with us in previous years also deserve our sincere thanks for their continued support and for continuing to champion Evidence Network in their new endeavours. Thanks to Shannon Turczak, Camilla Tapp, Lindsay Jolivet, Ayat Mneina, Alex Peden and Mireille Bohémier. There are many consultants and contractors who have also helped Evidence Network along the way, and who have been a pleasure to work with. Thanks goes to Gary Slywchuk of Troy Media; Eileen Affleck of Folio Designs; Jane Shulman; Lou Lamontagne and Margot Lacroix of Intersigne; and Michael Rae and associates at LexiCom. On-going words of advice and guidance from a wide range of individuals and organizations have been greatly appreciated and perpetually useful: from John Cruickshank; Jeffrey Simpson; John Hinds; David McKie; Gerry Nott; Margo Goodhand; Nick Hirst; Gerald Flood; Christine Nunez; the Atkinson Foundation; Christine Pierroz; the Science Media Centre of Canada; Janine Harasymchuk; Jennifer Thornhill Verma and her colleagues at the Canadian Foundation for Healthcare Improvement; Michelle Driedger; Alan Katz; Ariel Bautista; Sophie Buternowsky and Robyn Tamblyn. We are also thankful for the past participation of co-founder, Sharon Manson Singer, who helped launch EvidenceNetwork.ca. And of course, crucial to our project was the funding of the Canadian Institutes of Health Research (2009-2017), Research Manitoba (2009-2017), the Manitoba Centre for Health Policy (2009-2017) and the George and Fay Yee Centre for Healthcare Innovation (2014-2017). We are thankful for your support and confidence in our project. Together, this talented collection of journalists, academics, communicators, policy makers and funders have not only made Evidence Network possible, they’ve made it thrive. We are looking forward to many more years ahead. Noralou Roos, Director, and Kathleen O’Grady, Managing Editor, EvidenceNetwork.ca
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Why We Need More Canadian Health Policy in the Media
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Introduction Stepping beyond the ‘hallowed paywalls’ of academic publication Why academics need to make sure their evidence matters By Kathleen O’Grady and Noralou Roos Why We Need More Canadian Health Policy in the Media is our fourth in a series of eBooks, bringing together opinion-based commentaries on pressing Canadian health policy issues from Evidence Network’s more than 80 Canadian and international academic experts. Why do we do this? To make sure the evidence matters. An average paper in a peer-reviewed academic journal is read by no more than 10 people, according to Singapore-based academic, Asit Biswas, and Oxford-researcher, Julian Kirchherr, in their controversial commentary, “Prof, no one is reading you,” which went viral last year. They cite some remarkable statistics – as many as 1.5 million peerreviewed articles are published annually with as many as 82 percent never cited once, not even by other academics. In other words, most academic writing rarely influences thinking beyond the privileged circles in which it is constructed – and the vast majority are far from influencing public policy and debate on critical issues. Other academics question such dire statistics and use different approaches to shore up the numbers, such as changing what counts as a citation (including self-citations and nonacademic citations), and using a longer window to check for citations. But their attempts to improve the portrait of academic influence are not much better. A cheeky article on the topic in the Smithsonian, entitled, “Academics write papers arguing over how many people read (and cite) their papers” notes that a 2007 study claimed half of academic papers are read only by the author and the journal editors – a stab to the heart if there ever was one. They also cite (not without irony) a 1990 study which claims a whopping 90 percent of academic papers are never cited. Dahlia Remler on the London School of Economic blog casts doubt on the damning figures in her article, “Are 90 percent of academic papers really never cited?” and notes that citation rates actually vary widely by field. Still she acknowledges that as many as one third of social sciences articles go uncited, 82 percent for the humanities and 27 percent for the natural sciences. What started out as a skeptical rejoinder ends with a simple plea: “Academic publication needs fixing.” Lest the sciences think they come out looking good here by comparison, evidence from other quarters is not so favourable. Twenty years ago, the journal Science found a mere 45 percent of articles published in the top 4,500 science journals were cited within five years. A more recent study found a decline in that figure – only 40.6 percent of articles in the top science and social science journals were cited within five years. In other words, the problem is not a new one and appears to be worsening. Why? There’s simply too much to read. 15
We are awash in a sea of unread journal articles There has been a dramatic growth in the number of journals, and by extension, journal articles, published every year. The STM Report from 2015 notes there are more than 28,000 active scholarly peer-reviewed English-language journals which publish around 2.5 million articles annually. The report notes the number of journals is growing at a rate of at least 3.5 percent per year; this reflects a growth in researchers of about three percent per year. Growth in the number of academic journals is possibly also linked to their surprisingly high profitability – as well as the counter movement to create open-access journals. To put these growth numbers another way: the rate of journal article output more than doubles every 20 years, notes the Chronicle of Higher Education. And those are the optimistic numbers. Another study pegs journal article growth at an average 6.3 percent per year. The result? A trend toward fewer citations per paper. It appears we are awash in studies no one ever reads. It’s not bad news for everyone as it turns out – just for most. As the number of journal articles increases, the number of citations on average per article, decreases. The STM report, however, notes that the distribution of citations is highly uneven, with 80 percent of citations coming from fewer than 20 percent of articles. As one researcher summarized the trend: “fewer journals and articles [are] cited, and more of the citations [are] to fewer journals and articles.” In other words, the deluge of uncited papers is punctuated by a handful that rise to the surface like the tip of an iceberg. But lest you get the impression the established journals are the ones benefitting here, the trend is just the reverse. The dominating influence of elite journals may be on the way out. Turns out highly cited papers published in highly cited journals are on the decline, while the number of highly cited papers coming from new and less established journals rises steadily. There are any number of mitigating factors for why we have so many unread journal articles – the publish or perish mantra that seems to kick in earlier with each generation of scholar; the parsing of a study into many component parts to maximize journal article output; the inflation of referenced articles and co-authors to boost impact factors; an academic system that rewards researchers for output and not necessarily influence – to name a few. No change is imminent, unless, as one commentary notes, “the system of rewards is changed.” But not least of all, part of the blame is surely the result of a system that looks down upon or at least disregards academic engagement with media, policy makers and the wider world it claims to address. The truth is, few beyond the academy know or read academic journals.
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Incentivizing Academics to Engage With the Media It would be a small – but critical – step for academics to tell audiences why their research matters. Presumably much of the research in journal articles would and should matter to those beyond academic circles – particularly those who are in the business of creating policy. Biswas and Kirchherr in their “Prof, no one is reading you,” propose just such an approach. The answer to researchers being trapped in the echo chamber of academic journals, they suggest, is to step beyond them – and engage the mainstream media: “If academics want to have an impact on policymakers and practitioners, they must consider popular media, which has been ignored by them.” This is not a refutation of the journal publication, or the important evidence it imparts, but an extension of the publication process. So why is this not happening already – at least not frequently? An article in SciLogs put it this way: “The biggest hurdle is that academia has yet to find an incentive for them to take time away from the lab to engage the public. Universities still operate under an ancient system that values only scholarly output.” Academic physician, Daniel Cabrera calls for a change in the way traditional journal citation “impact factors’ are used for academic promotion. He suggests instead we establish a system that also rewards academics who engage and share their knowledge with the public via traditional, new and social media too. Journals and citation counts are no longer enough. Cabrera points to the many publicly available and robust metrics now available from media and social media and concludes: “As Clinician Educators, we should champion the movement from a 50-year old journal-based index that imperfectly serves as a surrogate of influence to modern analytics with the ability to monitor, measure and share the realtime influence of scholars in their institutional spheres but also in their public spheres.” The time has come, he suggests, for academics to engage beyond journal articles and communicate their evidence and ideas to a broader interested public. By no means are these calls for academic engagement with the media – and beyond – isolated. It’s become somewhat of a clarion call. Last year, the Guardian published a commentary entitled, “Academics: leave your ivory towers and pitch your work to the media.” As an academic herself, but also a journalist, the author, Kristal Brent Zook says she’s wondered why her academic colleagues don’t engage or write for the media more often: “Why don’t we hear more from the doctors behind the data?” So she asked around. The answers she got from a survey of academics surprised her. It turns out the main reason is fear. According to Zook, academics don’t engage with the media because of fear of the unknown – both the media, and how it works, and of engaging with the general public. There’s also an unspoken wariness, at worst, hostility, between academics and journalists who have differing cultures, time lines and agendas.
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However, according to Sense About Science USA, the journalist door is (almost) always open. They recently published new media guides for scientists and surveyed more than 200 journalists in the process. They found 92 percent of journalists are always open to scientists calling them if they have information; 94 percent of journalists said want to hear from sources if they feel they were misquoted or misrepresented; and 94 percent always or most of the time read the academic article(s) in question before contacting the scientist for interview about their research.
What Happens When Academics Step Outside the Echo Chamber of Academic Journals? In her commentary, Zook notes the positive outcomes that arise when academics do engage the media. One academic said that a single of her posts went viral, ended up on numerous syllabuses, and opened up opportunities to write academic articles, book chapters and even a book, and indirectly, a grant. “It was a catalyst,” she said. Another highlighted how writing for the media made her a better writer. She realized how riddled her writing was with jargon and that these big words were often a ‘crutch’ – “I have to cut through the bullshit and just say what I really mean.” In a recent British Medical Journal blog, David Payne echoes the call for broader public engagement: “Being an academic is all about people knowing about your research…Don’t leave a paper to its own devices.” Publication is not enough, in other words – it’s the beginning of a process of engagement, not the end of it. Duncan Green, similarly, in the London School of Economics Impact blog says that much of academic life is “spent within the hallowed paywalls of academic journals” but that academics could and should engage more with new and social media to attract an audience to their research and give their research meaningful impact. He calls engagement with a wider audience “an antidote to futility.” Like Payne and Zook, he cites specific instances where engagement clearly resulted in significantly increased journal article readership, among other real world and academic outcomes. So it’s not about abandoning traditional academic publishing, but expanding its scope and reach – and making their evidence matter. What academic wouldn’t want that? A Wall Street Journal article headlined, “Why the Dean of Harvard Medical School Tweets” similarly outlines how successful engagement strategies – in this case, using Twitter – can make academic research meaningful beyond the academy, and reach other educators, policy makers, economists and politicos with important outcomes. Harnessing traditional and new media to engage with wider audiences helps make the research live on, in other contexts, and affect change.
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How the Public Reaps the Rewards of Academic Engagement So engaging the public through traditional and new media is good for academic up-take in a wide range of ways, but it turns out it’s also good for the general public too. According to Deepti Pradhan writing for the Op-Ed project, only two percent of citizens in the U.S. are actively and formally learning about science – the rest learn about science “through the general media.” Quality evidence in media outlets can help shape public perceptions and public debate on important policy issues. The lack of it can sometimes have devastating consequences. Declining vaccination rates is a good example. In a study last year, 60 autism scientists were polled about the importance of communicating their work to the public. Fifty-nine felt their research would be of interest, yet less than half felt it was ‘very important’ for them to do this – in other words, they felt it wasn’t their job. Half felt they didn’t have opportunities to communicate with the public, and half felt they didn’t have the time to do so. But the study authors emphasize the outcome of just such a lack of engagement. They note that the field of autism – including amongst the parents and caregivers of kids with autism – is riddled with misinformation. This has real world consequences, not least of which is the all too recurring myths around the harms of vaccination (that they cause autism – substantial evidence says they don’t) which directly affects rates of vaccination in the population. The evidence is there, and it’s good, but it’s not getting to the public. The lack of communication between scientific researchers and the public “threatens the relationship with the community they’re trying to help,” claims an editorial from the Simons Foundation Autism Research Initiative. Other calls for academic engagement with the world beyond journal publication include Ben Goldacre in the Times Higher Education who says we need more academic engagement in the public policy process specifically: “we need more of this interaction, not less.” He writes articles in the mainstream media regularly and meets with policy wonks and politicos in an effort to get research out of journals, informing policy-making and legislation-building in the process. According to Goldacre, “Policy staff are crying out to be lobbied” by knowledgeable academics. They want and need the evidence to do their work and academics want their work to matter. It’s a perfect marriage of sorts. As one policy maker said to him, “If none of the [academics] are ever calling me, then what do they do all day that they all think is more useful?” A damning indictment. The refrain of having academics dive into the policy debates and discussions that have real life consequences come from many quarters and from around the world. It is motivated – on the whole – not from a critique of the scholarship but from a desire to see quality evidence affect change, for our public investment in higher learning to bear fruit in public policy and beyond. But there are real barriers that can’t be ignored. The challenge for many academics is that even if they want to engage in such public discussions – to go where the audiences already are, in traditional, new and social media – they don’t often know how to go about it and few have the time or the resources to do it properly. 19
About EvidenceNetwork.ca: How 700 Words Can Make a Difference It was in just such a context that EvidenceNetwork.ca was born in Canada. Founders, academics Noralou Roos and Sharon Manson Singer were frustrated that research they knew well in the field of Canadian health policy seemed to rarely make it into the mainstream media. There were a few notable exceptions – produced by the handful of remaining well-trained health journalists scattered across the country. On the whole, they found the media discussion dominated by hyperbolic language from left- and right-wing think tanks and political parties. The extremes got air time, but most of the nuance and depth of any research was lost. Roos and Manson Singer wanted to inject more evidence into the discussions and to see the rich world of academic research given equal air time. So they created EvidenceNetwork.ca – with a sizeable grant from the Canadian Institutes of Health Research and Research Manitoba, to create a bridge between the world of academia and the world of journalism. What started out as an experiment in 2011 has blossomed into a full media service for academics and a clearinghouse of high quality, original health policy articles ready for publication for media outlets. At first, EvidenceNetwork.ca simply offered, on a static website, the names and contact details of academics in the field of health policy who were willing and able to be interviewed by the media in balanced, non-partisan terms without vested interests. This was only modestly successful. Next, EvidenceNetwork.ca decided to more directly get academics engaged with the media. So we created a Media Advisory Committee to give us advice. In consultation with our academic experts, we discovered academics often worry they’d lose control of the message and the way their research is represented in the media in traditional interview formats. At the same time, we learned from our media advisors, how academics often failed to heed the tone, style of language and breadth of discussion permitted in submissions to media publications. From this tension was born the idea to help our academic partners craft op-eds – the opinion-based commentaries that appear in most media outlets. Op-eds frequently influence politicos, policy makers and other decision-makers, and are a popularly read media genre where studies and evidence come to the fore. We knew that many Universities already offer media training to academics – one-day or one-hour ‘how-to’ courses on how to write and pitch op-eds – so we wanted to offer something more robust. We adopted a slightly different model with the idea that academics can’t be all things to all people. They can’t be expected to know inside-out the media environment or have the time or interest to develop relationships directly with journalists and editors. So we decided to do that for them. EvidenceNetwork.ca acts as a mediator and editorial service for academics who are asked to first write a rough draft of their op-ed. We guide them on how to proceed with the first draft – the dos and don’ts of the process (See Appendix A – How to write an op-ed). After that, we take it from there. Our editorial team works on tightening up the op-ed 20
with the needs of specific media outlets in mind. Rough drafts are often trimmed to specific word counts, the argument is tightened and jargon-laced language is excised in place of plain or conversational language suiting traditional op-ed style. The author is part of this process throughout. The op-ed routinely goes through three or more rounds of edits and – if the material is controversial or political in any way – it goes through an informal peer review process with other experts vetting the piece for balance and accuracy. All points of evidence are hyperlinked to their sources. Once we are certain the piece is ready for the media, we secure author approval, and then EvidenceNetwork.ca shops the op-ed to the major media outlets on behalf of the author. The result is that the author maintains control of the message and the language of the article, while at the same time benefitting from the expertise of EvidenceNetwork.ca staff who liaise regularly with media editors to learn what styles and formats they prefer and require, and to establish trust and rapport. The media love to receive the free, quality content written to their specifications and from a wide range of academic experts across the country. The academic experts are not expected to know the media landscape so are walked through the process – and the media placement is managed for them. The cost of the operation is minimal and the turnaround time for an op-ed is rapid – in keeping with media time constraints. Everyone ends up happy. In the parlance of the 1990s, it’s a win-win-win. We have the data to prove it. Op-eds produced in participation with EvidenceNetwork.ca have been a resounding success. In the last year alone, we edited and placed over 100 op-eds. Almost four dozen were published in the top five media outlets alone (Globe and Mail, National Post, Toronto Star, La Presse and Le Devoir) in a single year, and 191 more were published in the bigger city media outlets and 665 in the smaller regional media in 2015. Year over year we’ve improved these metrics (See Appendix B and C). In total, we’ve published 494 op-eds garnering more than 2000 media hits in fewer than five years, publishing in the biggest media outlets to the smallest niche and rural papers. Like the commentators who plead for more academic engagement with the media and who tout the real world benefits of the exercise, our little Canadian experiment has proven that a measly 700 words (the average size of an op-ed) matters. Our op-ed writers, as a result of their op-eds, have been cited by Ministers, invited to Parliamentary hearings, committees and briefings – at the federal and provincial levels. Our op-eds have kicked off other media investigations, editorials and interviews for our writers – in print, online, radio and TV – and several of our op-ed writers have won academic engagement awards from their universities for their efforts. How much of the research documented in the op-eds has been picked up and used in political, policy and other circles is harder to measure – but we know at the very least the research is getting out there and not just sitting in academic journals. Op-eds don’t require much time investment, they are high profile and often shared widely on social media. They become part of the public discussion and dialogue around important issues of the day. 700 words, it turns out, can make a difference.
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About this Book This e-book is the fourth in a series of collections of our published op-eds. This volume represents op-eds from 2015, so it is a snapshot or repository of the health policy debates of the year – and what a year it was, with a fraught and heated federal election campaign. The op-eds here often address the political landscape (what the political leaders should be addressing in their campaigns), and then after the election, what the priorities should be for the incoming party. While the federal leadership has changed, many of the issues still remain, and the research, timely. The book is arranged in several chapters starting with the always popular Aging Population – including discussions on pensions, homecare, long-term care and assisted dying. Next is Health Care Costs and Spending, which includes everything from what should be included in our publicly covered health system to debates around privatization, wait times and patient-centred care. Health is More than Health Care encompasses all the social factors that influence health status, such as affordable housing, climate change, poverty and early childhood education, among other factors. Pharmaceutical Policy addresses the idea of pharmacare and if and how it should be implemented, wades into the vaccination debates, and details the effects of pharmaceutical influence on doctors and patients. Finally, we also include a small section Comparing Canadian and American Health Systems since there are many lessons to be learned from one system to another and back again. We hope with the creation of this e-book that we continue to be part of the movement – clearly a global movement now – that pushes academic evidence out into the world in an accessible format so that it does not sit idle behind journal paywalls but makes a difference in the world in which we live. We also hope that the bridge we’ve helped build between mainstream media and academic research sets a precedent for further exchanges and participation between these two distinct groups. We also hope that our oped model will be copied and replicated by others elsewhere. We all benefit when research is read widely and discussed soundly. It’s how we can make sure evidence matters.
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Chapter 1: Aging Population
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Why Canada needs a national plan to address dementia and Alzheimer’s By Howard Feldman and Carole Estabrooks One of the biggest threats to quality of life and health in aging is the loss of cognitive abilities and functional autonomy that are associated with dementia, including Alzheimer’s disease. The projections of the number of Canadians living with dementia are staggering with over 750,000 individuals affected today, an attendant doubling by 2030 – and with health care costs of $293B by 2040. In September 2015, the Canadian Academy of Health Sciences (CAHS) held a Forum on dementia in Canada. This brought together social scientists, biomedical and health services researchers, health care practitioners and technology experts to review current knowledge about prevention and care of dementia with the goal of advancing solutions. The overarching message of the Forum was that while we have seen many successful pilot projects across the country, there is no mechanism to ensure that these best practices and evidence are scaled up so that all communities in Canada benefit. So what should be done? Canada needs a national action plan to address dementia and Alzheimer’s. And we need one soon. Here’s why. Drugs are not presently the answer, and imminent pharmaceutical solutions seem unlikely with more than 200 drug development failures in the last 30 years. Prevention is promising but challenging. The recently reported FINGER study shows that dietary counselling, exercise training, blood pressure control and cognitive training achieved significant benefits in cognition and well-being. Unfortunately, there is no clear way to scale-up these important findings for the population as a whole. Then there’s quality of life, mobilization and sustaining a safe environment which are also critical for people already living with dementia in their homes and community settings. There are promising solutions, ranging from age friendly community design to technology – much that Canada could learn from. Dementia-friendly communities and optimizing built environments are being explored internationally to enhance accessibility, way-finding and engagement in community life. Those affected with dementia may also stay in their homes longer, through “smart” technologies that prompt tasks and collect data that can be relayed to family and health care providers. Robotics, too, may support an individual’s cognitive strength while futuristic self-driving cars come ever closer to implementation. In other words, there’s no magic bullet. What we need is a multi-faceted approach that requires real leadership and adequate resourcing for implementation.
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There are some key challenges across the country that need addressing for starters. Accessibility to assessment, diagnosis, treatment and comprehensive continuity of care is a major challenge in all jurisdictions across the country. Quebec offers a promising model with the family doctor at the center of an interdisciplinary team, coordinating care and supporting affected individuals and their families through their disease course. Home care needs national attention too. The type of home support available across Canada varies widely, with limited provision being the common feature. The truth is family and friends of persons with dementia provide most of the care and the health care system tends to be reactive rather than guiding or integrating care. We can address this with a national focus. There are noteworthy programs that have been developed within provincial boundaries but which have not yet spread to other jurisdictions. In Saskatchewan, for example, researchers and clinicians have created a “one stop shop” dementia intervention clinic using telehealth, allowing more care to be provided in the home community, making it easier for those living in rural areas – a major challenge in Canada. A national plan also needs to address the later stages of living with dementia. Right now we are highly dependent on residential care settings where there are significant challenges across the country in providing consistent quality of care, quality of life and quality end of life care. We can no longer hope for simple solutions or a miracle drug to cure our dementia problem in this country (if we ever could). And the status quo simply won’t hold. What we need is a strategic action plan for the country that facilitates prevention strategies, advances systems of care delivery, re-shapes our living and built environments and mobilizes technology so that all Canadians with dementia – regardless of who they are or where they live – are supported in their communities as long as possible, and when that is no longer possible, receive exemplary quality care. We’ve known about the rising rates of dementia – and the catastrophic costs to the health care system – for years. What we need now is a multi-faceted action plan with government, the private sector, and the community at large coming together. Howard Feldman is an advisor with EvidenceNetwork.ca and Professor of Neurology, Faculty of Medicine, University of British Columbia. Carole Estabrooks is Professor & Canada Research Chair, Faculty of Nursing, and University of Alberta. They are both co-chairs, Canadian Academy of Health Sciences 2015 Forum on Dementia.
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Le Canada a besoin d’un plan d’action national sur la démence et la maladie d’Alzheimer Par Howard Feldman et Carole Estabrooks La détérioration des habiletés cognitives et de l’autonomie fonctionnelle associée à la démence, notamment à la maladie d’Alzheimer, constituent l’une des plus grandes menaces pour la santé et la qualité de vie au cours du vieillissement. Les projections sur le nombre de Canadiens atteints de démence donnent le vertige : plus de 750 000 personnes en souffrent aujourd’hui et leur nombre devrait doubler d’ici 2030; d’ici 2040, le coût des soins atteindra les 293 milliards de dollars. En septembre dernier, l’Académie canadienne des sciences de la santé (ACSS) tenait un forum sur la démence au Canada qui a réuni des chercheurs en sciences sociales, des scientifiques spécialisés dans le domaine biomédical et les services de santé, des professionnels de la santé ainsi que des experts en technologie. On y a fait le point sur les connaissances actuelles en matière de prévention et de traitement de la démence dans le but de proposer des solutions. Le principal message qui ressort de la rencontre est le suivant : malgré le succès des nombreux projets pilotes menés d’un bout à l’autre du pays, il n’existe aucun mécanisme qui permettrait d’étendre les pratiques exemplaires et les données probantes qui en découlent pour que l’ensemble de la population en profite. Que faire devant ce constat? Il faut adopter un plan d’action national sur la démence et l’Alzheimer. Nous en aurons besoin bientôt. Voici pourquoi. Tout d’abord, les médicaments ne sont pas la solution pour l’instant; ils ne risquent pas de le devenir dans un avenir très rapproché, vu les multiples échecs de la recherche pharmaceutique depuis une trentaine d’années, qui se dénombrent à plus de 200. Ensuite, la prévention est une avenue prometteuse, mais exigeante. L’étude FINGER, publiée récemment, a montré que le counseling diététique, l’exercice, le contrôle de la pression artérielle et l’entraînement cognitif amélioraient sensiblement les fonctions cognitives et le bien-être. Malheureusement, il n’y a pas de moyen évident de faire profiter l’ensemble de la population de ces importantes découvertes. Par ailleurs, la qualité de vie, la mobilisation et la sécurité de l’environnement sont des considérations essentielles pour les personnes atteintes de démence qui vivent encore chez elles et dans leur milieu de vie. Il existe des solutions intéressantes, dont les aménagements adaptés aux personnes âgées et les aides techniques font partie. Ce sont des aspects au sujet desquels nous pourrions en apprendre beaucoup. Ailleurs dans le monde, on explore des moyens d’aménager des milieux de vie et des cadres bâtis adaptés à la démence, dans un souci d’améliorer l’accessibilité, la capacité de 26
s’orienter et la participation à la vie sociale. Les personnes souffrant de démence peuvent ainsi vivre chez elles plus longtemps, grâce à des technologies « intelligentes » qui accomplissent des tâches et recueillent des données pouvant être transmises aux proches et aux prestataires de soins. La robotique peut servir à soutenir la capacité cognitive; les voitures futuristes sans conducteur, par exemple, semblent une réalité à portée de main. En d’autres mots, il n’y aura pas de solution miracle. Il faudra recourir à une approche multidimensionnelle, appuyée par un véritable leadership et des ressources adéquates pour sa mise en œuvre. Nous devrons d’abord nous attaquer à certains problèmes fondamentaux. Dans l’ensemble des provinces et territoires, l’accès en matière d’évaluation, de diagnostic, de traitement et de continuité des soins constitue un enjeu majeur. Le Québec a mis en place un modèle susceptible de nous inspirer : le médecin de famille assume le rôle de pivot central au sein d’une équipe multidisciplinaire; il ou elle coordonne les soins et appuie les personnes touchées et leurs proches tout au long de l’évolution de la maladie. La question des soins à domicile exige également une action à l’échelle nationale. Les structures de soutien varient grandement d’une province à l’autre; elles ont en commun d’être limitées. En réalité, les soins que reçoivent les personnes atteintes de démence sont prodigués en grande partie par leurs proches et leurs amis. Le système de santé tend à réagir aux besoins en matière de soins plutôt que de guider ou d’intégrer leur prestation. Nous pouvons nous attaquer à ce problème par une action coordonnée à l’échelle nationale. Des programmes remarquables ont été mis sur pied dans certaines provinces, ils n’ont pas encore traversé leurs frontières. En Saskatchewan, par exemple, des chercheurs et des cliniciens ont créé, grâce à la télémédecine, une clinique d’intervention « à guichet unique »; elle permet d’offrir davantage de soins à domicile, ce qui facilite les choses pour les personnes vivant en milieu rural — un défi majeur dans notre pays. Tout plan national doit aussi tenir compte des stades avancés de la maladie. En ce moment, nous dépendons largement des établissements de soins de longue durée. C’est toutefois un secteur qui présente des défis en matière d’uniformité des services, sur le plan de la qualité des soins, de la qualité de vie et de la qualité des soins de fin de vie. Il n’est plus possible d’espérer de solution simple ou de remède miracle au problème de la démence (comme si cela avait été dans l’ordre du possible). Et on ne peut plus se contenter du statu quo. Notre pays a besoin d’un plan d’action pour soutenir des stratégies de prévention, élaborer des systèmes de prestation des services de santé, refaçonner les milieux de vie et les cadres bâtis et miser sur la technologie. L’idée serait de maintenir le plus longtemps possible dans leur milieu de vie tous les Canadiens atteints de démence, peu importe qui ils sont, et où ils vivent; et lorsque ce n’est plus envisageable de le faire, de leur offrir des soins d’une qualité exemplaire. Il y a des années que nous savons que le taux de démence augmente et que les coûts seront catastrophiques pour le système de santé. Il nous faut adopter sans tarder un plan 27
d’action stratégique à volets multiples, qui ralliera les gouvernements, le secteur privé et l’ensemble de la population. Howard Feldman est conseiller auprès du site EvidenceNetwork.ca et professeur de neurologie à la Faculté de médecine de l’Université de la Colombie-Britannique. Titulaire d’une chaire de recherche du Canada, Carole Estabrooks est professeure à la Faculté des sciences infirmières de l’Université de l’Alberta. Tous deux ont coprésidé le forum sur le thème de la démence organisé en 2015 par l’Académie canadienne des sciences de la santé.
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The real costs of informal caregiving in Canada National strategy needed for unpaid caregivers in the workplace By Nicole F. Bernier The phenomenon is not exactly marginal: according to a recently released government report, one in every three workers in Canada is assisting a chronically disabled person – many of them seniors – with transportation, household maintenance or day-to-day tasks. The 6.1 million employed workers who are providing such care, free of charge, to a family member or friend are more likely to experience interruptions at work and to arrive late or even be absent from work. Many are less available than they would otherwise be to work overtime, travel for work or advance their careers. Without a doubt, the impacts of informal caregiving commitments do not remain confined to the home: they are felt in the Canadian workplace and reduce productivity. They translate into 2.2 million hours of reduced effort in the workplace every week and cause an estimated $1.3 billion productivity loss annually, says the report. With the anticipated growing numbers of seniors requiring care, the costs of unpaid caregiving and reduced productivity will likely expand over the next two decades. What should we do about them? As Canadian employers are increasingly confronted with the reality the work of informal caregiving has on their employees, it only makes sense that they should be the first to recognize and support informal caregiving. Some of them already offer flexible arrangements (e.g., compressed work weeks, work from home, unpaid and even paid leaves) to employees with caregiving commitments. This said, not all employers are equally supportive, if at all, and many Canadian workers with caregiving responsibilities are paying the price: reduced income, career limitations and exit from the labour force. A year ago, the federal government established the Employer Panel for Caregivers which consulted with employers to help them find ways to better support their employee caregivers. The consultation was premised on the (realistic) assumption that unpaid care will remain the main source of long-term care in this country. The most significant insight it gained is this: while employer support to employee caregivers may foster engagement and greater retention in the workplace, there might not be a business case for many employers to voluntary engage in this. Put another way, moral appeal and compassion for employee caregivers will not translate into a massive, spontaneous movement in the Canadian workplace to address the issue any time soon. What else is needed? Should the costs of caregiving and reduced productivity belong uniquely to caregivers and their employers? It is becoming increasingly difficult for Canadian policymakers to ignore their own essential role – beyond that of offering limited and sporadic supports – to address the issue. 29
Confronted with a similar situation, the United Kingdom, Australia and New Zealand have, in recent years, adopted national caregiver strategies. At home, Manitoba and Nova Scotia are leading in many ways, but efforts across the country remain fragmented and inconsistent. Canada can do better. Needed as part of a national strategy are integrated policy instruments to support caregivers and their employers. First, Canada’s workplace legislation, which is primarily a provincial jurisdiction, needs to ensure minimum standards to protect workers with caregiving commitments. Second, we also need a comprehensive set of financial instruments – possibly a combination of private or public programs – to better protect the workers’ incomes and their employers’ productivity losses. Third, more substantial coverage of home care, nursing care and supportive services (e.g., adapted transportation or supervised day centers) for the disabled is an essential component that would benefit everyone. Is this financially realistic? Policymakers still need to recognize the undeniable costs of unpaid caregiving. So the real question should be instead: How should these costs be shared? Caregivers are already contributing a lot: A study estimated that if governments had to pay for caregiving provided free of charge by people 45 and over in this country, it would have cost about $25 billion in 2009. Some argue that governments should compensate caregivers. I don’t think they should. But governments do need to ensure that while providing unpaid caregiving, workers never incur catastrophic income losses or lose their jobs as a result. Financial and in-kind supports are critical especially when caregiving commitments extend to several hours a week over a long period of time. This should be covered by public programs. Instead of having a situation where we have some employers who provide workers with coverage and some not, only a coherent national strategy will allow Canadian workers looking after a spouse or relative to better focus on their work, their employers to better focus on their mission and disabled persons to get the care they need. Nicole F. Bernier is an expert advisor with EvidenceNetwork.ca and research director of the Faces of Aging program at the Institute for Research on Public Policy.
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Le coût véritable des soins informels au Canada Il faut une stratégie nationale pour les employés qui sont proches aidants Par Nicole F. Bernier Selon un rapport récent du gouvernement, un travailleur sur trois au Canada s’occupe d’une personne qui souffre d’une invalidité chronique (une personne âgée dans la plupart des cas) en lui fournissant un soutien en matière de transport, d’entretien ménager ou d’exécution de tâches de la vie quotidienne. Les 6,1 millions d’employés qui dispensent ces soins gratuitement à un parent ou à un ami sont plus susceptibles que leurs collègues de connaître des interruptions de travail, de se présenter en retard au travail ou même de s’en absenter. Nul doute, la prestation de soins informels a des répercussions qui vont bien au-delà du domicile. Selon le rapport précité, elles se traduisent par une perte de 2,2 millions d’heures de travail par semaine et une baisse de productivité estimée à 1,3 milliard de dollars par année. Si l’on tient compte du nombre croissant de personnes âgées nécessitant des soins, les coûts associés aux soins non rémunérés et à la perte de productivité augmenteront vraisemblablement au cours des deux prochaines décennies. Que faire face à cette situation ? On s’attendrait à ce que les employeurs canadiens, directement concernés, soient les premiers à reconnaître la réalité des soins informels. De fait, certains ont adopté des politiques de soutien aux employés ayant des obligations comme proches aidants : semaines de travail comprimées, horaires de travail variables, travail à domicile, congés non payés ou même rémunérés. Mais tous ne sont pas également compréhensifs, et bien des employés en font les frais. Parmi les conséquences, mentionnons la baisse des revenus, les freins à la carrière et, ultimement, le retrait du marché du travail. Il y a un an, le gouvernement fédéral a mis en place le Groupe d’employeurs sur la question des aidants naturels. Celui-ci a tenu des consultations en vue d’aider les employeurs à trouver des moyens de soutenir davantage leurs employés qui sont proches aidants. Le Groupe de travail a notamment constaté que les mesures de soutien accordées aux proches aidants peuvent favoriser l’engagement et le maintien au travail des employés mais que cela n’est sans doute pas suffisant pour convaincre une majorité d’employeurs d’y recourir de leur plein gré. Autrement dit, les principes moraux et la compassion ne risquent pas de se traduire dans un avenir proche en vaste mouvement spontané de transformation des lieux de travail. Les coûts associés à la prestation de soins et à la perte de productivité doivent-ils être assumés uniquement par les proches aidants et leurs employeurs ? 31
Il devient de plus en plus difficile pour les gouvernements canadiens de négliger l’importance de leur propre rôle dans ce dossier, bien au-delà des programmes publics peu ambitieux et sporadiques qu’ils ont mis en place jusqu’ici. Confrontés à une situation semblable, des pays comme le Royaume-Uni, l’Australie et la Nouvelle-Zélande ont adopté ces dernières années des stratégies nationales s’adressant aux proches aidants. Chez nous, le Manitoba et la Nouvelle-Écosse tracent la voie à suivre à de nombreux égards, mais les efforts restent fragmentés et inégaux à travers le pays. Le Canada peut faire mieux. Nous avons besoin d’une stratégie nationale qui intégrera des outils de politique à l’intention des proches aidants et de leurs employeurs. Premièrement, la législation sur le marché du travail (une compétence essentiellement provinciale) doit contenir des normes minimales afin de protéger les employés ayant des obligations comme proches aidants. Deuxièmement, il faut établir un éventail complet d’instruments financiers (éventuellement une combinaison de programmes privés ou publics) soutenant les employés en matière de revenu et aidant les employeurs en cas de pertes de productivité. Troisièmement, il est nécessaire d’améliorer substantiellement la couverture des soins à domicile, des soins infirmiers et des services de soutien (p. ex. renforcer l’offre du transport adapté ou de centres de jour supervisés). Ce volet est essentiel et profiterait à tous. Un tel plan est-il réaliste du point de vue financier ? En vérité, lorsque les décideurs auront reconnu les coûts indéniables engendrés par la prestation de soins non rémunérés, la question se posera plutôt comme ceci : de quelle façon pourrions-nous partager ces coûts ? Les proches aidants en font déjà beaucoup : selon une étude, si les gouvernements de notre pays devaient prendre en charge les soins dispensés gratuitement par leurs citoyens de 45 ans et plus, la facture se serait élevée en 2009 à environ 25 milliards de dollars. Certains estiment que les gouvernements devraient rémunérer les proches aidants. Je ne partage pas cet avis. Je pense toutefois qu’ils doivent veiller à ce que les employés qui dispensent des soins non rémunérés ne soient pas exposés à des pertes de revenu catastrophiques ou à l’éventualité de perdre leur emploi. Il est essentiel de mettre en place des mesures de soutien financier et non financier soutenant les proches aidants, en particulier quand la prestation de soins représente plusieurs heures par semaine pendant une durée prolongée. Ces mesures devraient faire l’objet de programmes publics. Au lieu de se contenter d’une situation où seuls quelques employeurs prévoient des dispositions à cet égard, le Canada devrait adopter une stratégie nationale cohérente en 32
matière de soins informels. C’est le seul moyen de permettre aux employés s’occupant d’un conjoint ou d’un proche de continuer à s’investir au travail, d’aider les employeurs à se concentrer sur leur mission et de faire en sorte que les personnes nécessitant des soins puissent bénéficier des services dont elles ont besoin. Nicole F. Bernier est experte-conseil auprès d’EvidenceNetwork.ca et directrice de recherche du programme Les défis du vieillissement à l’Institut de recherche en politiques publiques.
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Why we need to think twice about adopting an Australian model of pension reform By Robert L. Brown In a recent nation-wide commentary, authors Charles Lammam and Stephen Kirchner of the Fraser Institute urge the Province of Ontario to adopt an Australian model of pension provision instead of expanding the Canada Pension Plan as proposed in the Ontario Retirement Pension Plan. This creates an interesting debate as it pits the collective approach to pension provision as now exists in the Canada Pension Plan (CPP) with the Individual Accounts Social Security approach (very much like RRSPs) as defined in Australia. The authors note several apparent advantages of the Australian system, but each of the advantages are fraught with difficulty and may, in fact, prove to be disadvantages. The authors correctly point out that the Australian system of mandatory employmentbased RRSPs provides greater choice and flexibility in both the investment of funds and in their allocation for retirement expenditure. Individuals can choose an investment strategy based on their preferences and circumstances. All true. But substitute the word “responsibility” for “flexibility” and the argument takes on a new feel. Yes, you are able to invest as you wish. In fact, you are responsible for investing your dollars to achieve the highest rate of return available. Is this something for which you feel capable? Would you like to take on this responsibility or would you rather an arms-length agency like the Canada Pension Plan Investment Board do this for you? Of course, you can buy investment advice. But this is expensive. You will pay anywhere from 150 to 300 basis points (1.5 percent to 3.0 percent) in management expense fees for these services. These high expense ratios are at least partly the result of very intense competition among private sector retirement funds for your dollars with lots of advertising and high commissions on sales. These fees are killers in a low return economy as we have today. Every additional one percent fee over a 40-year period reduces final assets by about 20 percent. Stated another way, a three percent fee per annum will cut in half your retirement replacement rate (your standard of living) versus an account with no fees. In this matter, Australia is no shining example. Despite its mandatory “Superannuation” system, management fees still range from 1.5 percent to 1.75 percent. The CPP operates with an expense ratio of less than one percent. And, finally, there is no evidence that these active management fees reap the fund holder any higher returns. Passive accounts 34
do just as well on average (and after the impact of the fees is taken into account, passive investing does much better on average). Then you retire. Again, in Canada, under the CPP, you just let them know you are retiring and they start sending monthly benefit checks that will last your lifetime. And the benefits are inflation indexed. In the Individual Accounts world of Australia, you are responsible to draw down your funds on your own as your fund pays out a lump sum upon your exit from the labour force. How can you do this wisely when you have no idea how long you will live? Two outcomes are likely. You will draw down your funds too rapidly and run out of money and be dependent on GIS benefits for your retirement security. Or, you will draw down funds too slowly and live your life at a standard of living below what you could have provided. The CPP handles this by pooling all the funds of all participants and thus assumes the longevity risk (which is very small given the size of the CPP participant pool). What evidence do we have on outcomes from the two systems? The Melbourne Mercer Global Pension Index ranks Australia number two in the world with a rating of 79.9 in terms of the viability and sustainability of its pension system. Denmark is number one at 82.4. Canada slides in at number seven (with an Index of 69.1). The index is based mostly on the fact that Australia has a mandatory pension system so that coverage rates are almost universal. In Canada, however, coverage rates outside of the Canada Pension Plan are less than universal. While 86 percent of workers in the public sector have a pension plan, only 25 percent of workers in the private sector have anything at all. Finally, if the goal is not just coverage, but actual retirement income security, then Australia receives failing grades. One in three Australian seniors live in poverty despite being among the most highly educated senior citizens in the world. This rate is comparable to Thailand, Ecuador and Bolivia. For Canada, the OECD reports that the poverty rate amongst the elderly is at 7.2 percent – third lowest in the OECD. So before we blindly adopt the Australian pension system as our own, we need to take several long moments in deep thought and contemplation – and look at the evidence. Robert Brown is an expert advisor with EvidenceNetwork.ca, a Retired Professor of Actuarial Science, University of Waterloo and Immediate Past President of the International Actuarial Association. He lives in Victoria, BC.
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Pros and cons of an expanded Canada Pension Plan By Robert L. Brown The Conservative government has announced it would like to have a dialogue with Canadians about a potential expansion of the Canada Pension Plan (CPP). While this, in itself, is a purely political action — since it commits the government to nothing — it is worth looking at what the possible outcomes might be. There are serious concerns among pension experts in Canada that the current generation of workers (the next generation of retirees) is not saving enough to guarantee retirement income security. Seventy-six percent of workers in the private sector have no pension plan at all. They are left totally to their own initiative. They are not trained in this “retirement-incomesecurity” science. They can get retirement savings products but at extremely high fees (e.g., 250 to 300 basis points). And sometimes, their agent does not even work on their behalf, but rather acts to maximize the income of the agent. Might it thus be wise to finally consider an expansion of the CPP at a time when both the CPP and its investment arm (the Canada Pension Plan Investment Board—CPPIB) are riding high in the polls? The answer is not obvious. Far from it. Amendments made to the CPP in 1996 state that any new benefits must be fully-funded. That means that you only get back what you have paid for in full. Under current rules, it takes 39 years at a minimum to earn a full benefit. So if you make a contribution today (2015) you would only have earned 1/39th of a full benefit. Full benefits would not be available until 2054. So if we think we have a problem in terms of people who plan to retire in 2054 not saving enough today, then we must amend the CPP now. The CPP is currently organized and administered like a Defined Benefit plan. Moving to Voluntary Contributions, as the Conservatives wish, would force it to be administered much more like a Defined Contribution plan. Why does this matter? If workers can move their money in and out of the CPP fund freely, this will create the potential for anti-selection on the part of the participants (move in when the times are good and out when bad), resulting in the need for the CPPIB to move toward much more liquid shorter-term assets with lower rates of return. It would also mean much higher administrative costs for the CPP (especially the investment arm, the CPPIB, as they would have to track the cash flows of individual accounts). 36
This would be on top of the high expense ratio for the CPPIB – estimated in the range of 90 to 100 basis points (i.e., 0.90 to 1.00 percent) which is multiples of what other very large plans cost (e.g., HOOPPs, BC Public Service and even some private sector plans like Bombardier which run with expense ratios closer to 25 basis points). It would also make all Canadian workers much more dependent on the investment capabilities of the CPPIB and the decisions they make versus the myriad of private managers now being used. So, the word “voluntary” cannot be taken lightly. Further, the CPPIB is having problems keeping all of its $265B invested in safe, but high yield investments today. What will it do with another tier of contributions? Finally, one can certainly expect a vehement push-back from the private sector that caters to retirement savings today at a nice profit margin. So, what if the contributions are mandatory? That will result in serious problems for very poor workers (and their employers). Consider forcing low-income workers (and their employers) to contribute to a new tier of the CPP. Not only do they not receive full benefits for another 39 years, but when they do get their extra CPP benefits, they will lose the impact of these extra payments as they see their Old Age Security (OAS) and Guaranteed Income Supplement (GIS) benefits clawed back. Since GIS payments are often matched by provincial schemes (e.g., GAINS in Ontario), many poor workers will lose $1 of OAS/GIS and provincial supplements for every new dollar of CPP benefits. So, they, and their employers, contribute out of money they need for higher order needs and they get no new net benefits at all. That is regressive. And we know that employers, such as those represented by the Canadian Federation of Independent Business (CFIB) will aggressively oppose any such mandatory imposition. In summary, we are faced with a myriad of questions and not only do we not have any good answers, we have no answers at all. Robert Brown is an expert advisor with EvidenceNetwork.ca, a Retired Professor of Actuarial Science, University of Waterloo and Immediate Past President of the International Actuarial Association.
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What do Canadians need from pension reform? A gentle policy nudge to enhance coverage and pension contributions – here’s how By Robert L. Brown Pension reform continues to hold interest across the country, especially given the willingness of the federal Conservatives to at least talk about expanding the Canada/Quebec Pension Plan (C/QPP). Pundits and politicos are opining on ‘voluntary’ or ‘mandatory’ enhancements to the C/QPP. Is that what Canadians want? Clearly, Canadians want at least the following: a system that can be trusted, the lowest cost possible, high rates of investment returns, (within a range of prudent safety) transparency and a governing process that puts the interests of plan participants first and foremost. Further, they want a system that will stay with them even if they change jobs and employers — turning savings into monthly cheques in retirement, until death. Most workers cannot access such systems today. Only 32 percent have workplace pensions of any type. In the private sector, only 24 percent have anything. Further, the superior Defined Benefit Plan coverage is down everywhere. We also know that very poor workers should not be forced into a mandatory system. Why? Because, after paying mandatory contributions, they will receive very little to no extra benefits because of the claw back provisions in our Guaranteed Income Supplement (GIS) (along with Quebec supplements). In fact, the working poor can easily lose a full dollar for every new dollar of income they produce on their own. We can do better although it will take some will on the part of legislators, both federal and provincial, to amend Pension Acts and the Income Tax Act. Here’s how it works. The government allows certain institutions to create large pooled Retirement Income Funds to which any worker can contribute (within some tax limits). After a very short establishment period, these funds must achieve a minimum size (at least $10B early but even larger later). The funds must have a Board of Directors of experts who will guarantee good governance and that the plan participants’ needs are paramount. Expense ratios will be capped (and policed). 40 basis points (0.40 percent) is appropriate since many large pension plans today operate with expenses below 25 basis points. You are automatically enrolled, with automatic payroll deduction if you are not in a Registered Pension Plan — but you can act to opt out. This ‘nudge’ (according to the evidence) should result in ultimate participation rates in the 80 to 90 percent range. But, it does allow poorer workers to opt out, as they should. 38
Your retirement income goal will be a Defined Benefit. From this goal, one subtracts OAS and C/QPP benefits. The fund provides the balance. Using slightly conservative actuarial assumptions (e.g., investment rates and life expectancy) the fund decides necessary contributions to attain your goal. Every year you get a statement showing the record of the fund over the past year and whether you are ahead or behind the projected values to reach your goal. At retirement, you continue in the fund and it pays your monthly benefit cheques. Behind the scenes, the fund carries the longevity risk of the group (not very volatile given the size requirements of the fund) or buys annuities (on a group basis — more competitive than for individual annuities). Your benefits will be highly probable, but not fully guaranteed. If we have another 2008 meltdown, you may face a short- term decrease in benefits. Note that what you get is a monthly benefit for life, not a lump sum at retirement. Who can offer such a fund? Anyone who can meet the capital requirements – any banks, and insurance companies. Large pension funds could also offer this product. It is do-able. It just requires some imagination and a few (but important) tweaks to existing pension and income tax laws. Canadians want this. They deserve no less. Robert Brown is an expert advisor with EvidenceNetwork.ca, a Retired Professor of Actuarial Science, University of Waterloo and Immediate Past President of the International Actuarial Association.
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Dying badly in Canada Canadians now have a right to medically hastened death, but no right to quality palliative care By Harvey Max Chochinov A few days after the Supreme Court of Canada overturned the prohibition against doctorassisted suicide, I received a note from a wonderful colleague of mine saying that her closest friend’s 53 year-old son had just died of spinal cancer. Two weeks before his death he had visited his general practitioner, experiencing “terrible pain.” Despite his anguish, his physician refused to give him morphine, claiming that because he was a smoker, he was “more likely to become addicted.” While this seems unfathomable, even grotesque, ignorance and lack of skill in attending to the needs of dying patients are still tragically common in Canada. Despite the impressive strides that palliative care has taken — in areas such as pain and symptom management, and sensitivities to the psychosocial, existential and spiritual challenges facing dying patients and their families — at their time of licensure, physicians have been taught less about pain management than those graduating from veterinary medicine. Once in practice, most physicians have knowledge deficiencies that can significantly impair their ability to manage cancer pain. Doctors are also not generally well trained to engage in end of life conversations, meaning that goals of care often remain unclear; and patients may not receive the care they want, nor the opportunity to live out their final days in the place they would want to die. In light of the Supreme Court’s decision, these issues have never been more important, nor the need to resolve them ever more pressing. The Court has given Parliament a year to sort out how it will move forward and rewrite the criminal code. Within these deliberations, it should be noted that the authority to provide a hastened death will be conferred on physicians, many of whom lack core competencies to care for patients nearing death. To be clear, dying badly in Canada will rarely be the fallout of not having access to a lethal overdose or injection, and almost invariably, the result of inadequate or substandard endof-life care. With the clock ticking, the time for physicians to learn how to look after their patients until the very end, is now. The Supreme Court felt that patients needed to be provided more choices. By adding doctor assisted suicide into the mix, what options will dying patients in Canada actually have? For 70 to 80 percent of Canadians, palliative care is not available and hence, not a real choice. A dear friend of mine recently died of brain cancer. She spent her final months in hospice, where she received exquisite end-of-life care. She died comfortably, and in as much peace as can be found by someone having to leave this world far too soon. 40
In the future, how might this kind of scenario play itself out in the many Canadian settings that do not have adequate palliative care? There, the choices will come down to settling for sub-optimal care; dislocating from friends and family to seek out better care elsewhere; or, if one is so inclined, considering medically hastened death. We are about to become a country that extends patients the right to a hastened death, but offers no legislative guarantees or assurances that they will be well looked after until they die. As Canada deliberates its response to the Court’s decision, federal and provincial governments will need to make substantive investments in hospice and palliative care in order to offer patients and families choices that are equitable, compassionate and real. While autonomy has driven the ‘right to die’ agenda, fear has been its engine. Now policy makers will need to grapple with how to draw a circle around autonomy, which means determining for whom and under what conditions medically hastened death will be permitted. Establishing those boundaries has implications for who will feel more or less afraid, who will feel more or less valued and who will anticipate death with more or less sense of calm. Of this we can be sure: the width of that circle and the stability of its diameter will profoundly influence the culture of caring for dying Canadians, and those amongst us who are most vulnerable, for generations to come. Harvey Max Chochinov is an expert advisor with EvidenceNetwork.ca and a Distinguished Professor of Psychiatry at the University of Manitoba. He holds the only Canada Research Chair in Palliative Care, is Director of the Manitoba Palliative Care Research Unit and is Chair of the Canadian Virtual Hospice (virtualhospice.ca)
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When is it ok for doctors to let someone die? End-of-life care in Canada needs another look By Charles Wright The long overdue public, medical, legal and political debate on end-of-life care is now well underway in Canada. Medical journals and the general press are commenting regularly on the subject, the Canadian Medical Association is changing its ethics guidelines, Quebec has decriminalized assisted dying and the Supreme Court of Canada recently ruled that the law banning assisted suicide is unconstitutional (indicating that an assisted suicide law must be drafted by our legislators soon). One of the most difficult and poorly understood issues in end-of-life care is the use of cardiopulmonary resuscitation (CPR). Surveys of the general public’s knowledge about the success rate of CPR reveal a wide gap between the perception and the reality. Two major factors are responsible for this misapprehension: public education by TV programs rather than by accurate medical information, and the fact that CPR has come into common hospital practice, even in very inappropriate circumstances. Let’s take a look at the facts. The techniques used for CPR were developed 50 years ago to deal with the fatal abnormal heart rhythm with cessation of blood circulation, often caused by a major heart attack. The brain can only survive 3-4 minutes when there is no blood circulation so the only hope for survival is prompt application of chest compressions and artificial respiration. If you had a severe heart attack like this while in hospital or passing the door of a hospital emergency department, you would have a 20 percent chance of survival. In all other situations, the success rate of CPR is very small and reaches zero in patients with terminal chronic disease. In spite of this reality, CPR has become usual practice in North American hospitals for all patients dying in hospital from whatever cause unless a specific doctor’s order – do not resuscitate (DNR) – is on the chart. If there is no DNR order hospital policies, written or unwritten, currently require nurses and doctors to respond to death (often called cardiac arrest) with CPR. This is an inexplicable development, based on no medical evidence of benefit. The adverse effects, physical, mental and emotional, of CPR attempts are common and serious. Fractures of the sternum and ribs are a usual occurrence. If "successful" resuscitation does occur, the patient may suffer a variety of mental difficulties ranging from impaired brain function or changed personality, to serious permanent brain damage, regarded by most people as a fate worse than death. For the family, CPR creates a chaotic scene in which they usually must leave the room just at the time they feel most need to be with their loved one. The nurses and doctors are sometimes very uncomfortable, feeling trapped into applying a therapy that they know is not in the patient’s best interest. This conflict between good professional judgment and 42
current policy may cause what is called a "slow code," where CPR is performed, but without enthusiasm, when it is known to be futile This is the invidious result of a policy that is as disrespectful to the care team as it is medically useless for the patient. This policy puts physicians in an absurd position, directing them to behave unethically by giving treatment that they know is both harmful and of no benefit. Fortunately better communication with patients on these issues is now being emphasized throughout the medical profession so that an appropriate chart notation and better decisions about DNR decisions can be made. The need for people also to make advance directives (often called living wills) and to discuss them with family is greater than ever as medical technology advances, but there is a serious legal problem. You may have an advance directive signed in perfect health clearly stating your wishes, but if and when you become incompetent, current law in some provinces permits your next of kin or power of attorney to ignore it. Surely new legislation must recognize and prevent this potential abuse that most people would find offensive and unacceptable. Patients and nurses may fear that a DNR order will mean that the patient does not receive all other aspects of appropriate care and attention from the health care team. There have been unfortunate examples of this in the past, but the growing emphasis on better end-oflife care includes ensuring that a no-CPR order has no effect on the full extent of care the patient receives in any aspects other than the acceptance of death if and when it occurs. The attitudes, policies and practices surrounding the current misuse of cardiopulmonary resuscitation need open public, professional and legal education and debate. CPR was designed to help patients with very specific cardiac problems, not to attempt to deny and prevent death in all circumstances. Charles J. Wright is an MD and consultant in medical and academic affairs, program planning and evaluation. He is an expert advisor with EvidenceNetwork.ca
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Quand est-il acceptable pour un médecin de laisser une personne mourir? Il est nécessaire de poser un nouveau regard sur les soins de fin de vie Par Charles Wright Bien que tardif, le débat politique, légal, médical et public entourant les soins de fin de vie est maintenant bien engagé au Canada. Les revues médicales et les médias abordent en effet le sujet régulièrement, tandis que l’Association médicale canadienne a entrepris de modifier ses lignes directrices en matière d'éthique et que le Québec a décriminalisé l’aide médicale à mourir et attend avec impatience la décision de la Cour suprême du Canada à ce propos. L’une des questions les plus difficiles et les moins bien comprises concernant les soins de fin de vie est celle du recours à la réanimation cardiopulmonaire (RCP). Les études portant sur les connaissances du public à propos du taux de réussite de la RCP révèlent un écart considérable entre la perception et la réalité. Deux facteurs importants sont responsables de cette méconnaissance : le fait que ce que le public obtienne son information médicale principalement d’émissions de télévision plutôt que de sources scientifiques et médicales respectées, et le fait que la RCP soit devenue une pratique hospitalière courante, même dans les circonstances où elle n’est aucunement appropriée. La technique de la RCP a été élaborée il y a 50 ans afin de contrer les arythmies cardiaques mortelles avec arrêt de la circulation sanguine, généralement causées par une crise cardiaque importante. Le cerveau ne peut survivre que de trois à quatre minutes lorsque la circulation sanguine est interrompue, donc le seul espoir de sauver une personne en arrêt cardiaque est d’effectuer des compressions thoraciques rapides et de pratiquer la respiration artificielle. Les chances de survie d’une personne subissant une telle crise cardiaque seront de 20 pour cent si au moment de la crise elle est déjà à l’hôpital ou dans la salle d’urgence. Dans tous les autres cas, le taux de réussite de la RCP est infime et même nul chez les patients souffrant d’une maladie chronique en phase terminale. Malgré ce fait, la RCP est devenue en Amérique du Nord une pratique courante pour tous les patients hospitalisés qui sont en train de mourir, quelle que soit la cause, à moins qu’une ordonnance de nonréanimation signée par un médecin figure au dossier. En l’absence d’une telle ordonnance, les politiques hospitalières, écrites ou verbales, exigent que le personnel infirmier et médical tente d’éviter la mort (arrêt cardiaque) en pratiquant la RCP. Cette exigence ne repose cependant sur aucune explication valable ni sur aucune preuve médicale d’un effet bénéfique. Les tentatives de RCP entraînent fréquemment des effets indésirables graves, sur le plan physique cérébral et émotif. D’une part, les fractures du sternum et des côtes sont fréquentes, et d’autre part, un patient qui a été réanimé « avec succès » risque de souffrir 44
de diverses incapacités : d’une altération des fonctions cérébrales ou d’un changement de la personnalité à de graves séquelles permanentes au cerveau. Ces séquelles sont souvent perçues par la plupart des personnes comme étant un sort pire que la mort. La RCP entraîne également les membres de la famille dans une scène de chaos pendant laquelle on leur demande habituellement de quitter la pièce, alors qu’il s’agit du moment où ils ressentent un grand besoin d’être présents pour leur proche. Quant aux membres du personnel infirmier et médical, il arrive que la pratique de la RCP les rende profondément mal à l’aise. Certains d’entre eux se sentent obligés d’appliquer un traitement qu’ils savent très bien ne pas être dans l’intérêt du patient. Ce conflit entre le bon jugement professionnel et la politique de l’hôpital peut mener à ce qu’on appelle un « retard intentionnel », c’est-à-dire une exécution sans vigueur ni enthousiasme de la RCP. Il s’agit là de l’effet pervers d’une politique qui est à la fois irrespectueuse envers les équipes de soins et inutile pour les patients. Elle place les médecins dans une position intenable, les obligeant à se comporter de façon non éthique en prodiguant un traitement qu’ils savent être sans avantage et même dommageable. Heureusement, au sein de la profession médicale, on insiste beaucoup plus sur l’importance d’une meilleure communication avec les patients concernant ces questions, de sorte que l’information appropriée est notée au dossier et que les décisions touchant les ordonnances de non-réanimation sont prises de façon plus éclairée. Étant donné les progrès technologiques de la médecine, il encore plus nécessaire que les patients formulent des directives précises (souvent appelées testaments biologiques) et qu’ils en discutent avec leur famille. Toutefois, un problème légal d’envergure subsiste. Même si une personne prépare et signe légalement ses directives alors qu’elle est en parfaite santé, le cadre législatif dans certaines provinces autorise que son plus proche parent ou son mandataire ignore cette directive si cette personne devient inepte. Toute modification législative devra donc incontestablement tenir compte de cette possibilité et prévenir le risque d’un non-respect des volontés d’une personne mourante, que la plupart des gens estimeraient offensant et inacceptable. Il est possible que les patients et le personnel infirmier se méfient des ordonnances de non-réanimation, craignant qu’une telle disposition veuille dire qu’un patient ne recevra pas de l’équipe de soins toute l’attention et les soins autres que la RCP dont il pourrait avoir besoin. De malheureux exemples se sont à ce titre produits dans le passé, mais l’importance croissante accordée aux soins de fin de vie vise notamment à faire en sorte que les ordonnances de non-réanimation n’aient aucun effet sur la pleine étendue des soins que reçoivent les patients, quels que soient ces soins, sauf en ce qui a trait à l’acceptation de la mort lorsque celle-ci survient. Les attitudes, les politiques et les pratiques entourant le recours actuellement abusif à la RCP devraient faire l’objet d’un débat professionnel et légal, ainsi que d’une discussion publique et d’une campagne d’éducation. La technique de la RCP a été conçue pour aider les patients souffrant de problèmes cardiaques très précis, non pour tenter d’éviter la mort à tout prix.
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Charles J. Wright est médecin et conseiller en affaires académiques et médicales ainsi qu’en planification et évaluation de programme. Il est également expert-conseil à EvidenceNetwork.ca.
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Chapter 2: Health Care Costs and Spending
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What should be covered by our publicly funded health care system? Patients and doctors need to learn the difference between ‘need’ and ‘want’ By Brian W. Rotenberg All across Canada provincial governments are grappling with ever growing health care demands in the face of shrinking resources. Our enviable publicly funded health system is now well into a downward spiral of unenviable disrepair. As patients are becoming more knowledgeable about their own care, and as doctors develop a wider array of options available to treat diseases, the costs are increasing. The truth is, we can’t have it all. Both the physicians who deliver care and the patients who receive it need to start considering the concept of limited resources in our publicly funded health care system. One of the main tenets of the Canada Health Act is that medically necessary care should be insured by public funds and that all related hospital or physician care should be paid for by the public system. This is the soul of the cherished notion of “free” health care that most Canadians hold so dearly. But the tricky thing is that the Canada Health Act does not actually define what constitutes “medically necessary care.” This is left up to the individual health providers to determine, on a case-by-case basis. At first glance it might seem easy to distinguish “medically necessary” care from optional care. If a patient is sick, then the treatment needed to fix the problem is intuitively considered necessary – the idea being that medical needs dictate what will be provided by the public system. And in some circumstances, determining what is “medically necessary” is easy. Both patients and doctors could likely agree that if you have cancer, it needs medical treatment. If you have fractures from a car accident, they need to be fixed. Likewise there are many other examples that most of us could agree fall into ‘optional’ care, such as laser eye surgery to remove the need for glasses or cosmetic facial surgery – wants, not needs, that don’t merit public funding. In between these examples, though, is a wide gray area where distinguishing need from want is not nearly so clear. Is fixing an annoying nasal blockage a need or a want? Is getting arthroscopy for a sore knee a need or a want? How about a patient who wants blood tests that aren’t medically indicated, but they are just curious?
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Non-essential care is by no means limited to patient demand. There also exists a vast array of low-quality or low-impact health interventions initiated by doctors – and publicly funded. Many of these interventions are not supported by evidence. That blood test or chest x-ray your physician ordered for you before your elective operation? Very possibly unnecessary. The CT scan you had for pain in your lower back? The evidence says it will not improve your outcomes. The antibiotics you were prescribed for a persistent virus? Unnecessary and they won’t work anyway. Tests and treatments like these examples, and others, are not medically necessary and they are also costly to the struggling health care system. In fact, unnecessary tests can expose patients to harm because of false-positive rates. The “Choosing Wisely Canada” initiative spearheaded by the Canadian Medical Association is just beginning to explore the massive scope of unnecessary care and the impact it has on patients and the health system. Are doctors too often offering to use public funds to investigate or treat problems that are wants versus needs and not actually medically necessary? Are patients losing sight of the fact that no province has the funds to provide all care for all people all the time? Our contemporary free-for-all style of health care, a challenge on both sides of the medical consultation room, is totally unsustainable on the public purse. Doctors need to start openly and directly considering the concept of medical necessity when talking with patients about tests or procedures. Patients, in turn, need to keep in mind that their health care is not “free,” and that many of their health-related complaints likely represent wants, rather than needs. Working together we can salvage what is left of public health care in this country, but only if both groups promptly adopt a more realistic attitude toward medical necessity. Brian Rotenberg is an expert advisor with EvidenceNetwork.ca and an Associate Professor in the Department of Otolaryngology – Head & Neck Surgery at Western University, London, Ontario.
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Moving forward on health care reform Why more money for health care is not the answer By Allan M. Maslove In the Speech from the Throne and since, the new Liberal government has clearly said it is ready to re-engage with the provinces and territories on health care. This is a welcome development. For most of the past decade, the Harper government was distinctly unwilling to provide any leadership or even play a secondary role in health care reform. The fact that the new Trudeau Liberal government is ready to work with the provinces and do so quickly is a big step forward. But the prospect has likely raised many expectations of what new arrangements might emerge. First, many players will be looking for more money to flow from Ottawa to the provinces. But the Harper government, even as it withdrew from active participation, committed to adequate transfers to the provinces until 2024. There may be legitimate debates about the distribution of those transfers across the provinces, and there may be some new funding called for to support new initiatives in areas such as pharmacare or mental health, but the federal money now on the table in support of the range of health care services is more or less adequate. The health care problems we face are not the result of insufficient spending. In fact, more money may be counterproductive. The primary focus of any new accord needs to be on the structure of the federalprovincial arrangements. The most commonly visualized instrument seems to be a return to something like the Health Accords of 2003 and 2004. Indeed, the Minister of Health referred to a promised re-engagement in these terms. What these Accords did was to identify a number of problem areas — most notably, wait times — where provinces pledged remedial actions to remedy them and Ottawa committed to increasing cash transfers to be used at the discretion of provincial governments. The expression at the time was that the cash transfers would “buy change” necessary in the health care system. But the link between the provincial actions and the federal money was tenuous at best in 2003 — and all but absent in 2004. So while the Accords did initiate significant flows of new money to the provinces and territories, they were not successful in spurring necessary health system reforms. They were not sufficiently specific to generate sustained efforts or sustainable change. In fact, the extra money Ottawa provided probably did more to hinder health reform across the country than promote it. Rather than “buying change,” the extra money bought peace and serenity (at least temporarily). Throwing additional money at problems was a lot easier than tackling structural change.
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The Accords were weak because to some extent the provinces and territories have different needs and priorities. To reach consensus on a single agreement it was necessary to be vague and general in terms of what each province and territory would do by way of reform. A better alternative going forward might be to more directly address particular regional concerns with a distinct contract between Ottawa and each province rather than a single accord. For a model for this we could look to the Paul Martin Liberal government’s arrangement for funding in two other areas. The first was the transfer of gas tax revenue to municipalities via the provinces for infrastructure investments. Ottawa signed one-to-one agreements with every province and territory. While the broad goals and structures were the same across all provinces, the individual contracts included variations that permitted some provinces to pursue regional goals within the national framework. A significant amount of much needed municipal infrastructure investment resulted from these agreements, and continues today. The same general model was used by the Martin government to conclude childcare agreements with the provinces, but before they could be implemented the Harper government was elected and chose not to proceed. This model of federal-provincial fiscal arrangements can more effectively promote health care renewal and should be considered by Minister Philpott going forward. A set of pharmacare agreements might be concluded that would create nationally universal and portable coverage while recognizing that provinces are starting from different positions and may have different specific needs and administrative arrangements in mind. Other issues such as home care and long-term care facilities might be addressed at the same time or in a separate set of contracts. The federal government would retain the capacity to represent national goals and interests, and the provincial governments would have flexibility to pursue their respective regional objectives within the national framework. A stronger link between national objectives and each province’s priorities offers a better chance of sustainable health care reform. Allan M. Maslove is an expert advisor with EvidenceNetwork.ca and a Distinguished Research Professor, School of Public Policy & Administration, Carleton University.
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An era of restraint in health care spending in Canada The question is whether the current decline represents a permanent bending of the health care cost curve or a temporary pause By Livio Di Matteo In the wake of new health expenditure data from the Canadian Institute for Health Information (CIHI), the evidence continues to mount that Canadian public health expenditure growth is moderating. Moreover, adjusting for inflation and population growth, per capita provincial and territorial government health expenditures have actually declined since their peak in 2010. From a high of $3,915 (2012 dollars), real provincial and territorial government health spending per capita has declined by 3.9 percent to reach an estimated $3,762. This decline, however, is not evenly distributed across health expenditure categories or jurisdictions. When health expenditure categories are examined, the largest drop in real per capita provincial/territorial government health spending is for capital spending with a drop of 28 percent since 2010. Capital spending represents an easy target for government restraint given that postponing capital projects, such as new buildings or diagnostic equipment, often does not have an immediate impact on service delivery. Next largest is real per capita drug spending, dropping 11.3 percent, which is remarkable given drug spending was once one of the fastest growing components of provincial government health spending. According to CIHI, drug expenditure has been affected by jurisdictions introducing generic pricing controls combined with patent expirations and fewer new drug introductions. Smaller declines are in the areas of hospital and other institutional spending and administration. However, physicians, other professionals and public health appear to have escaped the decline. Real per capita physician spending is up 3.0 percent since 2010 while spending on other professionals is up 12.5 percent and public health spending rose one third of one percent. Situations also vary across the provinces and territories when it comes to health spending change reflecting the diversity of the federation. Eight out of 10 provinces and two of the three territories saw declines in real per capita government health spending. The percentage change in real per capita government health spending since 2010 ranges from declines of nearly seven percent each in Alberta and Ontario and five percent in New Brunswick, to increases of 0.5, three and seven percent in British Columbia, Nova Scotia and the Northwest Territories respectively. This diversity may be a function of differential rates of population aging and population growth as well as underlying economic performance and its effects on own source government revenues.
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The health care cost curve is being bent in a manner not seen since 1992 to 1996 when real per capita provincial and territorial government spending dropped nearly eight percent. This decline followed a severe recession and fiscal restraint in the face of mounting deficits that was augmented by reductions in federal cash transfers for health with the introduction of the Canada Health and Social Transfer. A key difference today is that federal health transfers continue to rise though their rate of growth will decline after 2017. The key question is whether the current decline represents a permanent bending of the health care cost curve or a temporary pause. In the wake of the spending decline from 1992 to 1996, real per capita government health spending grew as the economy recovered and federal transfers enriched after the 2004 Health Accord. Indeed, real per capita provincial and territorial government spending grew 50 percent between 1996 and 2010. A similar rebound is unlikely this time. Starting in 2017, the growth of federal health transfers will be linked to the national rate of economic growth and inflation with a floor of three percent. Governments are likely implementing cost-control measures in advance of the day when federal transfer growth slows from the annual six percent increases of the Health Accord. However, the effort to restrain health expenditure costs given slower growth in both the economy and federal transfers will be counter balanced by the aging of the population and continued medical product innovation. While there has been a slowdown in drug innovation that has affected the growth of drug spending, this may change. As well, though aging has been a modest contributor to health spending growth to date, this may not continue. The Canadian population is aging but the front end of the baby boom bulge is just entering the age 65 to 69 category. Per capita provincial/territorial health spending in 2012 was $4,620 for those aged 60 to 64 and $16,231 for those aged 80 to 84. The effects of aging are not fully upon us yet. As a result, real per capita provincial government health spending will eventually resume growth but probably at a lower rate than that which characterized the period 1996 to 2010. Livio Di Matteo is an expert advisor with EvidenceNetwork.ca and a Professor of Economics at Lakehead University.
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Une ère de compressions budgétaires dans le domaine de la santé au Canada Par Livio Di Matteo Dans le sillage des nouvelles données portant sur les dépenses en santé publiées par l’Institut canadien d’information sur la santé (ICIS), les preuves démontrent que le ralentissement au Canada des dépenses publiques dans cette sphère est en augmentation. Après correction pour l’inflation et la croissance démographique, les dépenses par habitant des gouvernements territoriaux et provinciaux en santé ont en fait diminué, après avoir atteint un sommet en 2010. Les dépenses réelles de ces gouvernements par habitant ont diminué de 3,9 pour cent et sont passées à un montant estimé de 3762 $, avec un montant maximal de 3915$. Cependant, ce déclin ne touche pas de façon uniforme les diverses catégories de dépenses ou les divers secteurs de la santé. Un examen de ces catégories révèle que la plus importante diminution de dépenses réelle par habitant initiée par les gouvernements provinciaux et territoriaux touche les dépenses en capital et se chiffre à 28 pour cent depuis 2010. Les dépenses en capital constituent une cible facile pour les gouvernements désireux de faire des compressions budgétaires, puisque le report de projets d’immobilisation, comme la construction de nouveaux édifices ou l’achat d’appareils de diagnostic, n’ont souvent aucun impact immédiat sur la prestation des services. De plus, les dépenses réelles par habitant pour l’achat de médicaments ont chuté de 11,3 pour cent. Cette diminution est surprenante puisque les médicaments représentaient l’un des éléments avec la plus grande croissance parmi les dépenses des gouvernements provinciaux en santé. Selon l’ICIS, la mise en place par les autorités de mesures de contrôle des prix pour les produits génériques ainsi que l’expiration de brevets et la diminution du nombre de nouveaux médicaments introduits ont réduit les dépenses en médicamentation. Des déclins plus modestes ont été enregistrés pour les dépenses liées aux hôpitaux et autres milieux institutionnels et administratifs. Toutefois, les compressions ne semblent pas avoir frappé les médecins, les autres professionnels et le milieu de la santé publique. Les dépenses réelles par habitant pour les médecins ont augmenté de 3 pour cent depuis 2010. Quant aux autres professionnels, elles se chiffrent à 12,5 pour cent, et à un tiers d’un pour cent pour la santé publique. Les dépenses en santé varient selon les provinces et les territoires, ce qui reflète les diverses réalités au sein de la fédération. Les dépenses réelles par habitant effectuées par les gouvernements en santé ont chuté dans huit des 10 provinces et dans deux des trois territoires. Le changement du taux de dépenses gouvernementales réelles par habitant depuis 2010 varie. Des baisses de près de sept pour cent ont été enregistrées en Alberta et en Ontario, de cinq pour cent au Nouveau-Brunswick, alors qu’ailleurs, des hausses ont été recensées, soit de 0,5 pour cent en Colombie-Britannique, de trois pour cent en 54
Nouvelle-Écosse et de sept pour cent dans les Territoires-du-Nord-Ouest. Ces écarts peuvent découler des taux différentiels du vieillissement de la population et de la croissance de celle-ci ainsi que d’un rendement économique sous-jacent et ses effets sur les revenus autonomes gouvernementaux. Une telle fluctuation des coûts en santé n’a pas été observée depuis 1992 à 1996, lorsque les dépenses réelles par habitant effectuées par les gouvernements provinciaux et territoriaux ont chuté de près de huit pour cent. Ce déclin a été suivi d’une grave récession et d’importantes contraintes budgétaires dans un contexte de déficits grandissants. Le tout a été exacerbé par les réductions des transferts de fonds fédéraux destinés à la santé, avec l’introduction du Transfert canadien en matière de santé et de programmes sociaux. Or aujourd’hui, les transferts fédéraux en matière de santé augmentent de façon continue, bien que les taux de croissance déclineront à compter de 2017. Pour ce qui est du déclin actuel, la principale question est la suivante : s’agit-t-il d’un fléchissement permanent de la courbe ou d’une pause temporaire? Après le déclin des dépenses recensé entre 1992 et 1996, les dépenses gouvernementales réelles par habitant en santé ont augmenté avec le regain de l’économie et l’augmentation des transferts fédéraux à la suite de l’Accord sur la santé en 2004. En effet, les dépenses réelles par habitant effectuées par les gouvernements provinciaux et territoriaux en santé ont augmenté de 50 pour cent entre 1996 et 2010. Toutefois, cette fois-ci, un rebond semblable est peu probable. À compter de 2017, la croissance des transferts de fonds fédéraux destinés à la santé sera liée au taux nationaux de croissance économique et d’inflation, avec un plancher de trois pour cent. Il est probable que les gouvernements mettront en place des mesures de contrôle des coûts en prévision du jour où le taux de croissance des transferts fédéraux, qui se chiffre présentement à six pour cent par année selon l’Accord sur la santé, amorcera son déclin. Toutefois, les efforts pour restreindre les coûts en santé, vu la croissance plus lente de l’économie et des transferts fédéraux, seront compensés par le vieillissement de la population et par les innovations dans le domaine des produits médicaux. Bien qu’un ralentissement en innovation pharmacologique ait influé sur la croissance des dépenses en médicaments, la situation pourrait changer. De plus, le vieillissement de la population a, à ce jour, modestement contribué à la croissance des dépenses en santé mais cette tendance pourrait s’estomper. La population canadienne est vieillissante, mais la génération des premiers baby-boomers entre à peine dans la tranche des 65 à 67 ans. Les dépenses provinciales et territoriales par habitant en 2012 étaient de 4620 $ pour les personnes de 60 à 64 ans et de 16 231 $ pour les aînés de 80 à 84 ans. Les effets du vieillissement ne se font pas encore pleinement sentir. Par conséquent, les dépenses réelles par habitant effectuées par les gouvernements provinciaux en santé augmenteront éventuellement à nouveau, mais la hausse sera probablement plus lente que celle qui a caractérisé la période entre 1996 et 2010. 55
Livio Di Matteo agit comme conseiller expert auprès d’EvidenceNetwork.ca et est professeur d’économie à l’Université Lakehead.
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Canadians should modernize not privatize medicare By Bryan Thomas and Colleen M. Flood National Medicare Week has just passed, buoyed with optimism as a fresh-faced government takes the reins in Ottawa — elected partly on a promise of renewed federal leadership on health care. Yet these “sunny ways” are overcast by recent developments at the provincial level that entrench and legitimize two-tier care. Saskatchewan has just enacted a licensing regime for private MRI clinics, allowing those who can afford the fees — which may range into the thousands of dollars — to speed along their diagnosis and return to the public system for treatment. Quebec has just passed legislation that will allow private clinics to extra-bill for “accessory fees” accompanying medically necessary care — for things like bandages and anesthetics. Once upon a time, these moves would have been roundly condemned as violating the Canada Health Act’s principles of universality and accessibility. These days, two-tier care and extra-billing are sold to the public as strategies for saving medicare. Under Saskatchewan’s new legislation, private MRI clinics are required to provide a kind of two-for-one deal: for every MRI sold privately, a second MRI must be provided to a patient on the public wait list, at no charge to the patient or the public insurer. Quebec’s legislation is touted as reining in a practice of extra-billing that had already grown widespread. Underlying both reforms is a quiet resignation to the idea that two-tier health care is inevitable. This sense of resignation is understandable, coming as it does on the heels of a decadelong void in federal leadership on health care. Throughout the Harper government’s time in office, the Canada Health Act went substantially unenforced as private clinics popped up across the country. Even in its reduced role as a cheque-writer, the federal government took steps that undermined national unity around health care, switching the Canada Health Transfer to a strict per capita formula, which takes no account of a province’s income level or health care needs. If Canadians hope to reverse this trend, we cannot simply wage a rearguard battle for the enforcement of the Canada Health Act, as it was enacted in 1984. Even if properly enforced, the Act protects universal access only for medically necessary hospital and physician services. This is not the blueprint of a 21st century public health care system. We desperately need universal coverage for a full array of health care goods and services — pharmaceuticals, mental health services, home care and out-of-hospital diagnostics. Canada is unique among OECD countries in the paucity of what it covers on a universal basis despite falling in the top quartile of countries in levels of per capita health spending. 57
Far from being our savior, the Canada Health Act in its current incarnation is partly to blame – not because of its restrictions on queue-jumping and private payment but because it doesn’t protect important modern needs, like access to prescription drugs. There are limits on what a public health system can provide, of course — particularly as many provinces now spend nearly half of their budgets on health care. But fairness requires that these limits be drawn on reasoned basis, targeting public coverage at the most effective treatments. Under our current system, surgical removal of a bunion falls under universal coverage, while self-administered but lifesaving insulin shots for diabetics do not. A modernized Canada Health Act would hold the provinces accountable for reasonable rationing decisions across the full spectrum of medically necessary care. Instead of modernizing medicare, Saskatchewan and Quebec are looking to further privatize it. Experience to date suggests that allowing two-tier care will not alleviate wait times in the public system. Alberta has reversed course on its experiment with privatepay MRIs after the province’s wait times surged to some of the highest levels in the country. The current wisdom is that long wait times are better addressed by reducing unnecessary tests. A 2013 study of two hospitals (one in Alberta, one in Ontario) found that more than half of lower-back MRIs ordered were unnecessary. Skirmishes over privatization have to be fought, but they should not distract us from the bigger challenge of creating a modern and publicly accountable health system — one that provides people the care they need, while avoiding unnecessary care. Achieving that will make National Medicare Week a true cause for celebration. Bryan Thomas is a Research Associate and Colleen M. Flood is a Professor, Centre for Health Law, Policy and Ethics, University of Ottawa. Colleen is also an expert advisor with EvidenceNetwork.ca.
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Modernisons le régime de santé public, au lieu de le privatiser Par Bryan Thomas et Colleen Flood La Semaine nationale de l’assurance-maladie s’est déroulée en novembre dernier sous le signe de l’optimisme, avec l’entrée en fonction à Ottawa d’un gouvernement tout neuf ‒ élu en partie sur l’espoir d’un renouveau en matière de leadership fédéral dans le dossier de la santé. Mais certaines mesures récentes prises au niveau provincial, qui ont pour effet de légitimer et consacrer les soins à deux vitesses, font planer un nuage au-dessus des « voies ensoleillées » promises. En Saskatchewan, on vient tout juste d’instaurer un régime de délivrance de permis aux cliniques privées qui offrent des services d’IRM (imagerie par résonance magnétique). Ainsi, les patients qui en ont les moyens (la facture peut s’élever à des milliers de dollars) pourront obtenir un diagnostic rapide et se tourner ensuite vers le système public pour y recevoir des soins. Le Québec, pour sa part, vient d’adopter une loi qui permettra aux cliniques privées de facturer au patient les frais dits « accessoires » qui accompagnent les soins médicaux – pour des fournitures comme les pansements et les anesthésiants. À une autre époque, ces décisions auraient été réprouvées sans détour et considérées comme une violation de laLoi canadienne sur la santé et des principes d’universalité et d’accessibilité qui la sous-tendent. Aujourd’hui, on présente les soins à deux vitesses et la surfacturation comme des moyens de sauvegarder le régime d’assurance-maladie. En vertu de la nouvelle loi saskatchewanaise, les cliniques privées sont tenues de respecter un marché de type « deux pour un » : chaque fois qu’elles facturent une IRM à un particulier, elles doivent s’engager à fournir gratuitement un examen IRM à un patient de la liste d’attente du secteur public. Le Québec, de son côté, tente de faire avaler sa loi sur les frais accessoires en prétendant encadrer une pratique déjà largement répandue. L’adoption de ces deux réformes indique que nous sommes résignés tranquillement à l’idée que les soins de santé à deux vitesses sont inéluctables. Ce fatalisme est compréhensible vu le vide laissé par dix années d’absence totale de leadership fédéral dans le dossier. Pendant toute la durée de son mandat, le gouvernement Harper s’est largement abstenu, alors que des cliniques privées surgissaient ici et là dans tout le pays, de faire respecter la Loi canadienne sur la santé. Même dans son rôle réduit de signataire de chèques, le fédéral a pris des mesures qui ont miné l’unité nationale sur la question des soins de santé; il a transformé le Transfert canadien en matière de santé en une simple formule par habitant qui ne tient pas compte des revenus des provinces ni de leurs besoins en la matière. Pour avoir une chance de renverser cette tendance, nous ne pourrons nous contenter de mener un combat d’arrière-garde en réclamant le respect de la Loi canadienne sur la santé. Son adoption remonte à 1984; même si on l’appliquait en bonne et due forme, elle garantit l’accès universel uniquement dans le cas de services médicalement nécessaires 59
dispensés par les établissements de santé et les médecins. La Loi ne reflète donc plus la réalité d’un système de santé public au 21e siècle. Nous avons désespérément besoin d’un régime universel qui couvrirait une gamme complète de fournitures et de services : médicaments, soins de santé mentale, soins à domicile et services de diagnostic hors hôpital. Parmi les pays de l’OCDE, le Canada se démarque par la pauvreté de sa couverture universelle, même si ses dépenses par habitant le classent dans le quartile supérieur. La Loi canadienne sur la santé, dans sa mouture actuelle, est à blâmer en partie, non pas à cause des restrictions qu’elle impose sur le resquillage et le paiement des services par des particuliers, mais parce qu’elle ne tient pas compte de besoins désormais essentiels, comme l’accès aux médicaments d’ordonnance. En cela, elle est loin d’être la bouée de sauvetage qu’il nous faudrait. Bien entendu, il y a des limites aux services que le système public peut garantir, notamment au vu du fait que bien des provinces consacrent quasiment la moitié de leur budget à la santé. Toutefois, l’équité exige que nous établissions ces limites de manière rationnelle, en ciblant les interventions jugées les plus efficaces. Dans le régime actuel, l’excision d’un oignon est remboursée, mais les injections autoadministrées d’insuline ne le sont pas, alors qu’elles sauvent la vie des diabétiques. Si on modernisait la Loi canadienne sur la santé, on pourrait obliger les provinces à prendre des décisions sur le rationnement raisonnable qui permettraient de couvrir le spectre entier des soins médicalement nécessaires. Au lieu d’actualiser le régime d’assurance-maladie, la Saskatchewan et le Québec cherchent à le privatiser encore davantage. Jusqu’à maintenant, l’expérience nous enseigne que le fait d’autoriser les soins à deux vitesses ne contribuera pas à réduire les files d’attente dans le système public. En Alberta, où l’on a tenté l’expérience de la facturation des IRM aux particuliers, on a fait marche arrière après avoir constaté que les temps d’attente avaient grimpé jusqu’à devenir parmi les plus élevés au pays. On sait aujourd’hui que le meilleur moyen de gérer les listes d’attente, c’est de réduire les examens superflus. En 2013, une étude menée dans deux hôpitaux (un en Alberta, l’autre au Québec) a montré que plus de la moitié des IRM prescrits pour la région lombaire n’étaient pas nécessaires. Il faut continuer à lutter contre la privatisation, sans toutefois se laisser distraire d’une tâche plus importante : établir un système de santé moderne, qui rend des comptes à la population et lui offre les soins dont elle a besoin, tout en évitant les traitements superflus. La réalisation de cet objectif nous donnerait un véritable motif de réjouissance lors de la Semaine nationale de l’assurance-maladie.
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Bryan Thomas est associé de recherche et Colleen M. Flood est professeure au Centre de droit, politique et éthique de la santé à l’Université d’Ottawa. Colleen est également experte-conseil auprès du site EvidenceNetwork.ca.
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How proposed user fees for health services in Quebec threaten the Canadian health system By Ryan Meili and Danielle Martin With a federal campaign in full force grabbing the majority of the headlines, a significant threat to Canada’s most treasured national program is going largely unnoticed. For many years, certain physicians and clinics have quietly been charging extra fees for health services. In some provinces, the frequency of such charges has been increasing. These include hidden charges for medications that are many times their actual cost or access fees of hundreds of dollars for examinations such as colonoscopies. Because these fees are for services that are covered by the health system, this is in effect extra-billing, a practice that is against federal and provincial law. In Quebec, Minister of Health Gaetan Barrette has identified these fees as a problem, as have many others for many years. You might expect Barrette – a physician himself — to clearly inform patients and practitioners that this practice is illegal and put an end to it. Instead, he is trying to regulate and “normalize” these fees, in direct contravention of the Canada Health Act. When the Canada Health Act passed in the House of Commons in 1984 with unanimous support from all political parties, its primary purpose was to put an end to extra billing exactly like this. Charging patients at the point of care for medically necessary services strikes at the heart of the principle that access to health care should be based on need rather than ability to pay. It undermines equity, increases system costs and reduces commitment to the public health care system. It’s also illegal. Medicare is a defining program and a source of enduring commitment from coast to coast, and all political parties claim to support the Canada Health Act. Why are we not hearing resounding denouncement of Minister Barrette’s plan from our federal politicians? Who will commit to enforce the CHA in Quebec and elsewhere? User fees are a deterrent to seeking care by the people who need health care the most. Research has consistently demonstrated that forcing people with less money to pay a fee to access care means they will not consistently choose to do so, and as a result, may not seek out medical attention until later in the course of their illness. This means patient outcomes are likely to be worse and treatment more complicated and costly. Given higher levels of illness among people in poverty, user fees also function as regressive taxation, shifting costs to those who use the system most but can least afford to pay. Given these well understood problems with user fees, doctors in Quebec and across the country have expressed alarm at Minister Barrette’s proposed amendment to Bill 20, which regulates extra billing rather than prohibiting it. The Canadian Medical Association, Quebec Medical Association, Canadian Doctors for Medicare, Médecins Québécois pour le Régime Publique, and the Quebec College of Family Physicians have 62
all come out against this decision, joining patient groups, all of Quebec’s opposition parties, and Raymonde Saint-Germain, the independent Quebec Ombudsman. The amendment was passed on October 7th, with no public debate. This is not the first attempt to introduce user fees in Quebec. Each time, such attempts have been beaten back on the basis of solid evidence and thoughtful public debate. A proposed implementation of system-wide user fees was cancelled in 2011when further review showed that these changes would decrease access and not achieve significant system savings. In 2013, the Quebec National Assembly voted unanimously in favour of a motion against extra-billing. Now, despite these previous decisions, public and expert opinion, and the law, Barrette is effectively bringing user fees in through the back door. Rather than introducing user fees charged by government, he proposes allowing clinics to do so. This further fragments care and makes access even more inequitable. In this federal election campaign, the talk has been around reducing barriers to access by improving coverage of prescription medicines, home care and mental health care. Yet at the same time that our federal parties are committing to such much-needed expansion, they are silent on protecting the core of medicare: publicly funded doctor and hospital services. Any party that claims to be committed to the Canada Health Act should immediately state its position on the proposed amendments to Bill 20 in Quebec. To do less is to skirt the core federal responsibility for medicare in Canada. Ryan Meili is a family physician in Saskatoon, founder of Upstream: Institute for A Healthy Society and an expert advisor with the Evidence Network. Danielle Martin is a family physician and Vice-President Medical Affairs and Health System Solutions at Women’s College Hospital in Toronto. Both are members of the board of Canadian Doctors for Medicare.
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Do Canadians spend too much on taxes? Here’s why that’s the wrong question By Michael C. Wolfson “There are lies, damned lies and statistics” is the well-worn phrase, but nothing better sums up the recent Fraser Institute scare mongering about taxes being the single largest budget item of Canadian households. “Your family’s largest expense may surprise you,” the ideological-driven think tank wrote, with taxes as the punchline. This perspective was picked up in headlines across the country with few media outlets taking the time to look critically at how the finding was reached. The truth is, as catchy as the headlines may be, it is alarmist spin. Of course, if you divide all household expenditures into a number of different categories like food and transportation, but leave all the different levels and types of taxation lumped together in a single category, the Fraser Institute finding is neither false nor surprising. If, instead, we also lumped all of Canadians’ (non-tax) spending together, the resulting discretionary amount is a larger portion of household budgets than the taxes the Fraser Institute claims we pay. But there is more obfuscating magic in their figures. On the one hand, the Fraser Institute assigns the taxes paid by corporations to individuals and families, but they don’t assign the corresponding corporate profits to anyone. This inconsistency inflates their tax rate numbers. Let’s tackle the issue another way. If we examine Canada’s entire economy, the OECD pegs total taxes, including CPP and EI contributions, at about 31 percent of GDP. This simply does not square with the Fraser Institute’s figure of 44 percent. And let’s not forget that governments in Canada actually account for about 20 percent of GDP if we focus on their direct purchases – from teachers’ salaries to hospitals to roads and public libraries. Providing these kinds of public goods is why we have governments in the first place. Presumably the Fraser Institute would rather have Canadians, at least those rich enough to afford it, pay for private schools, private health insurance and toll roads instead. But where would this leave lower and middle income Canadians? Most of the rest of the economy’s taxes flow back to individuals and families as cash – ranging from child tax benefits to public pensions. These forms of redistribution and social insurance are fundamental to Canada’s social fabric. But there may be a silver lining. Such biased economic exercises raise a fundamental question: Just what indicators should we be using to keep score on Canada’s economic performance?
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In the 1990s, a cover story for the Atlantic Monthly was titled, “If the economy is up, why is everyone down?”, reflecting a widespread feeling that the most commonly used scorecard for the economy, gross domestic product (GDP), was misleading. The recent theological debate on whether or not Canada has been in a recession is also based on GDP trends. In 2009, then French president, Nicholas Sarkozy, frustrated with the focus on GDP, funded a group of Nobel laureates and internationally prominent economists to see whether there was a better economic scorecard. Their answer, in the area of incomes, was to focus on median family income – the income level that separates families into two equal sized groups when arrayed by income. For Canada, the trends in this measure of economic performance do not jibe with GDP per capita, nor with the family income figure used by the Fraser Institute. In 1997, median Canadian family after-tax income (in constant 2014 dollars) for a four-person family was about $64,000, just a few hundred dollars higher than it was in 1976. Nothing to celebrate, in other words. Over this same period, GDP per capita had grown by about 20 percent. After this period of stagnation, there was a clear turning point in 1997, with median family income (again using a four person family as the point of reference) then growing quite steadily, reaching just over $85,000 in 2013. This figure reflects real growth of 33 percent, faster than the roughly 26 percent growth in real GDP per capita over the same period. We have, then, three very different impressions of Canada’s economic performance: The Fraser Institute has generated implausibly high average tax rates, using opaque methods, with the implication that Canadians are losing close to half their income to some ne’er do well — their governments. The mainstream financial press focuses on short term wiggles in the GDP stats, and politicians try to score points on who is to blame or reward for particular wiggles in GDP. But far less effort is devoted to producing and trying to understand data on how actual Canadian families are doing. We need to make more use of modern kinds of “big data” to estimate median family income and related indicators like the prevalence of low income, the size of the middle class, the share of the top one percent and income inequality. Such information would help paint a truer portrait of Canadian household prosperity — both improvements and declines – across the country. It’s time we stopped buying biased and second-rate economic indicators and took a thoughtful look at how Canadians are really doing.
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Michael Wolfson is an expert advisor with EvidenceNetwork.ca and holds a Canada Research Chair in population health modeling/populomics at the University of Ottawa. He is a former assistant chief statistician at Statistics Canada, and has a PhD in economics from Cambridge.
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How to eliminate MRI wait lists in the public health system – and save Alberta millions of dollars a year in the process By Nick Mohtadi Value for money appears to be finally getting the attention it merits as Alberta’s new health minister, Stephen Mandel, takes the reins of the portfolio that is close to consuming 50 percent of the province’s operating budget. This is an area of magnificent opportunity. Public health care offers many examples of value waiting to be tapped. Near the top is magnetic resonance imaging (MRI). It is a highly valuable diagnostic tool for many conditions, but it is expensive technology. Waiting times for non-urgent MRI are long, and more than half the MRIs taken in Alberta may be unnecessary. It’s the last point that offers opportunity to increase value for money in public health care. A recent study by Alberta and Ontario researchers found more than half of MRIs on low back pain patients were inappropriate or of questionable value. This suggests about 13,000 lower back MRIs conducted in Alberta annually are not necessary. My research at the Acute Knee Injury Clinic in Calgary suggests similar waste occurs in diagnosing knee injuries. This work found almost two-thirds of the knee-injured patients who had an MRI could have been accurately diagnosed using other more readily available and significantly less expensive techniques and tools. Provincially, this translates to about 4,000 knee MRIs annually. In these two areas alone, there may be 17,000 unnecessary MRIs every year in Alberta, representing a cost exceeding $15 million. This does not suggest MRIs find nothing. It does, however, suggest an accurate diagnosis and effective treatment plan could be put in place without MRI. In the case of acute knee injury, we concluded that applying evidence-based guidelines on MRI use and training health care providers in effective examining techniques could cut MRI use by two-thirds. A lower-back MRI costs the public health system approximately $1,000 while a knee MRI costs around $550. Latest provincial figures show the median wait for a non-urgent MRI in Alberta was 18 weeks. Long waits have spawned a thriving private MRI business in Alberta. Next-day private MRIs are available at a cost to the patient ranging from approximately $750 to $2,450. This generates no value to patients if the MRIs they purchase are unnecessary. The root of the problem is the ‘system gap’ and relative ‘knowledge gap’ that exist in Alberta and, most probably, across Canada. The system gap is in the form of slow access to specialty opinion and the absence of guidelines that would help primary care providers know when an MRI should be requisitioned. The knowledge gap relates to lack of 67
training in how to accurately diagnose knee injuries, low back pain and other common bone and joint conditions without expensive tests. Bridging these gaps with provincial MRI guidelines and training in diagnostic techniques is not necessarily a difficult undertaking, and it can be done cost-effectively. This approach aligns with the Choosing Wisely Canada campaign organized in partnership with the Canadian Medical Association to reduce unnecessary medical tests, treatments and procedures. Most MRI requisitions in Alberta come from family doctors. Training two or three physicians in a Primary Care Network in diagnostic techniques for musculoskeletal conditions and having them apply new MRI guidelines routinely in practice could eliminate the majority of the inappropriate MRIs in this large area of medicine alone. Introducing incentives tied to provincial benchmarks for efficient use of public resources could add motivation for training. The savings could be huge. In 2012, Canadians had 1.7 million MRIs — double the number in 2004. Demand for MRI will continue climbing as our population ages and grows. It is not inconceivable that, with these changes, there would be no wait lists for MRI in the public system. Private MRI would be unnecessary. And Albertans would see quantifiable value returned for their health care dollars. Nick Mohtadi is an advisor with EvidenceNetwork.ca, an orthopaedic surgeon practicing in Calgary, a clinical professor at the University of Calgary and Director of the Acute Knee Injury Clinic.
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Five challenges for bending the health care cost curve in Canada Why health reform remains a challenge By Greg Marchildon and Livio Di Matteo Canadian economists received a pleasant surprise this year: expenditure growth on public health care in Canada finally appears to be slowing down. However, it is unclear if this slowdown is the result of explicit success in sustainably bending the cost-curve or more short-term cost-cutting in response to slower economic growth or future federal health transfers. So is it a blip on the health care horizon or the beginning of a trend? With the continued aging of the Canadian population, the diffusion of new health care technologies, and increased pressure for other public spending, we anticipate health care costs will continue absorbing the energies of governments in Canada for years to come. And bending – or breaking – the cost curve, will remain a perpetual challenge. Here’s why. 1. Bending the health-care cost curve is a long-term process that is much more than a quick cost-cutting exercise or yet another “structural re-disorganization.” But the voting public is impatient for change. Governments have a time horizon that operates within four-year cycles and are expected to demonstrate substantive improvement in the short run. 2. When it comes to cost control, there must be an emphasis on prices as well as volume or numbers of health providers. Cost control attempts to date have focused mainly on the number of service and health-providers with “prices” (the fees paid by government to providers per service) remaining the undiscovered country. At the same time, however, one person’s health spending is another person’s income, and constraining fees will likely be vigorously opposed by those affected (doctors and health providers), even if a clear public benefit can be demonstrated. 3. While health system sustainability is about revenues (how much tax money a province has at its disposal) as much as it is about spending, most provincial governments have seemingly determined that they are not prepared to increase tax revenues. The basis for this decision seems to be rooted in a general public aversion to higher taxes and a need for competitive tax systems. At the same time, there is an inconsistency in public attitudes that desire more and better public health services but with fewer or lower taxes. 4. While policy should be evidenced-informed rather than belief-based, the complexity of health-system change makes it difficult to draw a straight line from one evidence-based improvement to health-system change as a whole. Indeed, 69
improving the quality and quantity of evidence-based decision-making is perhaps the greatest challenge in systematically devising policies for bending the cost curve. 5. While comparative evidence is essential for a better understanding of policy problems, you cannot bend the health-care cost curve by cherry-picking reforms from other jurisdictions with other political and social contexts. Ultimately, solutions are devised within the context of specific political, economic and policy environments. Grafting quick fixes onto one health system based on experiences in another can quickly generate new problems to replace those they were intended to fix. A major hurdle for health reform is that we need to decide exactly what changes we want to make in our health system. While there remains room to increase efficiencies and gain greater value for money, bending the cost curve requires fundamental reforms to the way we manage and deliver health services in Canada. This is a reality many Canadians seem reluctant to face. Another challenge is getting federal, provincial and territorial governments to agree on the basic values or principles we want to preserve and enhance as we reshape policies, structures and the regulatory environments of health care in Canada. Both challenges are formidable but surmountable barriers to ensuring the sustainability of publicly-financed health care in Canada. Addressing these challenges will fall mainly on the shoulders of our provincial governments, and of course, the electorates they serve. However, the federal government also has both the potential and the responsibility to play an important role. One thing is certain: whoever wins the next federal election in 2015 will have to meet these challenges head on. Greg Marchildon is an expert advisor with EvidenceNetwork.ca, Professor and Canada Research Chair in Public Policy and Economic History (Tier 1) at the Johnson-Shoyama Graduate School of Public Policy at the University of Regina. Livio Di Matteo is an expert advisor with EvidenceNetwork.ca and Professor of Economics at Lakehead University. They are the editors of the newly released, Bending the Cost Curve in Health Care (University of Toronto Press).
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Cinq paris à relever avant de redresser la courbe des coûts de la santé au Canada La réforme de la santé demeure un défi Par Livio Di Matteo et Greg Marchildon Les économistes canadiens ont reçu une agréable surprise cette année : la croissance des dépenses publiques en matière de santé au Canada semble finalement ralentir. Par contre, on ne sait pas avec certitude si ce phénomène est attribuable à une baisse durable des coûts ou aux mesures à plus court terme adoptées en réaction à la faible croissance économique ou à l’avenir des transferts fédéraux en matière de santé. Doit-on l’interpréter comme un phénomène passager ou comme le début d’une tendance? Si l’on tient compte du vieillissement de la population, de la diffusion des nouvelles technologies médicales et de la pression croissante exercée sur les dépenses publiques dans d’autres secteurs, on peut s’attendre à ce que les coûts de la santé continuent d’accaparer l’énergie des gouvernements pendant encore des années à venir. L’objectif de redresser (ou de briser) la courbe des coûts restera un perpétuel défi. En voici les raisons. 1. Il s’agit d’une démarche de longue haleine, qui nécessitera bien plus qu’un rapide exercice de compression des dépenses ou qu’une énième « rédésorganisation ». Or les électeurs sont impatients de voir des changements. Les gouvernements disposent d’un horizon temporel limité; on voudrait qu’ils réalisent en quatre ans à peine des améliorations substantielles. 2. En ce qui a trait au contrôle des dépenses, il faudra mettre l’accent sur les prix, outre le volume de soins ou les effectifs. En effet, les mesures adoptées jusqu’ici ont visé principalement le nombre de services et d’intervenants, alors que les « prix » (c’est-à-dire les honoraires versés à ces derniers pour chaque service) demeurent un territoire inexploré. Toutefois, puisqu’en matière de santé, les dépenses de l’un correspondent au salaire de l’autre, il est probable que la limitation des honoraires soit dénoncée vigoureusement par les principaux intéressés (les médecins et les prestataires de soins), et ce, même si l’on peut faire la preuve indéniable du bien-fondé d’une telle mesure. 3. La question de la pérennité du système de santé concerne autant les revenus (les recettes fiscales dont dispose chaque province) que les dépenses, mais la plupart des gouvernements provinciaux semblent résolus à ne pas augmenter l’impôt sur le revenu. Cette décision semble motivée par une aversion généralisée de la population à l’égard des hausses d’impôt et par la nécessité de maintenir un régime fiscal concurrentiel. Le paradoxe, c’est qu’on veut des services de santé toujours plus nombreux et efficaces, tout en réclamant des baisses d’impôt.
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4. Les orientations devraient être fondées sur des données probantes plutôt que sur des convictions, mais le domaine de santé est si complexe qu’il est difficile d’appliquer des solutions avérées à l’échelle du système. Le plus grand défi consiste précisément à améliorer en qualité et en quantité les décisions guidées par des données probantes, afin de réussir à élaborer systématiquement des politiques qui permettront de contrôler les coûts. 5. Même si les données comparatives sont essentielles à l’analyse des problèmes en matière de politiques, il ne suffit pas, pour réduire les coûts, de grappiller des réformes adoptées ailleurs dans d’autres cadres politiques et sociaux. En dernière analyse, les solutions doivent être conçues en fonction de chaque contexte politique, économique et décisionnel. On ne peut pas se contenter de greffer des mesures qui semblent avoir produit des miracles ailleurs, car elles risquent d’engendrer de nouveaux problèmes à la place de ceux qu’elles étaient censées régler. Un élément déterminant fait obstacle à la réforme de la santé : il nous faut décider quels changements précis nous désirons opérer. Même s’il est encore possible de réaliser quelques gains en matière d’efficience et de rendement, redresser la courbe du coût exigera une transformation en profondeur de l’administration et de la prestation des services de santé. C’est une réalité que bon nombre de Canadiens ne semblent pas se résoudre à admettre. Un autre défi consistera à convaincre les gouvernements fédéral, provinciaux et territoriaux de s’entendre sur les valeurs fondamentales et les principes à préserver au moment de repenser les orientations, les structures et les cadres réglementaires dans le domaine de la santé au Canada. Ce sont là deux obstacles de taille, mais qu’il est possible de surmonter pour assurer la pérennité du réseau public à l’échelle du pays. Ces défis reposeront principalement sur les épaules de nos responsables provinciaux et, bien entendu, de leur électorat. Néanmoins, le gouvernement fédéral a lui aussi la possibilité et la responsabilité de jouer un rôle essentiel. Une chose est certaine : peu importe qui remportera les élections fédérales en 2015, les vainqueurs devront attaquer le problème de front. Greg Marchildon est expert-conseil auprès du site EvidenceNetwork.ca, professeur et titulaire de la Chaire de recherche du Canada en politique publique et en histoire économique (niveau 1) à la Johnson-Shoyama Graduate School of Public Policy à l’Université de Regina. Livio Di Matteo est expert-conseil auprès du site EvidenceNetwork.ca et professeur d’économie à l’Université Lakehead. Ils ont codirigé l’ouvrage Bending the Cost Curve in Health Care (University of Toronto Press).
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New hospital funding model is a leap of faith Activity-based funding may discharge patients from hospital ‘quicker but sicker’ By Karen S. Palmer and Gordon Guyatt Most Canadians probably don’t realize that health care in Canada is quietly undergoing a major transformation in funding that could significantly impact patients. Three provinces – Quebec, Ontario and British Columbia – are implementing a new funding model for hospitals and other provinces are watching with interest. Canadian hospitals have been traditionally funded through annual lump sum payments – global budgets – meant to pay for all care each institution delivers. The good thing about global budgets is that they are predictable, stable and administratively simple. The problem with global budgets, critics argue, is they lack incentives to boost efficiency, are not transparent and funding is not targeted to priority areas. Enter activity-based funding (ABF). Under ABF, hospitals receive a pre-determined fee for each episode of care, intended to fund the bundle of services provided to each patient with a particular diagnosis, regardless of the actual costs for any particular patient. The fee is expected to account for the anticipated complexity, type, volume and intensity of care ordinarily provided to clinically similar patients. ABF has captured the imagination of some policy-makers as an alternative to global budgets. But is ABF the best way to fund hospitals in Canada? And how will it affect patients? We recently published in PLOS ONE, a systematic review summarizing the global evidence on ABF from the last 30 years. We found that despite its long history, the impact of ABF remains uncertain. Canada should tread cautiously. High quality systematic reviews are the gold standard in appraising benefits and harms of health interventions. We screened 16,565 studies looking for those that assessed how ABF affected patients and health care systems compared to other funding mechanisms. Results of our review suggest that ABF is associated with a 24 percent relative increase in patients discharged from hospital to post-acute care services. We also saw possible increases in readmission to hospital. Shortening hospital stays is a worthwhile policy objective and may promote patient wellbeing. After all, most people prefer being home to being in hospital. But patients might require readmission to hospital if discharged too soon. Almost certainly, many will need some level of post-acute care after being discharged from hospital “sicker and quicker.” There’s the rub. Although Canada has publicly-funded hospital and physician care, funding for home care, rehabilitation care or other forms of post-acute care in the community is a mixed public-private enterprise. Increased pressure on post-acute care 73
capacity in communities could seriously undermine equitable access in Canada, unless accompanied by substantial increases in public funding. Our study results also found a possible increase in severity of illness among patients admitted to hospital using ABF. Does this mean that patients were sicker going into hospital? Maybe or maybe not. Since ABF tends to adjust hospital compensation for severity of illness, there is a financial incentive to code patients so that they appear as sick as possible – a practice known as ‘upcoding.’ Upcoding may be appropriate if it legitimately represents more accurate patient classification, but it may also be inappropriate if the intent is only to maximize hospital reimbursement. Either way, upcoding is likely to undermine at least one ABF policy objective: controlling costs. We found no consistent increase or decrease in patient death rates with ABF nor in the volume of care provided to patients, such as how much care they received in hospital or the number of patients treated, though results varied widely across studies. The inconsistency of results across studies for most outcomes suggests there may be contexts in which ABF is more — or less — likely to harm. The question arises: under what circumstances does ABF lead to better or worse outcomes? Does it have to do with specific attributes of how ABF is implemented? Or particular features of a health care system? Unfortunately, no credible explanations for the differences emerged from the evidence. So, is ABF a good idea for Canadian hospitals? It depends partly on what we hope to achieve, but also on what risks we are willing to take. Governments may not get the benefits they expect with ABF (though they might), and there may be adverse consequences for which they are unprepared (though there might not be). A few things seem likely: Governments considering ABF should plan for a probable increase in demand for post-acute care services following hospitalization, be aware of the large uncertainty around impacts on other critical outcomes, and be prepared to monitor and evaluate the impact of ABF. Implementing ABF in Canadian hospitals remains a leap of faith. Karen S. Palmer is an expert advisor with EvidenceNetwork.ca and Adjunct Professor at Simon Fraser University. Gordon Guyatt is a Distinguished Professor at McMaster University.
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Financement par activité : un saut dans l’inconnu Les patients pourraient devoir quitter l’hôpital « plus tôt mais aussi plus malades » Par Karen S. Palmer et Gordon Guyatt Une majorité de la population ne se rend probablement pas compte que le système de santé au Canada subit actuellement une profonde transformation de son financement, qui est susceptible d’avoir de grandes répercussions sur les patients. En effet, trois provinces — le Québec, l’Ontario et la Colombie-Britannique — sont en voie d’adopter un nouveau mécanisme de financement des hôpitaux qui suscite beaucoup d’intérêt dans d’autres provinces. Jusqu’à présent, les hôpitaux canadiens recevaient une subvention forfaitaire (une enveloppe budgétaire globale) qui devait couvrir la prestation des services dans son ensemble. Les avantages de ce type de budget sont qu’il est prévisible, stable et simple à gérer sur le plan administratif. Toutefois, les problèmes soulevés par plusieurs critiques incluent le manque d’incitatif à améliorer l’efficacité et la transparence du financement des soins et le fait que ces fonds ne cibleraient pas nécessairement des secteurs prioritaires. C’est ici que le financement par activité (FPA) entre en jeu. Selon ce mode de financement, un hôpital reçoit, pour chaque épisode de soins, un tarif établi à l’avance, supposé couvrir l’ensemble des services dispensés pour un diagnostic donné, et ce, indépendamment des coûts réels pour un patient donné. Ce tarif préétabli est censé tenir compte de la complexité des soins habituellement prodigués pour le diagnostic en question, ainsi que leur nature, leur volume et leur intensité. Le FPA a capté l’imagination de certains décisionnaires en quête d’alternatives au financement par enveloppes budgétaires globales. Mais s’agit-il de la meilleure façon de financer les hôpitaux au Canada? Et quelles seront les répercussions sur les patients? Nous avons récemment publié dans PLOS ONE une revue systématique qui examine les données mondiales publiées ces trente dernières années sur le FPA. Nous avons découvert qu’en dépit de sa longue histoire, ses effets sont incertains. Ce qui nous amène à conclure que la prudence est de mise dans ce dossier. Pour évaluer les risques et bénéfices d’une intervention de soins, les revues systématiques rigoureusement menées constituent une norme de référence. Nous avons ainsi passé en revue 16 565 études afin d’identifier celles qui ont analysé les répercussions du FPA sur les patients et sur les structures de soins, en comparant ce procédé à d’autres méthodes de financement. Nos résultats indiquent que le FPA est associé à une hausse relative de 24 % des cas dirigés par les hôpitaux vers des prestataires de soins en phase subaigüe. Nous avons également observé une augmentation possible des cas de ré-hospitalisation.
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Le raccourcissement des séjours à l’hôpital est certes un objectif louable, pouvant même contribuer au bien-être des patients. Après tout, les gens préfèrent leur chez-soi à l’hôpital. Toutefois, s’ils sont amenés à quitter l’hôpital trop tôt, certains pourraient aussi se trouver dans la nécessité d’y être réadmis précocement. Et un grand nombre des patients nécessitera presque assurément des soins en phase subaigüe, ayant reçu leur congé de l’hôpital plus rapidement et à un stade de guérison moins avancé que sous l’ancien régime de financement. C’est là que le bât blesse. Les hôpitaux et les soins médicaux canadiens sont financés par les deniers publics, mais les prestations des soins en phase subaigüe, dont notamment les soins à domicile et la réadaptation, reposent à la fois sur des régimes de financement publics et privés. La pression grandissante qui s’exercera sur ce secteur constitue un risque sérieux quant à un accès équitables aux soins, à moins d’une augmentation substantielle les fonds publics qui lui sont dédiés. Par ailleurs, notre étude a montré une augmentation probable de la sévérité des cas dans les établissements financés par activité. Est-ce dire que les patients concernés étaient à un stade avancé de la maladie au moment de l’admission? Peut-être, ou peut-être pas. Puisque le FPA tend à tenir compte de la gravité de la maladie, il constitue un incitatif financier à attribuer un code diagnostique aux patients de sorte à ce qu’ils paraissent plus sévèrement malades qu’ils ne le sont en réalité. Communément appelée « surcodage », cette pratique serait appropriée si elle reflétait une meilleure classification de la sévérité des diagnostics; mais elle serait inappropriée si son seul but était de maximiser le remboursement. Dans un cas comme dans l’autre, le surcodage risquerait de nuire à la réalisation d’au moins un des objectifs poursuivis par le FPA: le contrôle des coûts. Nos résultats n’ont pas montré d’augmentation ou diminution claire du taux de décès, ni du volume des soins, tels que la quantité des soins prodigués aux patients ou le nombre de patients traités. Toutefois, il est à noter une importante variation de ces résultats entre les études inclues dans notre revue systématique. Plus globalement, ces variations de résultats à travers les études, parfois contradictoires, donnent à penser qu’il y a peut-être des contextes dans lesquels le FPA est plus ou moins susceptible de causer du tort. Ce qui amène à la question suivante : dans quelles circonstances le FPA mène-t-il à une amélioration ou une aggravation du devenir des patients? La façon de le mettre en œuvre joue-t-elle un rôle que l’on peut anticiper? Qu’en est-il des caractéristiques spécifiques d’un système de santé? Malheureusement, les données actuelles ne fournissent aucune explication crédible aux variations observées entre les différentes études. Le FPA est-il alors une bonne idée pour les hôpitaux canadiens? Cela dépend en partie de ce que nous cherchons à accomplir, mais aussi des risques que nous sommes disposés à prendre. Il est possible que les gouvernements n’en tirent pas les avantages qu’ils en espèrent (bien que cela ne soit pas non plus exclu), et ils pourraient aussi s’exposer (ou non) à des conséquences négatives auxquelles ils ne sont pas préparés. 76
Il est toutefois raisonnable de s’attendre aux points suivants: les gouvernements qui songent à adopter le FPA devraient envisager une augmentation probable de la demande en matière de soins en phase subaigüe après l’hospitalisation; ils devraient avoir conscience de la grande incertitude autour des répercussions sur le devenir clinique des patients et des systèmes de soins; et enfin être en mesure de surveiller l’application du FPA ainsi que d’en évaluer les retombées. La mise en œuvre du FPA dans les hôpitaux canadiens reste donc essentiellement un saut dans l’inconnu. Karen S. Palmer est experte-conseil auprès du site EvidenceNetwork.ca et professeure adjointe à l’Université Simon Fraser. Gordon Guyatt est professeur distingué à l’Université McMaster.
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The Prentice health care levy is not a cure for the Alberta health system New health care tax needs to be tied to health spending By Herb Emery The Prentice government announced that it will restore the use of health care taxes so that Albertans can directly contribute to the health care system. On the surface, levying up to $1000 per person earning over $50,000 per year to contribute approximately $0.5 billion over two years towards an $18 billion medical treatment system sounds reasonable. But dig a little deeper and the tax looks less a cure for the health system and more of what ails it already. Prior to the budget, the government indicated that it was considering the use of visible health care premiums that would contribute directly to health care spending – a transparent mechanism. What Albertans are actually getting instead is a new tax purported to be for health that will merely be absorbed into general revenues. A healthspecific tax tied to health spending would at least offer the hope of introducing government accountability by shedding light on perpetually rising health care costs. What we get instead is nothing more than an open-ended commitment to pay a tax should the government fail to “bend the health care cost curve.” In work published through the School of Public Policy at the University of Calgary, we have shown the sizeable inflationary impacts on health spending when voters do not face a clear tax linked to the price of the spending. The “fiscal illusion” created by obscuring how health care spending is financed is estimated to have added $6.75 billion to public health care spending in Canada from 2001 to 2008. Where government spending is more clearly tied to tax prices or out-of-pocket costs, such as in education, we have seen greater public demand for spending restraint, particularly for teacher incomes, and calls for accountability in education outcomes. In the context of the payroll tax financed Canada Pension Plan, concerns over the rate of increase in the contribution levels resulted in dramatic reforms to the plan in the late 1990s that included pre-funding some of the plan’s future liabilities. Since the Premier has not tied the new health care levy to any specific expenditures in the health care system, such as physician billings or patient use of the system, the levy should be interpreted as just another tax with no purpose other than to raise revenue for a government interested in perpetuating the Canadian tradition in health care of avoiding tough choices. This is unfortunate since Alberta needs to make some tough choices if the publicly funded medical system is to be sustained and the province is to address its deficit. Government health care spending in Alberta is approaching half of all government expenditure. Stephen Duckett was one of the earliest commentators to point out that when it comes to health care, compared to other provinces, Alberta spends a lot per person and 78
achieves middle of the pack health outcomes and access to necessary services. By definition, this defines Alberta’s as an inefficient health care system. But there’s room for hope. The Prentice health care levies could change the health system for the better if it was implemented as a measure of accountability for health care system performance. Wouldn’t it be great to see a government with the incentive to change from a passive bill payer to fulfilling its actual role of being an effective purchaser of health care services? A transparent health levy tied directly to health expenditures could make this a real possibility. Imagine a “Prentice Premium” that would limit taxpayer tolerance for inefficient and unnecessarily costly provision of medical treatment. Studies have shown enormous costs linked to inappropriate health services, unnecessary referrals and an unwillingness to resource the health system appropriately beyond the scope of hospitals and doctors. Imagine a “Prentice Premium” that would activate voter demands for a patient oriented medical treatment system that operates beyond the 9 to 5, five day a week schedule when health care needs don’t follow a regular work week. And, after 75 years of talking about it, voters may demand the government make the prevention of chronic disease a priority. I applaud the Premier’s new health premium only if it will introduce meaningful accountability into health care spending. Because if this government cannot manage its responsibility to procure high quality, patient oriented and cost-effective health services in return for Albertan’s high level of public spending, then voters might feel it is time to let a new government give it a try. Herb Emery is an expert advisor with EvidenceNetwork.ca and the Director for Health Policy, School of Public Policy, University of Calgary.
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Putting health care on the federal election agenda By Robert McMurtry A federal election could be called any time in the next few months, judging by the media coverage and the ramping up of political activity. Many issues have been crowding into the media headlines in anticipation of the election — but with a notable absence of any consideration of health care by our political parties. Apparently the subject is still on the minds of the electorate though, at least amongst my own circle of friends, colleagues and neighbours, many of whom note the leading edge of our baby-boomers have now turned 65. A good starting point could be an overlooked recommendation in the Romanow Report (#5) tabled in 2002, which suggested that our Canada Health Act needs to be both modernized and strengthened in order to reify the principles of public administration, universality and accessibility. The recommendation also suggests we need to update the comprehensiveness of our health system and create a new principle of accountability. The recommendation is breath-taking in its scope – all the more since it is still relevant in 2015. Sadly, little, if any, progress has been made in the intervening 12 plus years since Romanow — and certainly not in the area of accountability, a sticking point for many Canadians. Some of the key issues in health care that need renewed public focus include making the health care transfer payment details to the provinces and territories more clear; clear goals and objectives for provinces and territories to “buy change” in delivery models that measure health outcomes of interventions and ensure that these interventions reflect best practices. Clearly, the enforcement of the Canada Health Act by the federal Minister of Health is not occurring nor is it clear with whom the responsibility lies, so this needs to be revisited. It is also not clear what the impact of trade agreements may be on the future of medicare – so it is imperative to have this discussion. Finally, the creation of a national pharmacare program – the feasibility and implementation – has been largely neglected by the current federal government, but not by the general public. Providing answers to these questions is the task of those who seek to represent us in Parliament; seeking answers to these and other questions is the responsibility of concerned citizens. From my direct experience as a physician and as a patient, medicare generally delivers on its promise of providing care for all in a timely and effective fashion. Unfortunately wait times for total joint replacements are now increasing in some jurisdictions. While the 80
principles of universality, comprehensiveness, accessibility, portability and public administration continue to resonate with Canadians, we must maintain a constant vigilance of medicare’s performance. Where do we go from here? While many progressive options are possible, one choice that has the potential for high impact with the prospect of an enormous return on savings merits our attention: the adoption of best practices across provinces and territories. In 2010, the Organization of Economic and Cooperative Development (OECD) estimates that on average, member states could save two percent of their GDP by 2017 with the adoption of best practices in their health care systems, and that Canada could save 2.3 percent. Given that Canada’s GDP is approximately $1.825 billion, this suggests the possibility of a savings of over $40 billion ($41.975) annually. What does it mean to adopt best practices? Simply put, an evaluation of success stories in health care delivery across Canada reveals “nuggets” in almost every jurisdiction. An example is the Alberta Bone and Joint Healthcare Institute that has revolutionized musculoskeletal care including hip and knee replacement, reducing wait times, shortening hospital stays and increasing satisfaction of patients all in a cost-effective manner. Another example is the practice of Patient Centred Care in the primary health care setting based on care, communication and common ground and treatment based on the best available evidence that patient and provider agree upon. This approach has been shown to reduce unnecessary tests, decrease the number of physician visits needed and provide higher satisfaction and better outcomes in the management of chronic conditions such as hypertension. For a health care system to continue to serve Canadians into the future, continued vigilance and progressive change with cost constraint must be attractive to policy and decision makers. Now it’s time we heard what our political parties plan to do for medicare. Robert Y. McMurtry is an expert advisor with EvidenceNetwork.ca, an active orthopedist and formerly Dean of Medicine at Western University and Assistant Deputy Minister of Health Canada. He was a special medical advisor to the Royal Commission of the Future of Health Care in Canada (Romanow Commission).
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Ambulance fees are an obstacle on the road to care By Ryan Meili and Carolyn Nowry Imagine you’re a physician seeing a six month old child in clinic. She has a fever and cough, she’s working hard to breathe and her oxygen levels are falling. You know she needs assessment in the emergency room and requires transportation in an ambulance in case her condition worsens en route. Her family understands the urgency of the situation, but asks, “Could we take her there in our car?” Experiencing a medical emergency is an incredibly stressful experience for patients and their families. This stress should not be compounded by worries about getting an ambulance bill they can’t afford. As physicians, we know the importance of the first few minutes of an emergency situation, and the crucial role of Emergency Medical Services (EMS) in saving lives. And yet ambulance fees remain a significant barrier to people receiving necessary care across Canada. young mother recently spoke to the Saskatchewan press about receiving a bill of $7000 after several ambulance trips were required for her severely ill daughter. Connie Newman of the Manitoba Association of Seniors Centres recently described to reporters the plight of an elderly woman who walked to the hospital in -40C because she could not afford an ambulance. How often are people forced to choose the unsafe option of driving themselves or their loved ones to hospital simply because they cannot afford to pay? One
A recent CBC Marketplace survey revealed that 19 percent of Canadians did not call an ambulance due to cost. Clearly, this is an issue that our provincial and territorial health ministers need to address. A look across our provinces and territories reveals a patchwork system for financing ambulance services. New Brunswick has recently removed ambulance fees for anyone who does not have private insurance coverage. All other provinces and territories in Canada – with the exception of the Yukon – charge ambulance fees. The burden of cost to patients is highest in the prairies: Manitoba charges up to $530 per trip, and Saskatchewan tacks on fees for inter-hospital transfers on top of the $245-$325 fee for an ambulance pick-up from home. In Ontario, the cost is typically much lower at $45 per trip, but increases to $240 if the receiving physician deems it unnecessary. The reality on the ground violates the spirit, if not the letter, of the Canada Health Act: equal access to physician and hospital services means little if safe passage to them is anything but. There are a variety of options to reduce this inequity in access. One option is to follow New Brunswick’s lead and offer full coverage. An alternative would be to only charge users if the ambulance ride is deemed medically unnecessary. However, differentiating ‘appropriate’ from ‘inappropriate’ ambulance use isn’t straightforward, and can vary between providers. What’s more, evidence suggests that institutions – schools, long-term 82
care facilities, hospitals and police services – more often initiate potentially unnecessary ambulance services than do individuals, as a result of compliance with internal policy or protocol. As with other areas of health care, user fees are a blunt tool: they reduce both necessary and unnecessary use of services. The risk of footing the bill could deter people, especially those living in poverty, from calling for help. This would deny them not only safe transport to hospital, but also the initial emergency interventions by paramedics that can mean the difference between life and death. Public education and enhanced availability of primary care are more effective ways to decrease unnecessary ambulance use. Ideally, ambulance services should be fully covered for everyone. This would, however, require provincial governments to take on more of the costs. In Nova Scotia that cost is an estimated $9.7 million, according to the Nova Scotia Citizen’s Health Care Network. This is a drop in the bucket of the $6.2 billion Nova Scotia health care budget; a small investment to ensure everyone, regardless of income, has access to vital emergency care. The variety and inequity of ambulance charges in Canada is a policy mess. Canada's Health Ministers should work together to establish a consistent and compassionate approach that balances cost with the need to remove barriers to care. Ryan Meili is an expert advisor with EvidenceNetwork.ca, a family physician in Saskatoon and founder of Upstream: Institute for A Healthy Society. @ryanmeili Carolyn Nowry is a family physician in Calgary, Alberta. They are both board members with Canadian Doctors for Medicare.
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Canada has mixed wait time results in health care We need governments to promote best practices across the country and improve patient outcomes By Robert McMurtry Wait times have long been a source of concern for Canadians, and in some jurisdictions, remain a significant problem. Recently the Canadian Institutes of Health Information (CIHI) released their report for 2015. There is both encouraging news and areas in need of attention. CIHI follows the wait times for five interventions across all jurisdictions in Canada including cancer care (radiation), cataract removal, surgery for hip fractures and total joint replacements of the hip and knee. In each instance, the question posed by CIHI is: “What percentage of people receive treatment in a timely fashion?” Establishing what constitutes “timely treatment” can be contentious, but in 2004, the provinces and territories agreed to standards for wait time maximums based on the best available evidence. CIHI continues to deploy these benchmarks to the present day. The positive news is that wait times have remained stable over time in spite of increased demand. For example, the numbers of patients receiving radiation therapy has grown by 34 percent since 2010, yet 98 percent of patients are treated within the benchmark. Surgery for hip fractures has shown an improvement of 6 percent to 84 percent for timeliness. Eighty-three percent of hip replacements were performed within benchmark while 79 percent of knee replacements made the mark. For cataract surgery, the number within benchmark was 80 percent. Unfortunately, CIHI is not able to address the question of appropriateness of treatment. The critical question: “Does this patient really need this surgery, now?” remains unanswered. Other studies show Canadian wait times in a mixed light. In an OECD study, Canada fares well in terms of timeliness of access compared to six OECD peer countries (United Kingdom, Australia, New Zealand, Finland, Estonia and Portugal), ranking first in cataract surgery and second in knee and hip replacements. (The other two interventions are not tracked in the other nations.) But a third study by the Commonwealth Foundation found that Canada does not fare well compared to peer nations with universal health care when accessing appointments for primary care and consultations for specialty care. Since accessibility is one of the five core principles of the Canada Health Act, it is a substantial issue that needs urgent attention. Furthermore, delays experienced in accessing these services would add to the total wait times for health care interventions. In other words, there’s much room for improvement in the Canadian health system. 84
Fortunately there are means at hand to address the problems of wait times and appropriateness of care, means that are already being deployed successfully in Canada, such as the work of the Cardiac Care Network in Ontario or the Alberta Bone and Joint Institute – or the Choosing Wisely Canada initiative of the Canadian Medical Association. But we need a broader uptake of such best practices across the country. Best practices not only enhance health care efficiency, they result in substantial economic savings too – a minimum of 15 percent according to most analyses. So how do we get there? Effective wait time management requires support from government leaders as well as cooperative administrative and clinical leadership. IS/IT infrastructure support to manage centralized wait lists is fundamental, as is a committed full-time staff monitoring wait times performance in jurisdictions, measuring performance against benchmarks and identifying “outliers” or patients who are experiencing untoward delays. With these elements in place, a system can be created that includes the ability to track the key information of broad trends, as well as the means to identify individual problems. In addition to timely care, we must also establish a clear rationale for treatment in the first place: Is this knee replacement really necessary now or should the patient lose weight or possibly have non-surgical management? When, why and how interventions need to be undertaken should be re-examined across the country. Building on the successes of best practices already established in some regions of Canada should set the agenda for the future – to enhance efficiency and quality of care at lower costs. Acting now will only strengthen Canada’s most coveted social program. Robert Y. McMurtry is an expert advisor with EvidenceNetwork.ca, an active orthopedist and formerly Dean of Medicine at Western University and Assistant Deputy Minister of Health Canada. He was a special medical advisor to the Royal Commission of the Future of Health Care in Canada (Romanow Commission).
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Patient-centred health care could reduce wait times and improve the Canadian health system By Robert McMurtry Recently I had occasion to spend time in a busy community hospital in order to deal with my apparent adverse drug reaction. Happily, full recovery ensued but the time spent in the Emergency Department (ED) and ward left a strong impression on me. When my wife and I arrived in the early morning, the ED was notably calm. Upon mentioning this observation to our nurse, she ironically demurred, presumably unwilling to tempt fate and bring on ensuing chaos. There is little doubt that her fears are real. Overcrowded EDs, stressed staff and concerns about patient safety are problems witnessed more often than any health care professional would wish. I wondered then, as I do now, if the chaos may be largely preventable — if only the appropriate systems and staffing that enable professionals to provide high quality care were put in place. A key systemic change we could make to our health care system would be to implement the often acclaimed, but infrequently achieved, continuum of patient-centred care. The continuum of patient-centred care could include a consistency of health care professionals familiar with a patient’s case and who are buttressed by the flow of relevant patient history and investigations. Patient centredness by the professional care-giver would target care, communication and common ground or a shared understanding between those receiving the care and those providing it. Such an approach would not only keep patients and families fully abreast of management details but also dramatically reduce the incidence of orphaned or overlooked patients. No longer need individual people languish in a twilight world of waiting and uncertainty. The best concept I have encountered to accomplish these goals is that of the case manager who can become a constant for an individual’s care. The role could be filled by a family physician, nurse practitioner or other health care professional. The key concept is to ensure continuity of care. It has been done before, but now we need to replicate the success across the country and across health care services. A good example is trauma care, which was provided on an ad hoc basis in Ontario until 1976 when the first comprehensive program of trauma care was created at the (now named) Sunnybrook Health Centre. The cooperative regionalized program included a continuum of care from paramedics and helicopter transport through all the steps of trauma resuscitation, operating rooms, Intensive Care Units, ward care, rehabilitation and
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community care. The result was nothing less than substantial improvements in patient outcomes provided cost-effectively. Another example of patient-centred care comes from Ontario’s Cardiac Care Network formed in 1989, which has demonstrably improved care and outcomes for cardiovascular patients in Ontario. For example, major surgeries are entered into a registry documenting procedures, outcomes and adverse events. Should any concerns arise, the information is available (with appropriate security in place) to the relevant practitioners or for quality control to third parties. Untoward events or trends can be readily evaluated and corrective action taken if needed. Some might object that these models are for a narrow scope of highly specialized problems and are too expensive in the present funding climate. Others, rightly, would emphasize prevention which has been integrated into these successful programs. The truth is that the health care system cannot afford the less efficient systems currently in place. A recent stellar example of patient-centred care comes from the Alberta Bone and Joint Health Institute (ABJHI) which now provides seamless delivery of care across diverse health care professionals and systems of delivery, including community care, out-patient and acute care. The institute deals with major joint replacements but also addresses chronic diseases such as arthritis. Better care is delivered more cost-efficiently by including both primary and secondary prevention which are integrated into the program. The result is that wait times have been effectively reduced while simultaneously controlling costs and also yielding higher patient and professional satisfaction. What then are the barriers to progress elsewhere in the country? Unfortunately decision-makers seldom respond to evidence provided by best practices — less than they should, in any case. Perhaps a new mind set is required across the health care system — a mind-set that incentivizes innovation and embraces progressive change. In the end, patients, health care professionals and decision-makers all need to work together and demand and deliver better care. I believe the answer lies with all of us. Robert Y. McMurtry is an expert advisor with EvidenceNetwork.ca, an active orthopedist and formerly Dean of Medicine at Western University and Assistant Deputy Minister of Health Canada. He was a special medical advisor to the Royal Commission of the Future of Health Care in Canada (Romanow Commission).
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Les soins axés sur le patient pourraient réduire les temps d’attente et améliorer le système de santé au Canada Par Robert McMurtry Récemment, à la suite d’une réaction indésirable manifeste à un médicament, j'ai eu l'occasion de passer du temps dans un hôpital communautaire très fréquenté. Par bonheur, je me suis complètement rétabli, mais mon séjour aux urgences m'a laissé une forte impression. Ma femme et moi étions arrivés à l'hôpital de bon matin; un grand calme régnait dans la salle d’urgence. J’en fis la remarque à l’infirmière, qui me contredit sur un ton ironique, se refusant peut-être à attirer le mauvais sort et le chaos qui s’ensuivrait. On ne peut guère douter que ses craintes soient fondées. Urgences bondées, personnel sous haute pression, inquiétudes liées à la sécurité des patients : ce sont là des problèmes dont les professionnels de la santé sont témoins plus souvent qu’ils ne le souhaiteraient. Je me suis demandé, et je continue à me poser la question, si ce désordre ne pouvait pas être évité dans une large mesure, si seulement nous arrivions à mettre en place des structures et des effectifs adéquats, qui permettraient aux intervenants de prodiguer des soins de grande qualité. Parmi les changements systémiques que nous pourrions envisager, je pense au continuum des soins centrés sur le patient, dont on vante souvent les mérites, mais qu’on met rarement en œuvre. Cette conception préconise la constance quant à la prise en charge du malade, c’est-à-dire par des professionnels qui sont bien au fait de son dossier médical, de ses antécédents et des examens qu’il a subis. Elle serait axée sur les soins à prodiguer, la communication et l’établissement d’un accord entre le bénéficiaire et les prestataires. Elle permettrait non seulement de garder le patient et son entourage au courant des détails de sa prise en charge, mais aussi de réduire radicalement le nombre de patients orphelins ou laissés pour compte. Il n’y aurait plus besoin de laisser des patients se morfondre dans une zone floue, dans l’attente et l’incertitude. Pour atteindre ces buts, la solution la plus indiquée à mon sens consisterait à faire en sorte que chaque patient dispose d’un gestionnaire de cas qui jouerait le rôle de pivot. Cette fonction pourrait être assumée par un médecin de famille, une infirmière praticienne ou un autre intervenant. L’idée maîtresse serait de favoriser une continuité des soins. Cette approche a déjà fait ses preuves; il faudrait désormais l’étendre à l’échelle du pays et à l’ensemble des services de santé.
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Les soins post-traumatiques autrefois dispensés en Ontario sur une base ponctuelle nous en offrent un bon exemple; le premier service du genre a été offert jusqu’en 1976 par le centre hospitalier aujourd’hui connu sous le nom de Sunnybrook Health Sciences Centre. Il consistait en un programme coopératif et régionalisé, axé sur un continuum de soins comprenant des services ambulanciers, le transport par hélicoptère, la réanimation, des salles d’opération, une unité de soins intensifs, des soins hospitaliers, un service de réadaptation et des soins communautaires. Les résultats de santé s’en sont trouvés grandement améliorés, et ce, à un coût avantageux, ce qui n’est pas rien. Un autre exemple de soins centrés sur le patient nous provient du Réseau des soins cardiaques de l’Ontario. Créé en 1989, celui-ci a permis d’améliorer sensiblement la prise en charge des personnes souffrant de maladies cardiovasculaires ainsi que leurs résultats de santé. Les interventions chirurgicales majeures, notamment, sont consignées dans un registre qui répertorie procédures, résultats et événements indésirables. Lorsqu’un problème survient, un praticien qualifié ou une tierce partie chargée du contrôle de la qualité peuvent consulter le registre (moyennant un accès sécurisé). Ils peuvent ainsi déterminer rapidement si une réaction ou une évolution est indésirable et prendre les mesures correctives qui s’imposent. Certains objecteront que ces modèles ne concernent qu’une petite poignée de services très spécialisés et qu’ils coûteraient beaucoup trop cher à instaurer dans le contexte budgétaire actuel. D’autres insisteraient avec raison sur le fait que la prévention fait partie intégrante de ce genre de programmes. La vérité, c’est que nous n’avons plus les moyens de maintenir les systèmes moins efficaces qui sont en place aujourd’hui. L’Alberta Bone and Joint Health Institute (ABJHI) offre un excellent exemple d’un modèle récent inspiré par une approche centrée sur le patient. Cet établissement préconise une prestation des soins sans discontinuité entre les différents intervenants et services, notamment entre les soins communautaires, les soins ambulatoires et les soins aigus. On y pratique des interventions majeures de remplacement de la hanche, mais on prend aussi en charge certaines maladies chroniques comme l’arthrite. En intégrant tant la prévention primaire que secondaire, on prodigue ainsi de meilleurs soins à meilleur coût. Le résultat, c’est qu’on est parvenu à réduire les temps d’attente tout en maîtrisant les dépenses et en rehaussant le degré de satisfaction tant chez les patients que les professionnels. Alors quels sont les éléments qui font obstacle à l’amélioration ailleurs au pays? Malheureusement, les décisionnaires ne réagissent que rarement aux données probantes que produisent les pratiques exemplaires – enfin, moins qu’ils ne le devraient. Peut-être faudrait-il insuffler un nouvel esprit à l’échelle du système de santé : un esprit qui valoriserait l’innovation et le progressisme.
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En dernière analyse, les patients, les professionnels de la santé et les décisionnaires doivent travailler ensemble pour réclamer et garantir la prestation de soins de qualité. Ma conviction, c’est que nous avons tous un rôle à jouer. Robert Y. McMurtry est expert-conseil auprès du site EvidenceNetwork.ca, orthopédiste, ancien doyen de la faculté de médecine de l’Université Western et ancien sous-ministre adjoint à Santé Canada. Il a agi à titre de conseiller médical spécial auprès de la Commission sur l’avenir des soins de santé au Canada (Commission Romanow).
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Barrette's reform ignores evidence on what works By Paul Lamarche, Réjean Hébert et François Béland Bill 10 has as its objective to improve the access and the quality of health and social services in the province of Quebec while diminishing bureaucracy and increasing efficiency. To accomplish these objectives the proposed law merges all public health and social service institutions in a given region into an integrated center of health and social services (CISSS). The Montreal region due to its size will be divided into five new distinct regions. As professors in the Department of Health administration in the School of Public Health at the University of Montreal we are in agreement with these objectives however we seriously question the ability of this reform to achieve them. Scientific evidence has shown that mergers of institutions in the health care sector do not generate economies of scale nor do they reduce bureaucracy and have had little or no effect on the integration of services or an increase in accessibility. The centralization that will result from this reform will not allow for the stated objectives to be achieved and will likely have important negative consequences. Mergers and Their Cost: Bigger is Not Better Nor Less Expensive The debate surrounding the optimal size of a health care institution has been going on for decades. This debate reached a crescendo during the 1980s in the United States and Great Britain. Experience shows that there are no cost savings in increasing the size of an acute care hospital over 200 beds. Hospitals with over 600 beds cost more to run than those hospitals of smaller size. It is also noted that not only are costs not reduced but that there are unexpected and negative effects on the offering of services most notably in the delays in the development and improvement of those services. It is interesting to note that a national conference was held in 2001 in the United States on the theme of " The Failure of Mergers ". Many studies both in England and the United States as well as Quebec have looked to explain the impact of integration on health and social institutions and their missions. These studies show very positive effects on the integration of care but that they were achieved through contractual agreements between autonomous organizations and not through mergers. Contracts between autonomous institutions to share the provision of services by implementing corridors of care achieve much better results than do mergers. Less bureaucracy: Not true We could ask are there too many bureaucrats? The question is complex and difficult to answer without objective data. Instead one can observe the evolution of administrative expenses as a portion of government expenses in health and social services in Quebec in the past and compare them to like expenses in other provinces. In Quebec according to the data from the Canadian Institute on Health Information the portion of administrative expenses in health care spending has decreased since 1975 from a 4 percent rate in the seventies to 1.3 percent into 2011 and then started slowly 91
increasing to 1.6 percent in 2014. General administrative expenses in other provinces have followed the same tendency. From 2.6 percent in 1975 they were reduced to 1.1 percent in 2014. In fact these expenses were more important in Quebec than Canada between 1975 and 2004 and very comparable from 2005 onward. General administrative expenses in Quebec were similar to other Canadian provinces after the Couillard reform when the role of regional agencies was reinforced. However between 2011 and 2014 the portion of general administrative expenses in Quebec's health care system did not follow any development in regionalization. In this context it is difficult to associate regionalization with an increase or a reduction in administrative expenses. It is also difficult to imagine how the abolition of regional agencies would lead to a reduction in these expenses. One is most likely to witness a displacement of bureaucrats focus from a decreasing concern for the offering of health and social services to the population to a greater concern for the political and bureaucratic aspects of managing the health care system. Centralization is not a guarantee of efficiency in our public health care system. Scientific data shows clearly that a decentralized system is closer to the centers of decision making of the population and allows for health and social services to be better adapted to the populations needs, especially those of the underprivileged or those living in rural or outlying communities. Contrary to industry, which seeks the production of uniform and standardized services at the best price, health systems need to be able to adjust services to the needs of the population being served. The disappearance of local institutions planned for in the new law risks standardizing services throughout a regional territory hence diminishing access to more marginal populations while increasing the inequalities of health. The creation of regional mega structures will result in an important loss of linguistic, cultural and community identity. Those institutions that have been serving their community for many years and are essential for their role in maintaining community ties and supporting community development will be lost. This loss of identity has been regularly shown as a factor in the demotivation of management personnel and professionals in the institution. This demotivation of staff is an important obstacle in their performance and the overall efficacy of the organization and the care provided to patients. Finally the centralization of decision making into large regional organizations with no local autonomy goes against the needs of a dynamic region with its many municipalities. Health care institutions are often the motors of the economy and the most important employer in these communities. The proposed reform will have the effect of drawing local leaders to the centers of regional decision-making. Merging unions will have the same effect of attracting staff to these same centers accentuating the demotivation in the smaller more outlying areas possibly leading to staff shortages.
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Scientific evidence does not support the presumptions of Bill 10 that there will be a reduction in bureaucracy with the centralization of decision-making. National and international experience has shown time and time again that the proposed reform will not have the desired effects that have been announced and in fact will make health care delivery more complex. We should learn from these experiences instead of increasing the centralization of decision-making in our health care system. Unfortunately we have the peculiar trait of trying the same solutions over and over again that have been already shown not to work. The following professors in the Department of Health Administration in the School of Public Health at the University of Montreal have signed this letter: Nicole Leduc, Régis Blais, François Champagne, François-Pierre Dussault, Lambert Farand, Marie-Josée Fleury, Mireille Goetghebeur, Mira Johri, Lise Lamothe, Nicole Leduc, David Levine, Michèle Pelletier, Louise Rousseau, Claude Sicotte, José Carlos Suarez Herrera.
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La réforme Barrette ne tient pas la route Par Paul Lamarche, Réjean Hébert et François Béland Le projet de loi 10 vise à améliorer l’accès et la qualité des services de santé et des services sociaux tout en diminuant la bureaucratie dans un souci d’efficience. Pour ce faire, le projet de loi fusionne tous les établissements publics de la santé et des services sociaux d’une région en un Centre intégré de santé et de services sociaux (CISSS), à l’exception de Montréal où il en prévoit cinq. Bien que nous, professeurs du département d’administration de la santé de l’École de santé publique de l’Université de Montréal soyons d’accord avec les objectifs de la réforme, nous remettons sérieusement en question l’efficacité de la réforme proposée à atteindre ses objectifs. Les preuves scientifiques révèlent que les fusions d’établissements ne génèrent pas les économies de coûts escomptés, ne réduisent pas la bureaucratie et n’améliorent pas l’intégration des services et leur accessibilité. Et la centralisation résultant de cette réforme ne permettra pas d’atteindre ses objectifs et aura des effets pervers importants. Les fusions et les coûts : plus gros n’est pas meilleur ni moins cher Le débat entourant la taille optimale des établissements de santé date de plusieurs décennies. Il fut à son apogée au cours des années 1980 aux États-Unis et en GrandeBretagne. Les expériences concluent qu’il n’y a pas d’économies de coûts en augmentant la taille des hôpitaux des soins aigus au-delà de 200 lits. Les hôpitaux de plus de 600 lits affichent même des coûts plus élevés que ceux des hôpitaux de plus petites tailles. Elles notent aussi des effets inattendus et négatifs sur la prestation de services, notamment des retards dans leur développement et leur amélioration des services. Il est d’ailleurs intéressant de noter qu’une conférence nationale s’est tenue en 2001 aux États-Unis sur : « L’échec des fusions ». Plusieurs études tant en Angleterre qu’aux États-Unis et au Québec se sont penchées explicitement sur les effets associés à l’intégration d’établissements de santé de missions différentes. Elles révèlent des effets très positifs de l’intégration des soins mais ils sont obtenus via des ententes entre organisations autonomes et pas par leur fusion. Des ententes entre établissements autonomes pour le partage de la prestation de services et la mise en place de corridors de soins procurent de bien meilleurs résultats que les fusions. Moins de bureaucratie : pas sûr? On peut se demander : y a-t-il trop de bureaucrates? Difficile de répondre à cette question. À défaut, on peut observer l’évolution du poids des dépenses d’administration dans les dépenses gouvernementales de santé au Québec au cours des dernières années et la comparer à celle des autres provinces. Au Québec, selon les données de l’Institut canadien d’information sur la santé, le poids des dépenses des administrations générales dans les dépenses de santé décroît depuis 94
1975. De 4,0% durant les années 1970, elles se réduisent à 1,3% en 2011, pour augmenter à 1,6% en 2014. Les dépenses administratives générales des provinces suivent la même tendance, moins accentuée : de 2,6% en 1975, elles se réduisent à 1,1% en 2014. En fait, ces dépenses sont plus importantes au Québec qu’au Canada de 1975 à 2004. De 2005 jusqu’en 2007, le Québec rejoint le Canada, pour s’en éloigner de nouveau. Les dépenses d’administration générale du Québec se rapprochent de celles de l’ensemble des provinces canadiennes après la réforme Couillard de 2003 au moment où le rôle des régions se renforce. Par ailleurs, l’augmentation entre 2011 et 2014 du poids des dépenses administratives générales dans le réseau québécois ne s’est pas accompagnée d’une poussée de la régionalisation. Dans ce contexte, difficile d’associer à la régionalisation un accroissement ou une diminution des dépenses administratives. Il est tout aussi difficile de penser que l’abolition des Agences régionales amènera une réduction de ces dépenses. Il faut plutôt s’attendre à un déplacement de « bureaucrates » et leur éloignement des lieux de dispensation de soins et de services à la population. Cela ne peut les mener qu’à détourner leur attention de la prestation des soins pour les concentrer sur les aspects politiques et bureaucratiques de la mission de gestion du réseau. La centralisation n’est pas gage d’efficience dans un système de santé public. Les données scientifiques démontrent qu’un système décentralisé rapproche le centre de décision de la population et permet aux services de santé de s’adapter aux besoins des populations, notamment les groupes défavorisés ou les communautés rurales ou situées plus en périphérie. Contrairement à l’entreprise qui vise la production d’un service uniforme et standardisé à meilleur coût, le réseau de santé et de services sociaux doit moduler ses services pour s’ajuster aux besoins de la population desservie. La disparition des établissements locaux prévue dans le projet de loi risque d’uniformiser les services sur le territoire régional, diminuant ainsi l’accès des populations plus marginales et accentuant les inégalités de santé. De plus, la création des mégastructures régionales entraînera une perte importante de l’identité linguistique, ethnoculturelle ou communautaire des établissements. En plus de priver ces communautés d’une structure essentielle à leur épanouissement, cette perte d’identité a été maintes fois démontrée comme facteur de démotivation des cadres, du personnel et des professionnels des institutions. Une telle démotivation est un obstacle important à la performance et à l’efficacité des organisations. Enfin, la centralisation va à l’encontre de l’occupation du territoire et de la vitalité des zones rurales ou périphériques. Dans ces secteurs, les établissements de santé sont souvent un moteur économique et un employeur importants. La réforme proposée aura un effet centripète qui attirera les leaders locaux vers les centres de décisions régionaux. L’amalgame des accréditations syndicales produira le même effet par l’attraction du personnel vers la ville centre, accentuant d’autant la dévitalisation des zones périphériques et les pénuries de personnel dans ces secteurs.
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En définitive, les preuves scientifiques existantes ne supportent pas la prétention du projet de loi 10 concernant les fusions des établissements, la diminution de la bureaucratie et la centralisation des décisions. Les expériences nationales et internationales ont maintes fois démontré que la réforme proposée n’aura pas les effets escomptés, bien au contraire. Nous devrions apprendre de ces expériences et améliorer nos processus au lieu de centraliser les structures. Mais l’homme est le seul animal à trébucher plusieurs fois sur la même pierre… Ont signé cette lettre les professeurs suivants du Département d’administration de la santé de l’École de santé publique de l’Université de Montréal : Nicole Leduc, Régis Blais, François Champagne, François-Pierre Dussault, Lambert Farand, Marie-Josée Fleury, Mireille Goetghebeur, Mira Johri, Lise Lamothe, Nicole Leduc, David Levine, Michèle Pelletier, Louise Rousseau, Claude Sicotte, José Carlos Suarez Herrera. François Béland is an expert advisor with EvidencNetwork.ca and Associate Professor at l’École de santé publique at the Université de Montréal.
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Why a new Health Accord needs to include better planning for health human resources By Ivy Lynn Bourgeault There is growing talk of a new Health Accord between the federal government and the provinces and territories. This is such good news — great news, in fact. If I were asked to have one thing on the agenda, it would be for an explicit conversation about the merits of having a dedicated health workforce agency in Canada — like pretty much every country has already, except Canada. Why a health workforce agency? First, let’s establish that the way we all experience our health system is through its people, our health workers. When we are waiting for care, that care is delivered by someone, a health worker, or more often, a group of health workers, each offering their skills and expertise. The health care “system” is largely its people. In simple economic terms, the health workforce makes up the bulk of the costs of our system – from doctors’ fees to nurses’ salaries, from personal support workers in long-term care centres to dieticians in the community. Which is why it is surprising that we put so few resources into the planning of how the people that make up our health system can best work, and best work together, to better meet the needs of patients and the population more broadly. Why do we not dedicate even a fraction of what we put into actually paying our health workers for their services into coordinated planning for those services? Let’s not forget that for many of our health workers in Canada, the tax payer also provides public funding for their education. But then, too often when the newly minted health professionals are ready to work, only those who have private health insurance have access to their services. It may be surprising to the public, as it was to me, to find out how little Canadian governments plan for the number and type of health worker we need now and in the future – from the medical specialists for an aging population with multiple chronic conditions, to the number of physiotherapists, occupational therapists and personal support workers to enable older adults to remain independent in their own homes. You might also be dismayed, as I am, at the tiny fraction of the one billion dollars a year in health research that goes toward better understanding our most valuable resource — its people, or what we call health human resources. But here’s the kicker: pretty much every country in the world has an agency or organization dedicated to knowing as much as it can about their health workforce so they are best able to meet the needs of patients and the broader population. Rich countries and poor countries alike have these organizations. Such agencies are especially critical for poor countries because they have to make the most out of the few health workers they have. 97
Canada, it seems, can afford to get it wrong, over and over again. It must be acknowledged that Canada does have a number of organizations that undertake a small part of the job of a health human resources agency, but it is far from a coordinated and sustained effort. For example, we have had three Task Forces in the past 20 years dedicated to the physician workforce, yet we are still plagued with problems of some highly trained surgical specialists finding it difficult to find operating room time; we have many Canadians going abroad for medical training; and we still have many communities going without family physicians. We don’t just need another short term task force to manage health worker supply. We need effective management of our entire health workforce on an ongoing basis. The issue with health human resources is not a problem of not enough – it’s not simply a supply problem, in other words. There are issues with how our existing health workforce is best utilized. Some of that is a distribution problem – getting the right kind of health workers to the right places to treat the people who can most benefit from their skills. There are also issues with how we can better enable health workers to work with each other and better address the increasingly complex health issues our population faces. Finding the best evidence to support the best approaches to more equitable and efficient utilizing of our whole health workforce is what a Canadian health workforce agency could examine. So, when the various stakeholders gather together to discuss what should go into a new Health Accord, I hope this time that the health workforce is front and centre. Ivy Lynn Bourgeault is an expert advisor with EvidenceNetwork.ca, a Professor in the Telfer School of Management and the CIHR Chair in Gender, Work and Health Human Resources at the University of Ottawa.
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Tout nouvel Accord sur la santé devrait prévoir un mécanisme de planification des ressources humaines Par Ivy Lynn Bourgeault On parle de plus en plus de renouveler l’Accord sur la santé entre le gouvernement fédéral, les provinces et les territoires. Quelle bonne nouvelle! Excellente, même. Si on me demandait de choisir une seule et unique question à inscrire à l’ordre du jour, j’opterais pour une discussion ouverte sur l’utilité d’instaurer une agence de planification de la main-d’œuvre en santé, comme on en trouve pratiquement dans tous les pays à l’exception du Canada. Pourquoi une agence de planification de la main-d’œuvre? Tout d’abord, il faut reconnaître que l’expérience que nous avons du système de soins passe d’abord et avant tout par ses principaux acteurs, c’est-à-dire nos travailleurs et travailleuses de la santé. Les soins que nous recevons nous sont prodigués par une personne en chair et en os, c’est-à-dire un intervenant ou, le plus souvent, une équipe d’intervenants qui possèdent chacun une expertise et des compétences particulières. Ces personnes « sont » le système de santé, pour une grande partie. En termes économiques simples, elles représentent l’essentiel des coûts qui lui sont associés : ils vont des honoraires des médecins aux salaires que l’on paie aux infirmières, aux préposés dans les centres de soins de longue durée et aux diététistes qui travaillent dans la communauté. On ne peut que s’étonner, dans ce cas, du peu de ressources investies dans la planification du travail, alors que ce serait un moyen de coordonner le mieux possible les activités des personnes qui constituent le système de santé et, ainsi, répondre de façon optimale aux besoins des patients et de la population en général. Nous ne consacrons même pas une fraction des sommes dédiées à la rémunération du personnel à la coordination des services dispensés par ses membres. Pourquoi? Au Canada, ne l’oublions pas, c’est l’argent des contribuables qui sert à payer, par le biais des fonds publics, la formation des prestataires de soins. Pourtant, il arrive trop souvent que les seules personnes capables de se prévaloir des services des professionnels fraîchement diplômés soient celles qui bénéficient d’une assurance privée. Les membres du public seraient surpris de constater, tout comme je l’ai été, le peu d’attention accordée par nos gouvernements à la planification de la main-d’œuvre requise à court et à long terme en santé, tant en matière de nombre que de composition. Pour donner un exemple, il faudrait pouvoir anticiper le nombre de spécialistes du vieillissement capables de prendre en charge des patients souffrant de maladies chroniques multiples. Ou encore, le nombre de physiothérapeutes, d’ergothérapeutes ou de préposés nécessaires pour préserver l’autonomie des personnes âgées dans le cadre de leur propre foyer.
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Tout comme moi, vous serez peut-être consterné d’apprendre qu’une infime portion seulement du milliard de dollars dépensé chaque année en recherche sur la santé est accordée à l’étude de notre atout le plus précieux dans ce secteur : ces personnes qu’on désigne sous le vocable de ressources humaines. Le plus surprenant, toutefois, c’est de se rendre compte qu’une grande majorité de pays, riches et pauvres, possèdent un organisme chargé de tout savoir sur les effectifs afin de répondre le mieux possible aux besoins des patients et de la population. Ce genre de structure joue un rôle particulièrement important dans les pays pauvres, où il faut en faire un maximum avec le peu de ressources humaines dont on dispose. Le Canada, apparemment, a les moyens de faire fausse route, encore et encore. Il faut admettre que nous disposons d’un certain nombre d’organismes qui remplissent une petite partie de ce rôle, mais on ne peut pas parler d’un effort coordonné et soutenu. Depuis vingt ans, nous avons tenu trois groupes de travail sur nos besoins en matière de médecins. Or des chirurgiens hautement spécialisés ne parviennent toujours pas à obtenir du temps en salle d’opération; bon nombre de personnes vont à l’étranger pour se former comme médecins; et nombreuses sont les localités qui ne comptent aucun médecin de famille. Pour gérer adéquatement l’offre en matière de main-d’œuvre, ce n’est pas d’un énième groupe de travail dont nous avons besoin. Il nous faut plutôt une structure qui s’occupera de la gestion efficace et continue de l’ensemble des effectifs. Le problème, ce n’est pas le manque de ressources humaines; autrement dit, ce n’est pas une question d’offre. Il s’agit plutôt de savoir comment s’y prendre pour bien tirer profit des effectifs à notre disposition. Il y a notamment le problème de la répartition : affecter les bonnes personnes au bon endroit, pour faire en sorte que leurs compétences soient utiles aux patients qui en ont le plus besoin. Il y a aussi celui de la coordination, à savoir réfléchir à des modes de collaboration entre professionnels qui nous aideront à affronter les questions de santé de plus en plus complexes qui se poseront à l’avenir. Une agence de planification de la main-d’œuvre en santé pourrait s’appuyer sur des données probantes pour déterminer quelles sont les meilleures approches en matière d’utilisation équitable et efficace des effectifs dans l’ensemble du système de santé. Bref, lorsque les différents interlocuteurs se réuniront pour discuter de ce qu’il faut inclure dans une nouvelle entente sur la santé, j’espère que cette fois-ci, la question de la main-d’œuvre sera au cœur des priorités. Ivy Lynn Bourgeault est experte-conseil auprès du site EvidenceNetwork.ca, professeure à l’École de gestion Telfer et titulaire d’une Chaire de recherche des IRSC sur le genre, le travail et les ressources humaines en santé à l’Université d’Ottawa.
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BC election represents crossroads for the future of medicine in Canada By Vanessa Brcic and Ryan Meili Normally provincial medical association elections are not national news. The one vote difference between first and second place in the race for president of the Doctors of BC – later declared a tie after a recount – might be enough to grab people’s attention. The real story here is what’s at stake, symbolically and practically, for the future of medical practice and Canadian health care as a whole. In the runoff vote ending this week on June 18th, the physicians of British Columbia need to do more than elect a new president; they must also decide which values should guide the profession: individual profit or the public good. The polarizing figure that has brought attention to this race, and put into stark relief the choices before us as a nation, is Dr. Brian Day. Day is a fierce advocate for greater private enterprise in Canadian health care. He has launched a slick “Vision 2020” campaign with an emphasis on increasing privately-funded, for-profit health care. He claims that this will somehow improve the public system despite ample evidence to the contrary. According to a provincial audit, his controversial for-profit clinics appear to have unlawfully billed patients and MSP five hundred thousand dollars in just one 30 day audit period. Day’s response to the audit was to sue the government for the right to continue doing so. Under BC law, Day is allowed to un-enroll himself from medicare and charge patients privately for care provided outside of a hospital or community care facility. Despite this professional freedom, he is advocating instead for an all-payer system, in which doctors in dual practice would be allowed to treat patients who pay privately to jump the queue, and those who rely on the publicly-funded system. This court case will likely bleed into his presidency if he is elected, yet he denies any conflict of timing or interest. His opponent in the race is Dr. Alan Ruddiman, a rural family physician. Ruddiman has leadership experience in rural issues, medical professionalism and education, and believes that our health system has suffered due to a lack of federal and provincial leadership on health reform. His main message is that our health system needs strong leadership, which should unite rather than divide doctors. He believes that doctors have an unrealized potential to partner with patients, allied health professions and health authorities to make meaningful change happen, and has indicated a commitment to greater generational and gender equity within the Doctors of BC.
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This election poses a number of important questions for the medical profession. Will doctors stand up for their perceived right to profit or for the system that cares for society’s most vulnerable? Will they vote with frustration and undermine the public system or will they unite to shape a better publicly-funded system that is equitable and accessible to all British Columbians? Perhaps most importantly, will they vote based on the evidence-based principles to which they are professionally obliged as physicians? There is a large body of evidence that indicates for-profit services are more costly and often lead to poorer quality care. Yet many physicians insist that population-level evidence is outside our scope of practice, and that our job is to look after individual patients, and perhaps our individual bank accounts. Is it truly outside our scope of practice to understand the evidence that more equitable societies benefit everyone, even the wealthiest among us – that lifting up the health and wealth of those living on the bottom rung of the economic ladder produces cost-savings and health benefits all the way up to the top rung of the ladder? Fifty percent or more of a population’s health is determined by the social and economic conditions in which people live – this is double the impact of health services, which is responsible for at most 25 percent of population health. Thus it is no surprise that the OECD’s commonwealth nations with high levels of income inequality are also the worst performing in this ranking: the US and Canada. Income inequality has grown in Canada as its health system performance ranking has declined. In BC, poverty costs us $8-9 billion annually, whereas eliminating poverty would cost us $3-4 billion. This is where real potential lies for us to improve health and the cost-effectiveness of our system. There is a growing recognition among physicians, young and old, of the responsibility of the profession to the population as a whole. This is accompanied by a greater interest in addressing the upstream factors that influence health outcomes. This election is an opportunity to choose between a socially accountable profession that improves health outcomes for all, and a self-interested profession that maximizes profit at the expense of quality, accessible and affordable health services. Vanessa Brcic is a family physician in Vancouver, board member of Canadian Doctors for Medicare, and Research Associate with the Canadian Centre for Policy Alternatives. Ryan Meili is an expert advisor with EvidenceNetwork.ca, a practicing family physician in Saskatoon and founder of Upstream: Institute for A Healthy Society and Vice-Chair of Canadian Doctors for Medicare.
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Dear Health Minister – please reinstate funding for Cochrane Canada Cochrane is a key global health care resource that needs Canada’s involvement By Tom Perry and Alan Cassels Imagine you’re our new Prime Minister, Justin Trudeau. Despite a grueling election campaign, you’re flush with energy and idealism in a country where “better is always possible.” One key priority is improving Canada’s prosperity but there are also many stated commitments to protect the environment, improve infrastructure and education and preserve our health care system. Now imagine you’re Canada’s new Minister of Health. Mr. Trudeau hands you a new list of priorities: improve the health of First Nations, develop a national seniors health strategy and advance the files related to dementia, diabetes, marijuana and assisted dying. Oh, and by the way, the provinces want bigger health budgets and there’s a clear call for a national Pharmacare plan. Clearly you’d want to approach these daunting challenges with the most reliable, comprehensive and unbiased information available instead of being swayed by the bestconnected lobbyists. Assuming you expect that healthy policies and costly health care programs should be based on the best evidence to determine which treatments or interventions are optimal, safest and best value, where would you turn? Since 1993, the internationally-acclaimed Cochrane Collaboration has been a key global resource comprised of some of the world’s leading health scientists, and supported by nearly 40,000 volunteers who systematize, sift and summarize health care evidence. Among the eminent founders of Cochrane was the (late) Dr. David Sackett of McMaster University, considered the godfather of evidence-based medicine (EBM). Like other leading medical scientists, Sackett felt compelled to stop medicine from operating in ignorance, and worked tirelessly to develop methods for assessing the evidence to enlighten health care and make it more successful. The first Cochrane review looked at whether it is helpful to give corticosteroids to a woman during premature labour, to help her baby’s lungs develop and prevent complications after birth. Some studies were positive; others not. Synthesizing all the evidence into a “systematic review” of seven trials of prenatal corticosteroids revealed what single studies could not. As Cochrane’s founder, Sir Iain Chalmers said of that systematic review, “We made the point that tens of thousands of babies had suffered and died unnecessarily (and cost health services more than they need have done) because information had not been assembled in a systematic review and meta-analysis to show the strength of the evidence.”
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There are now many Cochrane researchers preparing systematic reviews in a huge variety of areas, ranging from drugs and surgical treatments to nursing, physiotherapy and education. The Cochrane Library contains thousands of systematic reviews, painstakingly organizing evidence that helps patients, health professionals and policy makers make sound health care decisions. Over the years Canada has always pulled its weight in the Cochrane Collaboration, leading in such areas as hypertension, back pain, arthritis and child health. Our output has been momentous and in the last five years alone, Cochrane Canada has completed or updated more than 300 systematic reviews and trained nearly 3,000 people in review methods. The cost? A mere $2 million per year, within the range of a rounding error in the overall budget of the Canadian Institutes for Health Research (CIHR) which has funded Cochrane Canada for the last decade. That’s why it was such a surprise to hear that the CIHR terminated Cochrane Canada’s funding in September of this year. It was yet another blow to scientific research in what has been recognized internationally as a dark decade for scientific independence in Canada. Internationally, Cochrane Collaborations have always depended on national governments around the world, including branches in the UK, US, Australia, Denmark and dozens of other countries that recognize the value of independent, unbiased research synthesis. Cochrane reviews supply vital, independent information for patients, doctors and health policymakers around the world and Canada needs to be at the table preparing those reviews. The Canadian Medical Association Journal recently called for Cochrane Canada’s base funding to be reinstated, knowing what a vital source this organization is for our doctors. We couldn’t agree more. It is essential for Canadian health science – but also for Canadian health governance. Once the new Health Minister is named, it would be a prudent first step to reinstate the funding for Cochrane Canada so that Cochrane can continue to provide the necessary base of quality, balanced and comprehensive evidence from which the new Minister, along with their provincial counterparts, will have to weigh so many future decisions. It would be a shame to pull Canadian health scientists from the global stage now in what’s been promised as an era of real change. The repercussions would affect us all. Dr. Tom Perry is a medical specialist at UBC in Vancouver, and a former Minister of Advanced Education, Training and Technology in B.C. Alan Cassels is an expert advisor with EvidenceNetwork.ca and a pharmaceutical policy researcher at the University of Victoria. He is the author of the new book, The Cochrane Collaboration: Medicine’s Best Kept Secret.
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Rétablissez le financement de Cochrane Canada, madame la ministre Le Canada ne peut se passer de cette ressource indispensable Par Tom Perry et Alan Cassels Imaginez, madame, que vous êtes dans la peau de notre premier ministre Justin Trudeau. Malgré une campagne électorale éreintante, vous débordez d’énergie et d’idéalisme, dans un pays où il est « toujours possible de faire mieux ». Accroître la prospérité constitue l’une des grandes priorités, mais les engagements sont nombreux : protéger l’environnement, améliorer l’infrastructure et l’éducation, sauvegarder le système de santé. Imaginez maintenant que vous venez d’accéder au poste de ministre fédéral de la Santé. M. Trudeau vous remet une nouvelle liste de priorités : améliorer la santé des Premières nations; élaborer une stratégie nationale sur la santé des aînés; faire avancer les dossiers touchant la démence, le diabète, la marijuana et l’aide médicale à mourir. Ah! Et il ne faudrait pas oublier non plus que les provinces réclament de plus gros budgets en matière de santé et la population, un programme d’assurance-médicaments. Nul doute, vous voudrez disposer, pour relever tous ces défis, de l’information la plus fiable, complète et objective possible, plutôt que de vous laisser influencer par des lobbyistes qui ont le bras long. En supposant que vous êtes persuadée qu’il faut s’appuyer, pour adopter des politiques saines et instaurer des programmes coûteux, sur les meilleures données probantes qui soient, afin de déterminer quels sont les traitements ou les interventions les plus utiles, les plus sûrs et les plus efficients, vers quelle source vous tourneriez-vous pour les obtenir? Depuis 1993, nous pouvons compter sur un organisme de renommée internationale, qui réunit certains des plus grands scientifiques au monde et quelque 40 000 bénévoles qui s’emploient à systématiser, à passer au crible et à synthétiser des données en matière de santé. Il s’agit de la Collaboration Cochrane. Parmi ses éminents fondateurs figure le Dr David Sackett de l’Université McMaster, aujourd’hui décédé, que l’on considère aujourd’hui comme le parrain de la médecine fondée sur les données probantes. Comme d’autres chercheurs scientifiques réputés, le Dr Sackett a vu la nécessité de cesser d’exercer la médecine à l’aveuglette; il s’est employé inlassablement à élaborer des méthodes d’évaluation scientifique afin d’éclairer la pratique médicale et l’améliorer. La toute première étude Cochrane portait sur l’utilité d’administrer, pour favoriser le développement des poumons du bébé et prévenir les complications après la naissance, des corticostéroïdes aux femmes qui entrent en travail prématuré. Certaines études étaient concluantes, d’autres pas. Un examen systématique des données obtenues dans le cadre de sept essais cliniques sur les corticostéroïdes prénatals avait permis d’arriver à une conclusion qu’une seule étude n’aurait pu tirer. Comme l’a affirmé Sir Iain Chalmers, lui aussi fondateur de la Collaboration Cochrane : « Nous avons démontré que des dizaines de milliers de nourrissons avaient souffert et étaient morts inutilement (et que cela avait 105
coûté beaucoup plus cher que nécessaire aux services de santé), les données recueillies jusque-là n’ayant jamais fait l’objet d’une revue systématique et d’une méta-analyse aussi révélatrices. » Aujourd’hui, la Collaboration Cochrane compte un grand nombre de scientifiques qui préparent des examens systématiques dans un vaste éventail de domaines, allant des produits pharmaceutiques et des traitements chirurgicaux aux interventions en soins infirmiers, en physiothérapie et en éducation. La Bibliothèque Cochrane réunit des milliers d’examens systématiques et organise méticuleusement les données de façon à permettre aux patients, aux professionnels de la santé et aux décisionnaires de prendre des décisions judicieuses en matière de santé. Au fil des ans, le Canada a toujours appuyé Cochrane Canada, qui s’est démarqué notamment dans des domaines comme l’hypertension, les douleurs lombaires, l’arthrite et la santé de l’enfant. Son travail a une portée considérable : depuis cinq ans seulement, l’organisme a réalisé ou actualisé plus de 300 revues systématiques et formé près de 3 000 personnes à ses méthodes d’examen. Même s’ils ne représentent que 5 % de la population mondiale, 10 % des auteurs affiliés à la Collaboration Cochrane sont Canadiens. Le coût? Un modeste deux millions de dollars par an, soit en deçà d’une erreur d’arrondi dans le budget global des Instituts de recherche en santé du Canada (IRSC), qui finançait l’initiative depuis dix ans. D’où l’énorme surprise causée par l’annonce, en septembre 2015, du retrait de la subvention accordée à Cochrane Canada par les IRSC. Voilà un autre coup bas porté à la recherche au terme d’une décennie considérée internationalement comme bien sombre pour l’indépendance scientifique dans notre pays. Partout ailleurs, les Collaboration Cochrane au Royaume-Uni, aux États-Unis, en Australie, au Danemark et dans des dizaines d’autres pays ont toujours compté sur les gouvernements nationaux, car ces derniers ont reconnu la valeur des synthèses scientifiques indépendantes et objectives. La Collaboration Cochrane fournit aux patients, aux médecins et aux décisionnaires partout dans le monde une information indépendante et essentielle. Il est indispensable que le Canada continue d’en faire partie. Récemment, le Journal de l’Association médicale canadienne a réclamé qu’on rétablisse le financement des activités de base de Cochrane Canada, rappelant qu’il s’agit d’une source de renseignements incontournable pour nos médecins. Nous sommes parfaitement d’accord. Elle est essentielle non seulement pour la recherche, mais aussi pour la gouvernance en matière de santé. En rétablissant le financement de Cochrane Canada, la nouvelle ministre de la Santé ferait preuve de prudence. Elle et ses homologues provinciaux pourraient continuer à compter sur des données fiables, équilibrées et exhaustives pour soupeser les nombreuses décisions qui les attendent. Ce serait une honte d’écarter les scientifiques canadiens de la scène alors qu’on nous a fait miroiter une ère de véritable changement. Nous en subirions tous et toutes les répercussions. 106
Le Dr Tom Perry est médecin spécialiste à l’Université de la Colombie-Britannique à Vancouver. Il a été ministre de l’Enseignement supérieur, de la Formation et de la Technologie de cette province. Alan Cassels est expert-conseil auprès du site EvidenceNetwork.ca et chercheur en politiques sur les produits pharmaceutiques à l’Université de Victoria. Il est l’auteur d’un nouvel ouvrage intitulé The Cochrane Collaboration : Medicine’s Best Kept Secret, qui sera traduit et publié dans le courant de l’année aux Presses de l’Université Laval.
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Four things you should know about the pending Charter challenge against medicare By Colleen M. Flood and Kathleen O’Grady A long-running dispute between Dr. Brian Day, the co-owner of Cambie Surgeries Corporation and the British Columbia government may finally be resolved in the BC Supreme Court this year – and the ruling could transform the Canadian health system from coast to coast. The case emerged in response to an audit of Cambie Surgeries, a private for-profit corporation by the BC Medical Services Commission. The audit found from a sample of Cambie’s billing that it (and another private clinic) had illegally charged patients hundreds of thousands of dollars more for health services covered by medicare than is permitted by law. Dr. Day and Cambie Surgeries claim that the law preventing a doctor charging patients more is unconstitutional. Dr. Day’s challenge builds on the legacy of a 2005 decision by the Supreme Court of Canada overturning a Quebec ban on private health insurance for medically necessary care. But this case goes much further, not only challenging the ban on private health insurance to cover medically necessary care, but also the limits on extra-billing and the prohibition against doctors working for both the public and private health systems at the same time. A trial date was set to begin in 2012, but was adjourned until March 2015 so that the parties could resolve their dispute out of court and reach a settlement. It now appears such a resolution has not been reached and the court proceedings resume on 11 May. Here’s why this case matters. 1. Legal precedent: Whatever way the case is decided at trial, it is likely to be appealed and eventually reviewed by the Supreme Court. A decision from this level will mean all provincial and territorial governments will have to revisit equivalent laws. The foundational pillars of Canadian medicare — equitable access and preventing two-tier care — could well be vanquished in the process. 2. Wait times: Dr. Day will argue that Canada performs poorly on wait times compared to other countries, and that other countries allow two-tier care; thus, if Canada is allowed two-tier care, our wait times would improve. But this approach is too simplistic. Common comparisons to the English health system, for example, fail to recall that despite having two-tiers, they have in the past suffered horrendously long-wait times. Recent efforts to tackle wait times have come from within the public system, with initiatives like wait time guarantees and tying payment for public officials to wait times targets. 108
By looking to England we are not measuring like to like but apples to oranges. English doctors are generally full-time salaried employees while most Canadian physicians bill medicare on a fee-for-service basis. Consequently, the repercussions for permitting extra billing in Canada could eviscerate our publicly funded system, whereas this is not the case in England. Imagine if most doctors in Canada could bill, as those at the Cambie clinic have done, whatever they want in addition to what they are paid by governments? 3. Conflict-of-interest incentives: Evidence suggests there is a danger in providing a perverse incentive for physicians who are permitted to work in both public and private health systems at the same time. Wait times may grow for patients left in the public system as specialists drive traffic to their more lucrative private practice. Sound improbable? Academic studies have noted this trend in specific clinics that permit simultaneous private-public practice. And recent UK news reports have profiled a case where a surgeon bumped a public patient in need of a transplant for his private-pay patient. 4. Competition: Proponents of privatized health services often claim that it would add a healthy dose of competition, jolting the “monopoly” of public health care from its apathy. But free markets don’t work well in health care. Why? Because public providers and private providers won’t truly compete if the laws Dr. Day challenges are struck down. Instead, those with means and/or private insurance will buy their way to the front of queues. Public coverage for the poor will likely suffer, as is clearly evident in the U.S., with many doctors refusing to provide care to medicaid (low-income) patients in preference for those covered by higherpaying private insurance. Of course, this is all based on an outcome that is not yet known. It may be that the Charter challenge in BC is unsuccessful but clearly the stakes for ordinary Canadians are very high. Sadly Dr. Day is not bringing a challenge for all Canadian. Isn’t it long past time our governments and our doctors work to ensure all Canadians – and not just those who can afford to pay – receive timely care?
Colleen M. Flood is Professor and University Research Chair in Health Law & Policy at the University of Ottawa and an expert advisor with EvidenceNetwork.ca. Kathleen O’Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University and Managing Editor of EvidenceNetwork.ca. See also our Podcast on the issue: A Supreme Court case that could change the face of the Canadian health care system
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Four things we can do to improve health care in Canada What’s next for primary care? By Joshua Tepper Health care is the purview of the provinces in Canada, but health leadership – setting big picture goals, helping achieve best practices across the country and providing long-term, sustainable funding models – is the role of the federal government. As the federal election campaign wages, Canadians should be pressing federal political parties to take a leadership position on the health care file. Primary care, in particular, could benefit from increased national dialogue. If we want to improve health care in Canada, primary care is a good place to start. Evidence shows that the best health care systems in the world are founded on a strong primary care system – practices of family doctors, nurse practitioners and others who serve as the first (and ongoing) point of contact for patients. Canada has been a world leader in many aspects of primary care for a long time, and the last 10 or 15 years have seen some important changes – mostly for the better. There are more primary care providers than ever before, they are increasingly working in multi-disciplinary teams and more of them use electronic medical records — all factors which are linked to better outcomes for patients. Not long ago, millions of Canadians said they didn’t have a family doctor. Now in places like Ontario, as many as 94 percent of residents report having a primary care provider. While there is still more progress to be made on even this basic measure of access, there are several other ways we can and should improve primary care in Canada. 1. Timely access It is not enough to have a family doctor, you need to be able to see this individual promptly when you are sick. In Canada, only 38 percent of people report being able to see their primary care provider the same day or next day when they call. France, Australia and the United Kingdom all report 50 percent or higher rates, and countries such as Germany, New Zealand and Switzerland hover around 70 percent. Improving prompt access is critical to achieving continuity of care while reducing the number of people relying on walk-in clinics and emergency departments. 2. Doctors need to serve communities We need to move primary care to a population based model — this means a fundamental rethink of how primary care is organized. Perhaps the easiest analogy is public primary and secondary education. When you move to a new community, registering your children in the local public school is as easy as knowing your address and catchment area. The schools don’t have the choice of picking their students or saying they are ‘too full.’ Moving to a population based model of primary care will require a new level of planning and coordination – but it’s doable. We already have examples in several rural communities in Canada, and Community Health Centres in some regions also provide a 110
good model. Entire countries, like the United Kingdom, have already achieved this. It should be as easy to find a primary care provider as it is the local public school. 3. A commitment to equity and improving the quality of care We need to adopt a relentless commitment to improving quality in primary care. Canadian hospitals already have a couple decades of experience in building the skills, structures and programs to improve care —primary care can build on some of this success. There are six widely accepted domains of quality — all of them relevant to primary care: safety, timeliness (access), efficiency, patient centeredness, effectiveness, and, importantly, equity. In Canada, one of our great strengths is the richness of diversity represented across people and geography. It is critical that primary care, the gatekeeper and cornerstone to our health system, treat people equitably. It should not matter where you live, what language you speak, nor your age, sex, sexual identity or cultural background. 4. Integrate primary care into the rest of the health system Canada often ranks near the bottom of a dozen Commonwealth countries in patients’ experiences of an integrated health care system, including the timely availability of information across provider teams. It is about more than just getting hospital, lab and primary care computer systems connected (although this is a critical part), we need a fundamental redesign from sectors to systems while continuing to strengthen the foundational role of primary care. Patients don’t experience their health care as discrete parts, so it shouldn’t function that way. The responsibility for this change is spread across all parts of the health care system and a wide range of health care providers. While acknowledging that primary care looks different across Canada — varying payment models and structures according to the province or territory you live in — these four goals can be a unifying vision for the next, necessary evolution in health care. Joshua Tepper is an advisor with EvidenceNetwork.ca, a family physician at St. Michael’s Hospital and Associate Professor at the University of Toronto.
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Federal government moves to strip power from top public health scientist Demoting Chief Public Health Officer more about politics than promoting health By Colleen M. Flood and Steven J. Hoffman Buried in the current omnibus budget bill being studied by Parliament this week is a plan to demote the Chief Public Health Officer of Canada. He will no longer hold a deputy minister rank, he will have no direct line to the federal minister of health, he will be subservient to a bureaucratic agency president and he will have no secure public funding. The new Chief Public Health Officer has said he is in favour of this plan, as shrugging off managerial oversight for the Public Health Agency will free him to provide scientific advice. That may be so, but will anybody be listening? Will he even be allowed to speak? We seem to have forgotten the harsh lessons of SARS. It was just 11 years ago when the World Health Organization slapped Toronto with a travel advisory, costing the city $2 billion and 28,000 jobs. This was not because of the number of SARS cases (similar in number to Singapore, which had no such advisory) but because Ottawa did not have a public health leader who could effectively coordinate with the provinces and communicate the outbreak’s status to other countries. SARS shone a light on the enormous hurdles that Canada’s version of federalism – with provinces largely in charge of their own health dollars and direction – poses to effective country-wide pandemic responses. Significant change was needed and proposed, including the establishment of the Chief Public Health Officer and the Public Health Agency of Canada. The idea was that new structures and an empowered Chief Public Health Officer could forge a new vision for Canadian public health, ensuring collaboration and cooperation across provinces and territories. The key was building trust: provinces and their public health departments needed a guarantee that the federal government’s public health pronouncements were based on scientific principles rather than political talking points. Despite reforms, results have been patchy. Auditor General reports year over year have raised concerns that we have not yet achieved satisfactory progress on many measures, including information sharing across the country. Interestingly, it is the Auditor General who has shone a light on these concerns and not the Chief Public Health Officer. Why is that the case? Science has never actually been allowed to trump government politicking; the Chief Public Health Officer was made an officer of government instead of an officer of Parliament, thereby preventing him from exercising full independence like our Auditor 112
General, the Official Languages Commissioner and the Privacy Commissioner. That was a mistake. But at least he was given some independent powers to speak to Canadians and a mandate to engage in public activities and citizen dialogue. Even these limited powers, unfortunately, are slated for removal in the proposed legislation. Demotion and politicization of the Chief Public Health Officer is a wrong-headed move. It seems to be linked more to the public gagging of our government scientists than about promoting health or the public good. With an Ebola outbreak raging in West Africa, this is not the right time to be weakening our national public health infrastructure. This change makes us far less prepared for Ebola and other diseases like it. More than likely the omnibus budget bill will go ahead and we will be left to regret its folly in the wake of another harsh public health lesson – which may play out on the international stage, as in the case of SARS. After some hand-wringing – and undoubtedly several Commissions and reports – we will return to this inevitable conclusion: the Chief Public Health Officer of Canada needs to be independent of federal and provincial governments. Someone needs to speak public health truth to power on behalf of all Canadians. We are all less safe without it. Colleen M. Flood is a Professor of Law at the University of Ottawa and an expert advisor with EvidenceNetwork.ca. Steven J. Hoffman is an Assistant Professor of Law and Director of the Global Strategy Lab at the University of Ottawa and a Visiting Assistant Professor of Global Health at Harvard University.
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Le gouvernement fédéral s’apprête à dépouiller de ses pouvoirs l’administrateur en chef de la santé publique Une décision où la politique l’emporte sur la promotion de la santé Par Collen M. Flood et Steve J. Hoffman Le projet de loi omnibus à l’étude cette semaine au Parlement recèle une modification ayant pour but de rétrograder l’administrateur en chef de la santé publique du Canada. Celui-ci n’aura plus le rang de sous-ministre; il ne relèvera plus directement du ministre de la Santé, mais sera désormais soumis à l’autorité du président d’une agence bureaucratique, sans disposer de financement stable. Le nouveau titulaire du poste a lui-même déclaré qu’il était favorable à ce changement, en expliquant que le fait d’être libéré de ses responsabilités comme administrateur général de l’Agence de la santé publique l’aidera à se concentrer sur son rôle de conseiller scientifique. Peut-être, mais est-ce que quelqu’un écoutera ce qu’il aura à dire? Et lui permettra-t-on seulement d’exprimer son point de vue? Apparemment, nous avons oublié les dures leçons du SRAS. Seulement 11 ans se sont écoulés depuis le jour où l’OMS a flanqué à la ville de Toronto un avis aux voyageurs qui lui a coûté deux milliards de dollars et 28 000 emplois. Ce n’était pas le nombre de cas qui était en cause (il était semblable à celui qu’affichait Singapour, qui n’a pas écopé d’une pareille mesure), mais plutôt le fait qu’Ottawa ne disposait d’aucun responsable de la santé publique chargé de coordonner l’action au niveau fédéral et provincial et d’informer les autres pays sur l’évolution de la situation. À l’époque, le SRAS a mis en lumière les obstacles énormes que pose le fédéralisme canadien lorsque vient le temps de se mobiliser efficacement le pays en entier contre une pandémie (les provinces étant largement responsables des budgets et des orientations en matière de santé). Des changements importants s’imposaient. C’est ainsi qu’on a proposé de créer l’Agence de la santé publique, ainsi que le poste d’administrateur en chef. Ainsi, la nouvelle structure et les pouvoirs accordés à son responsable contribueraient à forger une vision renouvelée de la santé publique au Canada et à favoriser la collaboration et la coopération entre les provinces et les territoires. Pour parvenir à ce but, il fallait bâtir un climat de confiance : donner l’assurance aux provinces et à leurs services de santé publique que les déclarations du gouvernement fédéral en la matière seraient fondées sur des principes scientifiques plutôt que des considérations politiques. Malgré ces réformes, les résultats ont été inégaux. Année après année, les rapports du vérificateur général relèvent le manque de progrès notables sur de nombreux points, dont celui du partage d’information à l’échelle du pays. Fait intéressant à souligner, on doit ce
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constat au vérificateur général, plutôt qu’à l’administrateur en chef de la santé publique. Comment l’expliquer? La raison, c’est qu’on n’a jamais permis que la science ait préséance sur les politiques. L’administrateur en chef fut désigné à l’origine comme un agent du gouvernement plutôt qu’un agent du Parlement, ce qui l’empêche d’exercer sa charge en toute indépendance, contrairement au vérificateur général, au commissaire aux langues officielles ou au commissaire à la vie privée. Cette décision fut une erreur. À tout le moins, on lui a accordé quelques pouvoirs autonomes qui lui permettent de s’adresser à la population, ainsi que le mandat de participer à des activités publiques et au dialogue citoyen. Malheureusement, le projet de loi actuel va jusqu’à lui retirer ces maigres pouvoirs. En rétrogradant et en politisant cette fonction, nous faisons fausse route. Il s’agit d’une décision qui semble motivée davantage par la volonté de museler les scientifiques du secteur public que par le désir de promouvoir la santé et le bien commun. Compte tenu de l’épidémie d’Ebola qui sévit en Afrique de l’Ouest, il est malvenu d’affaiblir notre infrastructure nationale de santé publique. En effet, nous serons beaucoup moins prêts à affronter cette maladie et d’autres du même genre, le cas échéant. L’adoption du projet de loi omnibus semble plus que probable. Le jour où une autre impitoyable leçon de santé publique nous sera donnée — susceptible d’avoir une portée internationale, comme ce fut le cas pour le SRAS —, il ne nous restera plus qu’à regretter l’ineptie de cette décision. Après des grincements de dents et, sans aucun doute, plusieurs commissions et rapports d’enquête, nous reviendrons à cette conclusion incontournable : la fonction d’administrateur en chef de la santé publique du Canada doit être considérée comme une charge indépendante des gouvernements fédéral et provinciaux. Il nous faut quelqu’un qui puisse dire, au nom de la population, la vérité aux gens qui détiennent le pouvoir en matière de santé publique. Sinon, c’est notre sécurité qui s’en trouvera affaiblie. Colleen M. Flood est professeure de droit à l’Université d’Ottawa et experte-conseil auprès du site EvidenceNetwork.ca. Steven J. Hoffman est professeur adjoint et directeur du Laboratoire de stratégie mondiale à la Faculté de droit du même établissement, ainsi que professeur adjoint invité en santé mondiale à l’Université Harvard.
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Should eye exams be mandatory for school-age kids? Most Canadian children never have their eyes examined, yet one in six may have a vision problem By Elizabeth Lee-Ford Jones and Mélanie Meloche-Holubowski Currently only 14 percent of Canadian children under the age of six receive professional eye care. Since the measles outbreak in North America a few months ago, more school districts and provinces are considering mandatory immunization in order to attend school. Should eye examination be added to the list of school entry requirements? It’s been done elsewhere. Since 2004, all children in Massachusetts entering kindergarten must provide proof that they have undergone a vision screening within the last year. The government explains that school entry is the perfect “safety net” that ensures a proper start to academic life. Canada only has a partial safety net for eye care for kids at best. According to the Canadian Association of Optometrists (CAO), one in every six children may have a vision problem that makes it difficult to learn and read. For this reason, the CAO strongly recommends a comprehensive eye examination for every child before entering school. The medical journal, The Lancet, recently published a paper on whole population vision screening in children to detect amblyopia (lazy eye) and the authors recommend that screening of all children age four to five years at school entry “confers most benefit and addresses inequity in access to timely treatment.” So if professionals are so clear on the need, why aren’t kids getting eye exams in Canada? The CAO believes the costs associated with eyeglasses can be a barrier for many families — and many parents are simply unaware that eye examination for children is both recommended and free in most provinces (covered by the publicly funded health system). Some steps are underway to improve the situation. For example, Ontario has recently joined six other provinces in offering a program that is financed by both public and private purses. The Eye See...Eye Learn program provides no cost, comprehensive eye exams for kindergarten students, and importantly, offers a free pair of eye glasses if the child requires them — something that would normally cost parents around $250. Initiatives like the Eye See…Eye Learn program are a great step in the right direction, but it’s a half measure. Provinces are already partially funding this program, so why not take it a step further? Why not put in place a comprehensive eye health system so that children of all ages are systematically benefiting from vision care?
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We need health ministries to make sure that children who need glasses get them, and have access to professional eye care throughout their education trajectory. And maybe it is time to consider the requirement of documentation that a free eye exam has taken place before school entry. Children’s education at stake Vision problems have serious consequences for a child’s development; reading, writing, motor skills and behaviour can all be affected. Bottom line: early detection and timely treatment of eye conditions are effective and cost effective. Many parents and teachers have mistaken vision problems for behavioural issues or learning disabilities. But a child will not tell a parent if they cannot see properly (if they don’t know themselves). Systematically detecting vision issues in children will not only help them avoid unnecessary academic struggles, but it will also reduce the burden on schools, who must spend huge resources to help students who are falling behind. The Quebec Order of Optometrists says that 61 percent of Canadian parents are wrong when they believe they can detect their child’s visual problems without a professional. It may be highly instructive to know that high-IQ society Mensa’s youngest U.S. member is a two year-old girl who was originally misdiagnosed with “unspecified learning delays.” All she needed were glasses to correct her far-sightedness and amblyopia. Seeing through the costs Learning that your child needs glasses can be challenging for a parent with low-income. Philanthropic initiatives exist across the country to pay for the exorbitant cost of glasses; the Bonhomme à lunettes in Quebec, the Toronto Foundation for Student Success, the Vision Institute of Canada, for example, all provide a helping hand for vision care. But their capacity is often limited and families should not have to rely solely on the good will of such organizations in order to see. In the coming months, the CAO will meet with Members of Parliament and Senators in Ottawa in the hopes that early detection and treatment of eye and vision problems will become a public health priority. If Canada is serious about education – and serious about the health of Canadian children — it should move to make complete eye care part of the health care system. Elizabeth Lee-Ford Jones is an expert advisor with EvidenceNetwork.ca, and Professor of Paediatrics at The Hospital for Sick Children and the University of Toronto. Mélanie Meloche-Holubowski was the 2014 journalist intern at EvidenceNetwork.ca and is now the Podcast and Social Media Editor. She is also a journalist with Radio-Canada.
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Canadians want patient online health care options So what’s the hold up? By Jennifer Zelmer Eight in ten Canadian adults want online access to their own health information yet fewer than one in 10 currently have it, so says a new study published in Healthcare Papers. The gap is just as wide for other patient online services, such as booking appointments, evisits, or requesting prescription renewals or refills online; Canadians want them all, but most aren’t getting them. So, why not, when it seems we can do virtually everything else online these days? Take something as seemingly simple as e-visits. Email, even secure email, is a wellestablished technology that is used by millions of people every day. But offering secure e-visits for patients has proven to be complex. For example, where in-person visits are required by fee schedules, law, or professional practice guidelines, adoption is likely to be slower. In settings where e-visits become common, they tend to be recognized as a clinical service, often with dedicated time allocated to them. This means changes to workflow and practice patterns. Likewise, updates may be needed to professional practices, patient education, and privacy policies to ensure that e-visits are safe, effective and used appropriately. Canada is not without success stories, but they are in pockets, not yet widespread. For example, more than 360,000 British Columbians have signed up to access their lab results online. Thousands of patients at the Sunnybrook Health Sciences Centre in Toronto use the hospital’s MyChart system to access their records. And Nova Scotia’s personal health record demonstration project in Halifax was oversubscribed by both patients and clinicians. But Canadians want more, and so do providers. I can testify to some of the benefits of patient online services from personal experience. A few years ago I lived in Denmark where my ophthalmologist prescribed an antibiotic for an eye infection. Unfortunately, it didn’t work. When I called her office for follow up, I learned that she was away so I sent a secure email to my family doctor asking him to suggest an alternative. He replied less than an hour later. In that time, my doctor looked at my electronic health record, saw what his colleague had prescribed, and e-prescribed a different antibiotic that I could pick up at the local pharmacy. I don’t know how much this changed my long-term health outcome, but the speed and simplicity – plus the fact that I didn’t have to stumble blindly around the city trying to find a new doctor’s office – was priceless. There is, in fact, a growing consensus on the value of digital health solutions for consumers and we are starting to see some traction. For example, at this summer’s 118
General Council of the Canadian Medical Association, Canada’s doctors voted to support the creation and use of secure electronic communication between patients and health care providers. A number of provinces are also planning online portals for patients. But there is much work ahead. The Conference Board of Canada drew on survey data to estimate that if Canadians had had the option to consult with their physicians, access test results and request prescriptions renewals electronically, they could have avoided nearly 47 million inperson health care visits and saved almost 70 million hours in 2011. There is evidence that consumer health solutions can strengthen quality of care, patient outcomes, access to services, efficiency and equity. But achieving these benefits is not guaranteed. The right policy and regulatory environment needs to be in place. Implementation approaches need to take into account differences in patients served, care environments, the broader digital health infrastructure and approaches to realize anticipated benefits. The patient online services most in demand connect individuals with their health care teams. This means that they need to be user-centric, designed with patient safety and privacy in mind, integrated into clinicians’ workflows and workload, and made consistent with regulatory and legal frameworks. It will take thoughtful, well-aligned efforts to close the gap between desire for and availability of patient online services, making benefits widely available not just for a lucky few served by early adopters. Individuals and organizations will have to hold hands in a collective, collaborative effort, not something at which the health system always excels. But the strong and growing consensus on the importance of harnessing the power of digital solutions to improve health and health care suggests that progress is within reach. Jennifer Zelmer is an advisor with EvidenceNetwork.ca and Executive Vice President at Canada Health Infoway, a national not-for-profit organization charged with working with partners to accelerate the development, adoption and effective use of digital health across Canada.
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La population canadienne réclame des services de santé en ligne Pourquoi le processus est-il aussi long? Par Jennifer Zelmer Huit adultes sur dix au Canada aimeraient accéder à leur dossier médical en ligne, mais moins d’un dixième de la population qui peut le faire, selon une nouvelle étude publiée dans la revue Healthcare Papers. Le décalage est tout aussi grand dans le cas d’autres services en ligne comme la gestion des rendez-vous, les consultations médicales ou le renouvellement des ordonnances; la population aimerait s’en prévaloir, mais une majorité n’y a pas accès. Comment expliquer cette situation, alors qu’il semble qu’on peut pratiquement tout faire en ligne de nos jours? Prenons un service en apparence simple : les consultations en ligne. Le courrier électronique, voire le courriel sécurisé, est une technologie bien établie dont des millions de personnes se servent au quotidien. Malgré cela, proposer des consultations en ligne est une tâche qui s’avère complexe. Dans les cadres où le barème des honoraires, les lois ou les directives médicales exigent que le patient soit présent, l’adoption d’un service de ce genre risque d’être plus lent. Dans les milieux où il devient pratique courante, on tend à le considérer comme un service clinique et à aménager le temps de travail en conséquence. Cela implique qu’il faut modifier la séquence des tâches et les modes de prestation. Dans le même ordre d’idées, il faut aussi parfois adapter les méthodes professionnelles, l’éducation des patients et les lignes directrices de façon à ce que les consultations soient sécuritaires, efficaces et utilisées à bon escient. On compte bien quelques succès au Canada, mais ils sont circonscrits à certains secteurs. En Colombie-Britannique, par exemple, 360 000 personnes se sont inscrites à un service qui permet de consulter en ligne ses résultats de laboratoire. Au Sunnybrook Health Sciences Centre de Toronto, des milliers de patients accèdent à leur dossier médical grâce au système MyChart mis sur pied par l’établissement. En Nouvelle-Écosse, un projet pilote d’accès au dossier médical personnel a été pris d’assaut autant par les patients que par les médecins. Néanmoins, la population et les prestataires de soins s’attendent à davantage. Mon expérience personnelle me permet de témoigner des avantages que procurent les services informatisés. Il y a quelques années, alors que je vivais au Danemark, mon ophtalmologue m’avait prescrit un antibiotique pour une infection oculaire, qui n’avait pas donné de résultat. En appelant à son bureau, j’ai appris qu’elle était absente. J’ai alors décidé d’envoyer un courriel sécurisé à mon médecin de famille en lui demandant une solution de rechange. Moins d’une heure plus tard, il m’avait répondu. 120
Mon médecin avait consulté mon dossier électronique pour savoir ce que sa collègue m’avait ordonné et il m’a prescrit un autre antibiotique que j’ai pu trouver à la pharmacie locale. J’ignore si cela a eu une incidence sur mon état de santé à long terme, mais la rapidité et la simplicité de la démarche m’ont semblé inestimables – sans compter que je n’ai pas eu à errer à l’aveuglette à la recherche d’un autre médecin. On est de plus en plus d’accord sur le mérite des solutions informatiques proposées aux consommateurs en matière de santé. Les choses commencent à bouger. L’été dernier, lors du Conseil général de l’Association médicale canadienne, les médecins ont voté en faveur de la création et de l’utilisation de systèmes de communications sécurisées entre prestataires de soins et patients. Par ailleurs, un certain nombre de provinces planifient la mise en place d’un portail en ligne pour ces derniers. Il reste toutefois beaucoup de pain sur la planche. S’appuyant sur des données d’enquête, le Conference Board du Canada est parvenu à la conclusion suivante : si la population avait eu accès à des services en ligne pour consulter leur médecin, accéder à leurs résultats d’examen ou renouveler leurs ordonnances, ce sont près de 47 millions de visites en personne qui auraient été évitées et plus de 70 millions d’heures qui auraient été épargnées pour la seule année 2011. Il y a lieu de penser que ce genre de solution peut améliorer la qualité des soins, les résultats de santé, l’accès au service, l’efficacité et l’équité. Rien ne le garantit toutefois. Pour y parvenir, il faudra adopter des orientations et un cadre adéquats. L’informatisation des services en matière de santé doit tenir compte des différences entre les patients et les milieux de soins, ainsi que de l’infrastructure numérique dans son ensemble et des moyens de réaliser les bienfaits escomptés. Les services les plus prisés sont ceux qui mettent les patients en relation avec les équipes qui les prennent en charge. Par conséquent, ils doivent être axés sur l’usager et aménagés en tenant compte de la sécurité des patients et du respect de la vie privée, de l’organisation des tâches et de la charge de travail des prestataires de soins, ainsi que du cadre réglementaire et juridique. L’objectif de réduire l’écart entre la demande et l’offre en matière de services en ligne nécessitera une action réfléchie et bien coordonnée, car il s’agit du seul moyen pour que le plus grand nombre de patients, et non seulement une poignée de férus d’informatique, profitent des retombées. Les individus et les organisations devront se concerter et collaborer, ce qui n’est pas toujours l’une des grandes forces du système de santé. Le fait que nous soyons de plus en plus nombreux à être persuadés qu’il faut miser sur le pouvoir des solutions numériques pour améliorer la santé et la prestation des soins, nous permet de croire que le progrès est à nos portes. Conseillère auprès du site EvidenceNetwork.ca, Jennifer Zelmer est vice-présidente d’Inforoute Santé du Canada, un organisme à but non lucratif qui travaille avec ses partenaires afin d’accélérer la création, l’adoption et l’utilisation efficace d’outils de santé numériques partout au Canada. 121
Double-failing on health Why it is critical we learn from past health care mistakes By Joshua Tepper and Danielle Martin Forty is the new thirty. Orange is the new black. And failure is the new success. It seems these days that no success story is complete without a failure (or two) along the way: the bankruptcy that gave birth to a successful company; the entrepreneur who lost it all just before hitting the Fortune 500. Entire issues of the Harvard Business Review and the New York Times Magazine have been devoted to failure. In the business world leaders are often told: “Fail fast, fail early, fail often.” In many sectors it is understood that to innovate, we must accept – even celebrate – failure. Health care needs positive innovation. At nearly 12 percent of our GDP, health care is a huge part of the Canadian economy, and one in which new ways of doing business are needed – yet it is an industry that has not accepted that part of improvement must be a willingness to fail. Thus when we fail in health care we often double-fail: once in the event and again when we are unable to recognize, name and learn from that failure. In health care, where lives are on the line, failing early and often understandably sounds unpalatable. But of course we do fail in health care. And while we don’t want to encourage failure, we do need to shift away from a culture that can’t acknowledge failure towards one where it is understood to be part of the process of improvement. Failures in health care occur at two levels: the level of the individual patient and the system level. It is often easy to recognize failures at the patient level. These are when medications get mixed up, unnecessary infections occur or poor communication leads to harm. We are getting better at communicating failure at the provider-patient level. Organizations are adopting policies and approaches that facilitate sharing — moving away from “blame-and-shame” cultures in order to improve. However, learning within a single organization is not enough when there are thousands of organizations that make up our health system. Right now we have limited means to facilitate learning from each others’ failures across organizations. This is particularly worrisome in an industry where similar environments and sets of interactions repeat themselves. An ambiguously labeled vial that leads to medication error in one long-term care home will be identical to vials in hundreds of other homes. A cleaning process susceptible to human error used in one operating room will be used in dozens of other operating rooms the same day. System level failures in health care happen but are harder to see. 122
In a public health care system, too often system failures end up as fodder for Question Period battles rather than impetus for learning. When investments have been made in new models of health service funding and delivery that don’t work out, it can be difficult to proclaim failure as a means to move toward success. But in the absence of a willingness to be open about policy ideas that didn’t pan out, we risk continuing to invest in sub-par models of care delivery and we hinder our ability to achieve excellence as a system. Patients and the public are part of the answer. We all put tremendous faith in the health care system at times of incredible vulnerability. Patients and families want to trust in our system, they need to believe that when the stakes are so high, it will work. But providers and organizations also need to trust patients and the public that they will not only understand our failings but help us do better. The best way to honour a person who has been harmed by a health care failure is to do everything possible to learn from that failure so that it will not be repeated. Solutions are not easy. Some can be learned from other industries, some will be health care specific. We need structures and processes so learning can occur across the system. We need the health education system to prepare providers for a career learning from, and not burying, failure. Failures must become teachable moments, not professional risks. In an industry as large and complex as health care, where innovation is a must, we are bound to make errors. But it’s the double-failure that we should worry about: the inability to name and learn from our failures so that we can do better. Joshua Tepper is a family physician at St. Michael’s Hospital. Danielle Martin is a family physician and Vice President at Women’s College Hospital. They are both advisors with EvidenceNetwork.ca. See also our Podcast on the issue: Why it is critical we learn from past health care mistakes
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Double échec dans le système de santé Il est essentiel de tirer des leçons de nos erreurs passées Par Joshua Tepper et Danielle Martin L’échec est-il la nouvelle voie de la réussite? De nos jours, tout porte à croire qu’une réussite n’est pas complète si elle n’est pas précédée d’un échec (ou deux) : la faillite qui donne naissance à une entreprise prospère; l’entrepreneur qui perd tout, puis figure peu après au classement Fortune 500. Le Harvard Business Review et le New York Times Magazine ont consacré des numéros entiers à ce thème. Dans le monde des affaires, on répète souvent aux chefs d’entreprise qu’il est nécessaire de connaître l’échec « rapidement et fréquemment » pour mieux apprendre. Dans bon nombre de domaines, on sait que, pour innover, il faut accepter – et même applaudir – nos erreurs. Au Canada, le système de santé est en mal d’innovation positive. À près de 12 pour cent du PIB, il représente un pan énorme de notre économie. C’est aussi un secteur où il faudrait changer les méthodes, mais où l’on admet difficilement que, pour s’améliorer, il faut accepter de faire des erreurs. Lorsque survient un incident, on pourrait même parler de double échec, bien souvent, puisque s’ajoute à celui-ci une incapacité de reconnaître notre erreur et d’en tirer des leçons. Dans un domaine où des vies sont en jeu, l’échec est une éventualité difficile à envisager, on le comprendra. Bien entendu, il nous arrive d’échouer dans la pratique. Même si ce n’est pas une chose qu’il faut encourager, il reste que nous aurions avantage à passer d’une culture où l’on n’admet pas l’échec à une culture où l’on reconnaît qu’il fait partie intégrante du processus quand on cherche à s’améliorer. Les échecs dans le secteur de soins de santé sont de deux ordres : ceux qui touchent le patient et ceux qui concernent la structure dans son ensemble. Les premiers sont faciles à repérer; ils surviennent lorsqu’une erreur de médication, une infection injustifiée ou un problème de communication causent du tort à une personne. Depuis quelque temps, la façon dont on transmet ce genre d’information au patient s’améliore. Les organisations ont adopté des politiques et des méthodes qui facilitent la communication à cet égard, s’éloignant ainsi, et pour le mieux, d’une culture axée sur le blâme. Notre système de santé regroupe toutefois des milliers d’organisations, si bien que les leçons tirées au cas par cas ne suffisent pas. Les moyens dont nous disposons pour mettre en commun ces enseignements restent limités. Voilà une situation particulièrement préoccupante dans un secteur d’activité où les environnements et les interactions se ressemblent d’une organisation à l’autre. Ce flacon à l’étiquette ambiguë qui est responsable d’une erreur de médication dans une maison de soins de longue durée peut toujours être disponible à des centaines d’exemplaires ailleurs dans le réseau. Une 124
méthode d’entretien susceptible de provoquer une erreur humaine dans une salle d’opération peut être répétée le même jour dans des dizaines d’autres hôpitaux. Les échecs de nature systémique sont plus difficiles à déceler. Dans le réseau public, au lieu de devenir un moteur d’apprentissage, les échecs systémiques finissent trop souvent comme matière à débat sans fin pendant les périodes de questions. On peut concevoir qu’il difficile, quand on a investi dans un nouveau modèle de financement et de prestation des services, de vanter l’échec comme moyen de progresser. Pourtant, si l’on n’accepte pas de parler ouvertement des programmes qui n’ont pas donné les résultats escomptés, on risque de continuer à investir dans de piètres modèles de prestation tout en restreignant nos chances d’atteindre l’excellence à l’échelle du système. Les patients et le public font partie de la solution. Nous plaçons tous d’immenses espoirs dans nos services de santé dans des moments de grande vulnérabilité. Les patients et leurs proches veulent faire confiance au système; ils ont besoin de croire, lorsque l’enjeu est considérable, qu’il donnera des résultats. Or les prestataires de soins et les organisations doivent aussi apprendre à faire confiance aux patients et à la population et se convaincre que non seulement ils comprendront la nature de nos erreurs, mais qu’ils nous aideront aussi à nous améliorer. La meilleure façon de réparer un tort envers une personne victime d’une erreur, c’est de tout mettre en œuvre pour en tirer des leçons et ne pas la répéter. Les solutions ne se trouvent pas facilement. Certaines pourront être empruntées à d’autres secteurs d’activité; d’autres devront être conçues sur mesure. Nous avons besoin de structures et de processus qui favoriseront l’apprentissage à grande échelle. Les programmes de formation devront préparer les futurs intervenants de santé à une carrière où l’on apprend de ses échecs, plutôt que de les passer sous silence. Il faut considérer l’échec comme une occasion d’apprentissage, plutôt qu’un risque professionnel. Dans un secteur aussi vaste et complexe que celui des soins de santé, où l’innovation est indispensable, des erreurs sont à prévoir. Ce qui devrait nous préoccuper, surtout, ce sont les doubles échecs auxquels conduit l’incapacité d’admettre nos erreurs et d’en tirer des leçons pour parvenir à s’améliorer. Joshua Tepper est médecin de famille à l’Hôpital St. Michael’s et professeur agrégé à l’Université de Toronto. Danielle Martin est médecin de famille et vice-présidente de l’Hôpital Women’s College. Tous deux sont conseillers auprès du site EvidenceNetwork.ca.
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Rising rates of kidney failure signal need for public health strategy By Allison Dart and Mariette Chartier As many as forty thousand people in Canada are affected by kidney failure – a problem that is increasing across the country, with significant consequences for our health system. A report we released this month from the Manitoba Centre for Health Policy projects an increase of 68 percent in the number of Manitobans requiring dialysis or kidney transplant in the next decade. Manitoba already has amongst the highest rates of kidney failure in Canada but it is not alone. Rates of kidney failure are actually the highest in Newfoundland and Labrador, affecting approximately 1500 per million and rising. But most provinces have escalating rates, with about 1200 per million people affected in B.C., Saskatchewan and Ontario, and 1000 per million in Alberta. One could view the projected rates in Manitoba as a wakeup call for the country at large. Debilitating symptoms, decreased quality of life, mental health issues, financial challenges and frequent need for medical visits and hospitalizations significantly impact the lives of people with kidney failure. Those most affected include those most vulnerable: people living in remote Northern communities, in lower income areas and the elderly. But in addition to the human cost of bearing the burden of kidney failure, the economic costs to the health system are also significant. The biggest projected growth is expected in center-based hemodialysis, which costs the health care system up to $107,000 per year per patient. The most important health related risk factors for kidney disease include diabetes and high blood pressure. Diabetes in particular is a health problem that continues to increase each year across Canada, in adults and even in children. Pediatricians are now seeing kids as young as five with high blood pressure due to obesity, and as young as seven with type 2 diabetes. This is especially concerning because of the many years children have to live with these complications, and the higher risk that their health will be impacted during their lifetime. Our report specifically looks at the impact of diabetes on the future rates of kidney failure. In this “what if” scenario, the research team found that the projected number of people on dialysis could be decreased by nine percent in Manitoba if current rates of diabetes were kept steady. Imagine the impact if diabetes rates actually decreased. In other words, strategies for addressing diabetes prevention could go a long way in addressing kidney disease in the population too.
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Our report estimates that as many as 14 percent of adults and a surprising three percent of children already have kidney disease in Manitoba. Moreover, one third of these adults and 25 percent of these children are at high risk of progression. With such alarming numbers across the country, it is clear that Canada needs a public health strategy to combat kidney disease. What should this strategy look like? It needs to include action from all levels of government, with special attention to unifying care across jurisdictional barriers that affect our highest risk populations, such as First Nations people. A public health strategy should focus first on healthier communities. Children growing up with access to healthy foods and safe places to play are less likely to develop obesity, diabetes, and hence, kidney complications. Healthier choices need to be easier to make than unhealthy ones. Individualized and culturally sensitive education and coaching should be available to adults with unhealthy habits. Second, we need a public health strategy to target screening for high-risk populations, including Northern Indigenous populations, and those with known high blood pressure and diabetes. Thirdly, once individuals are identified with kidney disease, we need a surveillance system in place to track progress and ensure that at risk individuals are receiving the care they need, including therapies to optimize things like blood sugar and blood pressure as these approaches are proven to slow down kidney disease progression. Finally, a public health strategy should focus on those individuals with more aggressive or advancing disease being referred to specialty care by kidney doctors, nurses, dieticians, social workers and pharmacists. The rising rates of kidney failure in Manitoba, and the projected significant rise, are a symptom of many health issues in the population across the country. There are solutions to many of these challenges, including prevention, but a unified approach across jurisdictions is required to make meaningful change for the many Canadians at risk for kidney failure. It may save lives, and it may also save our health system millions of dollars in the process. Allison B. Dart is an advisor with EvidenceNetwork.ca, a pediatric kidney specialist and Assistant Professor in the Department of Pediatrics and Child Health, University of Manitoba. Mariette J. Chartier is a Research Scientist at the Manitoba Centre for Health Policy and an Assistant Professor in the Department of Community Health Sciences, Faculty of Medicine, University of Manitoba.
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L’augmentation des taux d’insuffisance rénale indique la nécessité d’une stratégie en matière de santé publique Par Allison B. Dart et Mariette J. Chartier Pas moins de 40 000 personnes au Canada souffrent d’insuffisance rénale. Ce phénomène qui s’accroît dans toutes les régions du pays a des répercussions notables sur notre système de santé. Dans un rapport récemment publié, le Manitoba Centre for Health Policy prévoit une augmentation de 68 % du nombre de personnes qui nécessiteront une dialyse ou une greffe de rein d’ici dix ans. Cette province affiche l’un des taux d’insuffisance rénale les plus élevés au pays, mais elle n’est pas seule dans sa catégorie. De fait, c’est à Terre-Neuve-et-Labrador que les chiffres sont les plus élevés : 1500 personnes par million d’habitants souffrent de ce problème et leur nombre continue d’augmenter. Le taux monte en flèche dans les autres provinces également. Il atteint 1200 personnes par million en Colombie-Britannique, en Saskatchewan et en Ontario et 1000 par million en Alberta. On pourrait considérer les projections concernant le Manitoba comme un signal d’alarme pour le pays dans son ensemble. L’insuffisance rénale a des répercussions multiples sur la vie des gens : symptômes débilitants, diminution de la qualité de vie, problèmes de santé mentale, difficultés financières, multiplication des visites chez le médecin et des séjours à l’hôpital. Les personnes les plus touchées font partie des groupes les plus vulnérables de notre société, dont les populations du Nort et celle des quartiers défavorisés, ainsi que les personnes âgées. Aux coûts humains engendrés par le fardeau de la maladie s’ajoutent des dépenses non négligeables pour le système de santé. La plus grande augmentation prévue concerne l’hémodialyse en établissement, qui peut coûter annuellement jusqu’à 107 000 $ par patient. Parmi les facteurs de risque les plus importants associés à l’insuffisance rénale, on compte le diabète et l’hypertension artérielle. Le diabète en particulier continue d’augmenter d’année en année dans tout le pays chez les adultes, et même chez les enfants. Aujourd’hui, les pédiatres voient même des enfants de cinq ans souffrant d’hypertension due à l’obésité et des enfants de sept ans atteints de diabète de type 2. Le phénomène est préoccupant, compte tenu des complications dont ces enfants souffriront pendant des années et du risque élevé de répercussions néfastes sur leur état de santé tout au long de leur vie. Notre rapport examine entre autres l’incidence du diabète sur le taux éventuel d’insuffisance rénale. Selon le scénario hypothétique envisagé par notre équipe de 128
recherche, il serait possible de réduire de 9 % le nombre anticipé de patients sous dialyse au Manitoba à condition de stabiliser le taux actuel de diabète. Imaginez les résultats si le taux de diabète diminuait réellement. En d’autres termes, les stratégies de prévention du diabète pourraient contribuer dans une large mesure à réduire l’incidence des maladies du rein dans la population. Selon notre rapport, nous estimons que proche de 14 % des adultes et, fait surprenant, 3 % des enfants souffrent de maladie du rein au Manitoba. De plus, le risque de progression de la maladie est élevé chez un tiers des adultes et un quart des enfants atteints. Devant les statistiques alarmantes relevées à l’échelle du pays, la nécessité d’une stratégie de santé publique pour lutter contre les maladies du rein s’impose. Que devrait-elle comporter? Notre action doit mobiliser tous les ordres de gouvernement; une attention particulière doit être portée à l’uniformisation des soins de santé, notamment ce qui touche les populations à risque élevé comme les Premières nations. En premier lieu, toute stratégie de santé publique doit être axée sur l’établissement de milieux de vie favorables pour la santé. Les enfants qui ont accès à des aliments sains et à des lieux où ils peuvent jouer en toute sécurité sont moins susceptibles de souffrir d’obésité, de diabète et, par conséquent, de complications rénales. Il faut rendre les choix santé plus accessibles que les choix malsains. Les adultes qui ont de mauvaises habitudes devraient avoir accès à une éducation et un accompagnement personnalisés, adaptés au contexte culturel. En deuxième lieu, il faudra prévoir un programme de dépistage au sein des populations à risque élevé, dont les communautés autochtones du Nord et les personnes qui souffrent d’hypertension artérielle et de diabète. En troisième lieu, nous devrons mettre en place un système de surveillance destiné aux personnes qui ont reçu un diagnostic de maladie du rein, afin de suivre leurs progrès et veiller à ce que les patients à haut risque reçoivent tous les soins requis. Les traitements visant à réguler la glycémie et la pression artérielle en font partie, puisqu’il a été démontré qu’ils ralentissent la progression des maladies du rein. Enfin, il faut aiguiller les personnes à un stade avancé de la maladie ou chez qui elle évolue rapidement vers les services spécialisés offerts par les néphrologues, les infirmières, les diététiciennes, les travailleurs sociaux et les pharmaciens. La hausse des taux d’insuffisance rénale au Manitoba et l’augmentation importante prévue sont symptomatiques des nombreux problèmes de santé relevés au sein de la population à l’échelle du pays. Il existe des solutions à ces derniers, y compris la prévention. Si l’on veut opérer des changements réels pour le bien des personnes à risque, 129
il faudra mener une action unifiée qui traversera les secteurs de compétence. Celle-ci pourrait non seulement sauver des vies, mais aussi nous faire épargner des millions de dollars en soins de santé. Allison B. Dart est conseillère auprès du site EvidenceNetwork.ca, pédonéphrologue et professeure adjointe au département de pédiatrie et de santé de l’enfant à l’Université du Manitoba. Mariette J. Chartier est chercheuse au Manitoba Centre for Health Policy et professeure adjointe au département des sciences de la santé communautaire de la Faculté de médecine à l’Université du Manitoba.
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Four things everyone should know about autism in Canada By Kathleen O’Grady Canadian governments have done little to address the crisis faced by autism families across the country. This sentiment was true in 2007 when it was put forward in the crossparty Senate report on the state of funding for the treatment of autism in Canada, aptly titled, Pay Now or Pay Later. And until recently, this sentiment could be used to sum up the role of the federal government which has largely left the crisis up to provincial ministries to manage. But they are slowly coming on side. This week the federal government appointed a new “Autism Spectrum Disorder Working Group” with a two million dollar budget to develop a plan for a “Canadian Autism Partnership” that will address autism research, information sharing, early detection, diagnosis and treatment, among other issues. It’s a good step forward but much more is needed, particularly on the health and educational services side of the issue so that real families get real help, now. According to the first comprehensive autism needs assessment survey of caretakers and professionals across the country, Canadian autism families are struggling to get the health services they need but can’t afford. As governments across the country try to tackle the gap between need and resources, here are a few things about autism everyone should know: 1. Autism is not a mental illness, a mental health condition or a learning disability Autism is a neurodevelopmental disorder that is characterized by impaired verbal and social communication; rigid, restrictive and repetitive behaviours; uneven intellectual development; sensitivity to sensory input; challenges with fine and gross motor skills; and gastrointestinal difficulties, among other characteristics. Autism is more accurately referred to as ‘autism spectrum disorder’ (ASD) because each person on the spectrum can exhibit a differing array of these characteristics and with wide ranging severity. There’s a favourite saying in the autism community: “If you’ve seen one person with autism, you’ve seen one person with autism.” There is no cure for autism, though there are several evidence-based interventions that can help address the challenges those with autism face. 2. The rate of autism in Canada is not yet fully known, but we have recent estimates Canadian media reports often cite autism rates from the United States. Research from the U.S. Autism and Developmental Disabilities Monitoring (ADDM) Network at the Centres for Disease Control and Prevention estimate 1 in 68 children in America has ASD. Since autism is five times more prevalent in boys than girls, they estimate 1 in 42 boys and 1 in 189 girls has ASD in the U.S. 131
So what are the rates in Canada? And are they on the rise? “Our best estimate at this time is that ASD affects 1 in 94 children six to nine years of age,” according to Dr. Hélène Ouellette-Kuntz, Professor in the Department of Health Sciences at Queen’s University and Director of The National Epidemiologic Database for the Study of Autism in Canada (NEDSAC). This estimate is based on diagnostic and services data from Newfoundland and Labrador, Prince Edward Island and Southeastern Ontario from 2003-2010. Many experts worry that the lower rates of autism in Canada may simply reflect, as Dr. Stuart Shanker of York University says, “the poorer number of autism services in the four regions where NEDSAC was able to conduct their research and collect their data.” New, more comprehensive rates of autism in Canada are expected in the coming year using administrative data from Manitoba. What we know so far from NEDSAC published materials suggests that autism rates are on the rise in Canada, though they vary widely across the studied regions. Even when you factor in increases due to the identification of previously undetected cases or diagnostic substitution (conditions that used to be labelled something else now being called autism), “we cannot rule out the possibility of a true increase in incidence,” says Dr. OuelleteKuntz. 3. Families can often wait several years to access autism services covered by the public health care system. Government support for such services are widely uneven across the country. It is not uncommon for families to wait several years to receive a diagnosis of autism for their child from publicly funded health services in most provinces. And once a child is diagnosed, interventions with a strong evidence base, such as behavioural therapy, speech therapy and occupational therapy, have wait times of several months up to several years in most places across the country. Once services are received, families have access to these therapies for only limited time periods and often beyond the window of time that most experts believe optimal. The wide range in disparity of publicly funded services for autism across the country has even generated a kind of ‘medical migration’ with several published accounts of families leaving their home provinces (most commonly, Atlantic, Ontario and Quebec) to move to Alberta or British Columbia where autism services are more readily available and/or more flexible. It is also no longer uncommon to find Canadian families using crowd sourcing campaigns to fund their children’s autism and related therapies. Many organizations and affected families across the country have been calling for a National Autism Strategy to address the critical lapses in health coverage.
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4. ‘Person with autism’ or ‘autistic’? So should you say someone is ‘autistic’ or ‘has autism’ – or does it matter? For most medical disorders, the usual rule is to refer to the person first followed by the condition (e.g., person with Down Syndrome, person with Cerebral Palsy) because the disability does not define the individual. Similarly, many affected families prefer the descriptor, ‘someone with autism’ since the individual is greater than their diagnosis. Specific traits can be described as ‘autistic,’ such as ‘hand flapping,’ but not the person. However, there is also a growing movement – often referred to as the neuro-diversity movement — among those diagnosed with autism and other neurological disorders that prefers the label ‘autistic’ for the person, since they believe you cannot separate the individual from the autism. If possible, opt for the preference of the affected person or families. But better still, refer to the individual by name. Kathleen O’Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University and Managing Editor of EvidenceNetwork.ca. She has two young sons, one with autism. You can follow her on Twitter at @kathleenogrady.
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Quatre faits incontournables sur l’autisme au Canada Les familles d’enfants autistes en situation critique Par Kathleen O’Grady Les gouvernements canadiens n’ont pas fait beaucoup pour remédier à la situation critique que vivent les familles d’enfants autistes. Cela était vrai en 2007 au moment de la publication, par un comité sénatorial interpartis, d’un rapport sur le traitement de l’autisme judicieusement intitulé Payer maintenant ou payer plus tard. Et ce l’était encore jusqu’à tout récemment; le gouvernement fédéral s’étant contenté ni plus ni moins par le passé de pelleter le problème dans la cour des provinces. Or il semble que les choses commencent tranquillement à bouger. Cette semaine, le fédéral annonçait la formation d’un Groupe de travail sur les troubles du spectre autistique doté d’un budget de deux millions de dollars. Celui-ci aura pour mandat d’élaborer « un plan relatif à un partenariat canadien en matière d’autisme », qui visera entre autres la recherche, l’échange d’information, le dépistage précoce, le diagnostic et le traitement. Il s’agit d’un progrès, mais il faudra en faire bien davantage avant de pouvoir affirmer que les familles bénéficient d’une aide véritablement digne de ce nom. Selon la toute première enquête exhaustive sur l’évaluation des besoins en matière d’autisme menée au Canada auprès des soignants et des professionnels, les familles doivent se débattre pour obtenir les services dont elles ont besoin, mais qu’elles n’ont pas les moyens de se payer. Tandis que les gouvernements d’un bout à l’autre du pays tentent de réduire le fossé entre les besoins et les ressources, profitons-en pour rappeler un certain nombre de points au sujet de l’autisme. 1. L’autisme n’est pas une maladie mentale, un problème de santé mentale ou un trouble d’apprentissage. L’autisme est un trouble de neurodéveloppement qui se caractérise notamment par : une difficulté à communiquer verbalement et à interagir socialement; des comportements rigides, restrictifs et répétitifs; un développement intellectuel inégal; une sensibilité aux stimuli sensoriels; des problèmes de motricité fine et globale et des troubles gastrointestinaux. Il est plus juste d’employer l’expression « trouble du spectre de l’autisme » (TSA), puisque ces caractéristiques se manifestent différemment selon les individus et de façon plus ou moins prononcée. D’ailleurs, il n’est pas rare d’entendre l’expression « connaître une personne autiste, c’est connaître une personne autiste ». Il n’y a pas de remède pour l’autisme, mais il existe plusieurs interventions éprouvées susceptibles d’aider les personnes touchées à surmonter les difficultés qui l’accompagnent. 134
2. On ne connaît pas avec exactitude le taux de prévalence de l’autisme au Canada, mais on dispose d’estimations récentes Les médias canadiens citent souvent des chiffres qui proviennent des États-Unis. Selon les recherches menées par le U.S. Autism and Developmental Disabilities Monitoring (ADDM) Network du Centre for Disease Control and Prevention, le TSA toucherait un enfant sur 68 chez nos voisins. Étant donné que l’autisme est sept fois plus courant chez les garçons que chez les filles, sa prévalence équivaudrait donc dans ce pays à un garçon sur 42 et à une fille sur 189. Quels sont les taux de prévalence au Canada? Et sont-ils en augmentation? « Notre estimation la plus plausible pour le moment, c’est que le TSA touche un individu sur 94 chez les enfants âgés de six à neuf ans », rapporte Hélène Ouellette-Kuntz, professeure au département des sciences de la santé à l’Université Queen’s, qui gère une base de données épidémiologiques nationale sur l’étude de l’autisme au Canada (NEDSAC). Ce chiffre se fonde sur l’information et les données diagnostiques recueillies de 2003 à 2010 auprès des services de santé à Terre-Neuve-et-Labrador, à l’Île-duPrince-Édouard et dans le sud-est de l’Ontario. De nombreux experts se disent préoccupés par le fait que le taux d’autisme peu élevé rapporté au Canada pourrait être attribuable, comme le soupçonne Stuart Shanker de l’Université York, « au faible nombre de services en matière d’autisme offerts dans les quatre régions où la NEDSAC a pu mener son enquête. » On s’attend à ce que des chiffres plus exhaustifs soient dévoilés au courant de l’année provenant de la base des données administratives recueillies au Manitoba. Ce que nous savons pour l’instant, grâce aux documents publiés dans le cadre de l’étude NEDSAC, c’est que le taux d’autisme augmente au Canada, mais qu’il varie largement d’une région à l’autre. Même lorsqu’on tient compte de l’augmentation attribuable aux cas non dépistés auparavant ou aux substitutions de diagnostic (concernant des cas qui avaient reçu un diagnostic autre que l’autisme), « on ne peut pas écarter la possibilité d’une augmentation effective de l’incidence », indique Hélène Ouellete-Kuntz. 3. Les familles doivent souvent attendre pendant des années avant de pouvoir accéder à des services spécialisés couverts par le régime public. L’aide gouvernementale en matière d’autisme varie grandement d’une province à l’autre. Dans la plupart des réseaux de santé provinciaux, il n’est pas rare de devoir patienter pendant plusieurs années avant qu’un enfant ne reçoive un diagnostic d’autisme. De plus, les familles doivent attendre de plusieurs mois à quelques années avant de pouvoir bénéficier d’interventions dont l’efficacité est démontrée, comme la thérapie comportementale, l’orthophonie et l’ergothérapie. Enfin, ces services ne sont offerts que pendant une période limitée et, bien souvent, plus tard que la fenêtre jugée optimale par la plupart des experts.
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Les fortes disparités observées entre les provinces auraient même engendré un phénomène de « migration pour des raisons médicales ». En effet, certaines familles ont rapporté avoir quitté leur région d’origine (la plupart du temps les Maritimes, l’Ontario ou le Québec) pour s’établir en Alberta ou en Colombie-Britannique, qui se démarquent par l’accessibilité et la souplesse des services offerts. Par ailleurs, il n’est plus rare de voir des familles canadiennes recourir à des campagnes de sociofinancement pour pouvoir se payer des services et des thérapies spécialisés. Un grand nombre d’associations et de familles réclament depuis un certain temps une stratégie nationale sur l’autisme qui permettrait de combler les lacunes de la couverture offerte par les régimes de santé publics. 4. Quels termes faut-il employer? Les mots qu’on utilise ont un certain poids, surtout lorsqu’il s’agit de désigner des individus. Doit-on dire qu’une personne est « autiste », qu’elle « souffre d’autisme » ou qu’elle est « atteinte d’un trouble du spectre autistique »? Dans une certaine mesure, l’évolution du vocabulaire reflète aussi celle des connaissances sur l’autisme, notamment en ce qui concerne son diagnostic. Ainsi, l’appellation « trouble du spectre de l’autisme » (TSA) (ou « trouble du spectre autistique ») a vu le jour ces dernières années. Son choix vise à refléter à la fois la diversité des manifestations du phénomène et le fait qu’elles se situent sur un continuum. Toutefois, certains déconseillent l’usage de tout terme associé au monde médical, comme les expressions « trouble », « maladie » « pathologie », « atteint d’autisme », « souffrant d’autisme », auxquelles on peut attribuer une connotation péjorative. Pour désigner la personne touchée, ils préconisent entre autres l’emploi du substantif « autiste » et de l’adjectif « autiste » (« personne autiste », « enfant autiste »), qu’ils jugent plus respectueux. Certains autistes considèrent même que leur identité est indissociable du phénomène. Par ailleurs, on relève l’émergence d’un mouvement à qui l’on doit l’invention de nouvelles notions telles que « neurodiversité », « neurotypique » et « neurodifférent », qui ont l’avantage de renverser la perspective en présentant les choses du point de vue des personnes autistes. Les trois termes se rapportent au fonctionnement cognitif : le premier fait allusion à la diversité des modes de cognition; le deuxième, au mode considéré comme le plus répandu; et le troisième, aux modes qui ne correspondent pas à la norme. Dans la mesure du possible, il est indiqué d’utiliser le terme privilégié par les principaux intéressés, c’est-à-dire la personne elle-même ou ses proches. Et si on peut désigner celle-ci par son nom, c’est encore mieux! Kathleen O’Grady est associée de recherche à l’Institut Simone de Beauvoir de l’Université Concordia et rédactrice en chef du site EvidenceNetwork.ca. Elle est mère de deux jeunes garçons, dont l’un est autiste. 136
Why it’s time for a National Autism Strategy By Kathleen O’Grady Over a year ago, I was invited to celebrate World Autism Awareness Day on Parliament Hill. It was attended by a dozen or more Senators from both major parties, political staffers and invited guests mostly from an assortment of autism non-profit organizations. I expected a somewhat predictable ‘feel good’ event about how far we’ve come and how far we have still to go. But an hour later there weren’t many dry eyes in the chamber. It turns out, many of the politicians who decided to join the event that day had personal experiences with autism. One Senator spoke at length of his daughter who struggles to get adequate services for his grandchild with autism, and how challenging it has been – economically, physically and emotionally — for the whole family. He cried openly. Another Senator spoke of a family she knows that is struggling with long wait times for essential services, such as speech or behavioural therapy. More than one participant spoke of the difficult choice families have made to uproot from jobs and life-long communities and move across the country to Alberta or British Columbia where autism services are often more readily available and flexible, particularly if a family happens to have more than one child on the autism spectrum. Others spoke of the economic burden of pursuing private therapies – funded out of pocket, often in the tens of thousands of dollars per year – resulting in refinancing homes or selling them altogether just to get their child with autism the basic supports they need to learn and thrive. What became clear that day is something I’ve heard autism champion, Senator Jim Munson say before: autism doesn’t affect Liberals or Conservatives or NDPers. It’s an equal opportunity neurodevelopmental disorder that affects Canadians across the political spectrum and clear across the country. What was also clear that day – and from a number of regional reports since — is that autism families in Canada are struggling, that diagnosed cases of autism are on the rise, and that most provinces are not able to keep up with necessary services. According to a recent survey from the Canadian Autism Spectrum Disorders Alliance (CASDA), almost three quarters of parents of preschoolers in Canada with autism wanted, but did not receive, early intensive behavioural intervention for their child — one of few interventions for autism with solid peer reviewed evidence. A similarly troubling report, released last month from the Ontario Auditor General, reveals that in some jurisdictions in the province, there are more children waiting for
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autism services than receiving them, with more than 16,000 children on wait lists that continue to balloon. This has largely been my own experience in Ontario. Despite being a proud advocate of our universal health care system, which is intended to serve those in need and not just those with the ability to pay, I found it failed me when I needed it most. When my son did not meet traditional developmental milestones, I discovered I would have to wait years to get a diagnosis in the public health system. We paid for a private diagnosis instead, but then we still had to wait more than two years for publicly funded behavioural therapy, which was provided to us for only six months. It was all too little, too late. Like so many other families affected by autism, instead of just waiting, we paid for our son’s essential health services privately – and he blossomed as a result. We are one of the lucky ones who could afford to do so, though not without struggle. Dire headlines on gaps and lacks in autism services are recurrent in the media from multiple regions across the country; you can almost recycle the headlines and simply rotate the province named. It’s not an exaggeration to say we have an autism services crisis in Canada. So what can be done? Plenty. Evidence shows that proper health and educational supports for those affected by autism pay off. Early intervention is key and heads off more expensive and extensive supports that are needed later in life if early intervention is not provided. It makes economic sense, in other words, to provide autism services early. Kids with autism are not lost causes, they are full of potential. We are failing them. The last federal government made a good start establishing an Autism Spectrum Disorder Working Group to bring together those working on the issues across the country to discuss key concerns and share best practices. But much more federal support is required to make things better – now — for Canadian families affected by autism. For starters, the new Liberal government could dust off the excellent cross-party Senate report – aptly titled – Pay Now or Pay Later: Autism Families in Crisis from 2007 and get to work. It’s number one recommendation? A comprehensive national autism strategy. We’ve waited almost a decade. Now is the time for the federal government to bring together the brightest minds in the country on the issue and enact a federal strategy to give our kids with autism the services they need to survive and thrive in communities across the country. It’s not only the right thing to do, it’s the smart thing to do.
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Kathleen O’Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University, the Managing Editor of EvidenceNetwork.ca and a mother of two sons, one with autism.
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Le temps est venu d’instaurer une stratégie nationale en matière d’autisme Par Kathleen O'Grady Il y a un peu plus d’un an, on m’a invitée à participer à une activité organisée sur la Colline du Parlement pour souligner la Journée mondiale de sensibilisation à l’autisme. Y assistaient une dizaine de sénateurs des deux principaux partis, des attachés politiques ainsi que les représentants d’un éventail diversifié d’associations du secteur de l’autisme. Je m’attendais ni plus ni moins à assister, comme dans la plupart des événements de ce genre, à un concert de « bons sentiments » sur les progrès accomplis jusque-là et le long chemin qu’il restait à parcourir. Au bout d’une heure, cependant, ceux qui n’avaient pas les larmes aux yeux dans la salle étaient rares. Il se trouve que bon nombre des politiciens présents ce jour-là avaient vécu des expériences personnelles touchant l’autisme. Un sénateur a parlé longuement de son petit-fils autiste et de la difficulté qu’avait sa fille à obtenir des services adéquats; de l’épreuve que traversait toute la famille sur le plan économique, physique et affectif. Il n’a pas pu contenir ses larmes. Une sénatrice a raconté les tracas d’une famille de son entourage obligée de patienter encore et encore avant de pouvoir accéder à des services essentiels, notamment en matière d’orthophonie et de thérapie comportementale. Plus d’une personne présente a évoqué les choix difficiles auxquels des familles sont acculées. Certaines décident même d’abandonner emploi et lieu d’origine pour déménager en Alberta ou en ColombieBritannique où les services sont plus faciles d’accès et souples qu’ailleurs, en particulier lorsqu’une famille compte plus d’un enfant autiste. D’autres ont évoqué le fardeau économique qu’entraîne pour les familles le recours aux thérapies privées ‒ des soins qu’elles payent de leur propre poche, souvent à hauteur de dizaines de milliers de dollars par année. Certaines finissent même par réhypothéquer leur maison ou par la vendre rien que pour être en mesure d’offrir à leur enfant les services de base dont il ou elle a besoin pour se développer et s’épanouir. Si une chose a été mise en évidence, ce jour-là, c’est que l’autisme ne fait pas de distinction entre libéraux, conservateurs ou néodémocrates, comme j’ai entendu un jour le sénateur Jim Munson, fervent défenseur de la cause, l’affirmer. Ce trouble de neurodéveloppement touche la population canadienne d’un bout à l’autre du pays, peu importe où l’on se situe sur le spectre politique. D’autres constats se dégagent de cette journée, que des rapports régionaux ont confirmés par la suite : les familles d’enfants autistes sont en difficulté; le nombre de cas augmente; la plupart des provinces ne parviennent pas à fournir tous les services nécessaires. 140
Selon une enquête menée récemment par l’Alliance canadienne des troubles du spectre autistique (ACTSA), près des trois quarts des parents d’un enfant autiste d’âge préscolaire au Canada auraient souhaité se prévaloir d’une intervention précoce en matière de comportement, mais n’en ont pas bénéficié. C’est pourtant l’une des rares thérapies dont l’efficacité a été démontrée scientifiquement. Selon une étude McKinsey (2014), plus de 1000 enfants au Québec ont attendu jusqu’à deux ans avant d’accéder à une évaluation diagnostique et plus de 800 enfants, d’un à trois ans avant de bénéficier d’une intervention précoce en thérapie comportementale. Un autre rapport troublant publié le mois dernier par la Vérificatrice générale de l’Ontario nous apprend qu’il y a plus d’enfants autistes qui attendent de recevoir des services que d’enfants qui en bénéficient. Plus de 16 000 enfants sont inscrits sur des listes d’attente qui ne cessent de s’allonger. Cet état de choses correspond largement à ma propre expérience en Ontario. Je me considère comme une fière défenseure du régime universel de santé et de la nécessité de donner des soins à tous ceux qui en ont besoin et non seulement à ceux qui en ont les moyens; toutefois, j’ai le sentiment d’avoir été abandonnée à un moment critique. Après m’être rendu compte que le développement de mon fils ne suivait pas les étapes habituelles, j’ai appris qu’il nous faudrait attendre des années, dans le réseau public, avant d’obtenir un diagnostic. Nous avons alors décidé de nous tourner vers le privé, après quoi il a tout de même fallu attendre plus de deux ans avant d’accéder à une thérapie comportementale dans un établissement public. Qui plus est, nous n’en avons bénéficié que pendant six mois. C’était trop peu, trop tard. Comme beaucoup d’autres familles touchées par l’autisme, nous avons décidé, au lieu d’attendre, de nous adresser à un prestataire privé et de payer les services essentiels dont notre fils avait besoin et qui lui ont permis de s’épanouir. Nous faisons partie des chanceux qui pouvaient se le permettre, même si ce ne fut pas sans difficulté. Les nouvelles déprimantes qui font la une des journaux sur les lacunes en matière de services destinés aux autistes sont récurrentes dans les médias, quelle que soit la région. On pourrait quasiment les recycler en changeant tout simplement le nom de la province concernée. Il n’est pas exagéré d’affirmer que nous faisons face à une crise dans ce domaine. Que peut-on faire face à la situation? Un tas de choses en fait. Les données confirment que la prestation de services adéquats en éducation et en santé aux enfants autistes et à leurs familles en vaut largement la peine. L’intervention précoce est un facteur essentiel; elle permet d’éviter le recours ultérieur à des services encore plus spécialisés et coûteux. En d’autres termes, il est logique, d’un point de vue économique, de les proposer dès un jeune âge.
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Les enfants autistes ne sont pas une cause perdue d’avance, bien au contraire; ce sont des individus pleins de potentiel. C’est nous qui ne sommes pas à la hauteur. Le gouvernement précédent avait franchi un pas dans la bonne direction en mettant sur pied un Groupe de travail sur les troubles du spectre autistique. Ce comité devait réunir des intervenants de toutes les régions du pays afin de discuter des principaux enjeux et mettre en commun des pratiques exemplaires. Pour véritablement améliorer les choses pour les familles concernées, toutefois, il faudra que le fédéral investisse encore davantage de fonds. Le gouvernement libéral pourrait se remettre au travail en dépoussiérant l’excellent rapport publié en 2007 par un comité sénatorial interpartis sous le titre éloquent de Payer maintenant ou payer plus tard : les familles d’enfants autistes en crise. Quelle était sa première recommandation? L’adoption d’une stratégie nationale en matière d’autisme. Nous attendons depuis presque dix ans que ce projet se concrétise. Le temps est venu pour le fédéral de réunir les meilleurs cerveaux sur cette question et de se doter d’une stratégie qui accordera à nos enfants autistes, dans toutes les régions du pays, les services dont ils ont besoin pour survivre et s’épanouir. Ce serait là une décision aussi juste que judicieuse. Kathleen O’Grady est associée de recherche à l’Institut Simone de Beauvoir de l’Université Concordia et rédactrice en chef du site EvidenceNetwork.ca. Elle est mère de deux garçons, dont l’un est autiste.
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Chapter 3: Health is More Than Health Care
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Why one of Canada’s big banks is calling for greater income equality Studies find public investments in childhood education, health and affordable housing good for the economy By Ryan Meili A moneylender sees the light, discovering a spirit of giving and generosity. It’s a classic Christmas tale of redemption – and redistribution – but this year the convert in question appears to be one of Canada’s biggest banks. In a recent report, economists at TD bank laid out “The Case for Leaning Against Income Inequality,” pointing out the dangers of the widening divide, and giving some strong suggestions on how to turn the tide. It’s a timely message, as another report released this week from the Broadbent Institute shows that the majority of Canadians desire action on income inequality, despite underestimating just how unbalanced the distribution actually is in this country. This widely held appetite for redistribution is particularly interesting, given that it’s been a dirty word for many years, abandoned by parties of all ideological leanings. While no one was talking about it, a massive redistribution was already happening right under our noses, as incomes and resources became increasingly concentrated in the hands of a smaller and smaller percentage of Canadians. The Broadbent Institute reports that the richest 20 percent now control over 67.4 percent of all wealth in the country. This redistribution happened while we were being told that inequality was of no great concern; so long as the economy was growing, everyone’s life circumstances were improving. That assumption has been challenged in recent years, in particular as it has become clearer that income inequality leads to worse health outcomes – most true for those who make the least. As studies that compare life expectancy by neighbourhood, such as Code Red in Hamilton have shown, people living in poverty often have life expectancies 20 or more years less than the wealthiest members of society. But the health effects of inequality are not confined to the most disadvantaged. As Richard Wilkinson and Kate Pickett described in their 2009 book, The Spirit Level, people living in less equal countries suffer from worse physical and mental health, even if they are at or near the top of the socioeconomic scale. It is perhaps discouraging that the health effects of inequality have not been sufficiently concerning to drive decision-makers to change direction, but a new kind of evidence may make a greater difference. It’s not only the people in unequal countries that are sicker, it’s their markets as well. The OECD reports that income inequality is at the highest level in 30 years, and that economic growth has been slowed by as much as 10 percent in some countries as a result. A 2014 IMF study showed that redistributive policies through tax and transfers not only 144
do no harm to the economy, but can improve performance in the long-term. In fact, it appears that public investments in child care and other services are far more effective in creating jobs and increasing economic growth than corporate or income tax cuts. Returning to the TD report, they recommend a variety of key public investments to reduce inequality, including affordable housing, health and social services, early childhood development and decreasing barriers to all levels of higher education, from skills training to professional colleges. These are encouraging comments to see, as they also address key social determinants of health, meaning they are not only good for the economy, but more importantly, good for Canadians. Overall, these are excellent recommendations. One drawback is a focus on means-testing the recommended programs. While this can be a way to decrease the overall cost of social programs, it can also erode the public support needed to maintain them, and at the same time, fail to reach the “hidden poor” — people who are earning middles class wages but unable to keep up with rising costs. Better would be a proportionate universality approach, as described in Sir Michael Marmot’s Fair Society, Healthy Lives report, which would see social benefits delivered to all Canadians but increased support to those in greater need. The most glaring gap in the TD report, however, lies in the recommendations for how to pay for the social investment required to decrease barriers to success. There is a passing and unenthusiastic reference to increasing income taxes on the top 1 percent of Canadian earners, and a revealing omission of any mention of corporate taxation, non-salary compensation or CEO salaries. Still, in keeping with the generosity of the season, and the spirit of the report, it’s extremely encouraging to see this shift in thinking coming from so many directions. When economists working for one of the ‘Big Five’ banks – Canada’s largest lender, in fact – come out with a strong position on income inequality, it’s indicative of how much this has moved from being a fringe concern to economic orthodoxy. Last year at this time we heard Conservative Cabinet minister James Moore channel his inner Scrooge, implying that the poverty of his neighbour’s child was none of his concern, and neither was the poverty of Canadians any business of the federal government. How delightful to hear a message far more in keeping with the spirit of the season, however unlikely the source. Ryan Meili is a Saskatoon-based family physician, expert advisor with EvidenceNetwork.ca and author of A Healthy Society: How a focus on health can revive democracy.
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Pourquoi une grande banque canadienne prône une plus grande égalité des revenus L’investissement public dans l’éducation des enfants, la santé et le logement abordable aident l’économie, confirment des études Par Ryan Meili C’est un grand classique de Noël, une histoire de rédemption et de redistribution de la richesse. Un prêteur sur gages a une révélation et découvre l’esprit du don et de la générosité. Cette année, il semblerait que le converti en question soit l’une de nos grandes banques canadiennes. Dans un rapport récent intitulé « Pourquoi lutter contre l’inégalité des revenus au Canada », des économistes de la Banque TD soulignent en effet les risques que présente le creusement du fossé entre riches et pauvres et avancent quelques solides propositions pour renverser cette tendance. Un message qui vient à point nommé, puisqu’un autre rapport publié cette semaine par l’Institut Broadbent confirme qu’une majorité de Canadiens réclame des mesures pour réduire cet écart, même s’ils sous-estiment son ampleur réelle dans notre pays. Ce regain d’intérêt généralisé pour la redistribution des richesses mérite d’être souligné; l’expression semblait bannie du vocabulaire depuis de nombreuses années et les partis de toutes tendances l’avaient abandonnée. Même si personne n’en a parlé, une redistribution massive s’opérait néanmoins pendant ce temps au nez et à la barbe de la population, qui allait se traduire par une concentration croissante des revenus et des ressources dans les mains d’un nombre de plus en plus restreint. L’Institut Broadbent rapporte que le 20% des plus riches détiennent aujourd’hui 64% de toute la richesse au Canada. Le phénomène s’est produit tandis qu’on nous serinait que l’inégalité n’était pas réellement une inquiétude; tant et si longtemps que l’économie serait en croissance, les conditions de vie de tous les citoyens allaient s’améliorer. Il y a quelques années, on a commencé à mettre en doute cette affirmation, notamment parce qu’il est devenu évident que l’inégalité des revenus conduit à une régression des résultats en matière de santé, en particulier chez les moins bien nantis. Les études qui comparent l’espérance de vie en fonction du quartier de résidence, comme le projet Code Red à Hamilton, démontrent que les personnes pauvres vivent souvent une vingtaine d’années de moins que les membres les plus riches de la société. Les effets négatifs de l’inégalité sur la santé ne se limitent pas aux plus démunis. Comme l’ont montré Richard Wilkinson et Kate Pickett en 2009 dans leur ouvrage The Spirit Level, les personnes qui vivent dans des pays peu égalitaires souffrent de problèmes de santé physique et mentale plus importants qu’ailleurs, et ce, même si elles sont au sommet ou près de l’échelle socioéconomique.
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On pourrait ressentir un certain découragement à l’idée que les effets de l’inégalité sur la santé n’inquiètent pas suffisamment les décideurs pour qu’ils changent leurs orientations, mais de nouveaux faits pourraient changer la donne. On constate en effet que dans les pays où l’écart est grand, ce n’est pas seulement l’état de santé des gens qui se dégrade, mais aussi celui des marchés. L’OCDE rapporte que l’inégalité des revenus n’a jamais été aussi forte en 30 ans et que dans certains pays, cette situation a ralenti la croissance économique par un facteur pouvant aller jusqu’à 10 %. Une étude du FMI publiée en 2014 montre que les politiques de redistribution par le biais des impôts et des transferts ne nuisent pas à l’économie, bien au contraire : ils peuvent améliorer le rendement à long terme. En fait, il semble que les investissements publics dans les garderies et d’autres services sont beaucoup plus efficaces pour stimuler la création d’emplois et la croissance économique que les baisses d’impôt accordées aux entreprises et aux particuliers. Revenons à notre rapport de la Banque TD. Pour réduire l’inégalité des revenus, ses auteurs recommandent un éventail d’investissements publics, notamment dans le logement abordable, les services sanitaires et sociaux, le développement de la petite enfance et l’abolition des obstacles qui bloquent l’accès aux études postsecondaires, de la formation technique à universitaire. Voilà des propositions encourageantes, puisqu’elles concernent aussi les déterminants sociaux de la santé; cette orientation n’est pas seulement bonne pour l’économie, mais aussi pour la population du pays, ce qui est encore plus important. Dans l’ensemble, ce sont d’excellentes recommandations. Un point faible cependant concerne l’idée de déterminer l’accès aux programmes sociaux en fonction des revenus. Bien que cette mesure puisse être un moyen de réduire leur coût global, elle peut aussi affaiblir le soutien collectif nécessaire pour les maintenir et nous empêcher d’atteindre les personnes dont on dit qu’elles sont « la face cachée de la pauvreté » – c’est-à-dire des membres de la classe moyenne en perte de vitesse face à l’augmentation constante du coût de la vie. Une meilleure approche serait celle que propose Sir Michael Marmot dans son rapport Fair Society, Healthy Lives, à savoir l’universalité proportionnelle; suivant celle-ci, les prestations sociales s’adresseraient à toute la population, tout en prévoyant un soutien supplémentaire pour les plus démunis. La lacune la plus manifeste du rapport de la Banque TD ressort dans les recommandations sur le financement des investissements sociaux requis pour réduire les obstacles à la réussite. On évoque avec fort peu d’enthousiasme la possibilité de hausser l’impôt sur le revenu des particuliers du centile supérieur, tout en évitant de parler de l’impôt des entreprises, des rétributions non salariales ou des salaires des chefs d’entreprise, une omission somme toute révélatrice. Néanmoins, on constate un changement de perspective qui s’accorde bien avec l’esprit de générosité des Fêtes, non seulement dans le rapport de la Banque TD, mais chez de nombreux autres acteurs sociaux. Lorsque les économistes de l’une des cinq plus grandes banques du pays – le plus grand prêteur en fait – adoptent une position aussi radicale sur 147
l’inégalité des revenus, tout porte à croire que les tenants de l’orthodoxie économique ne considèrent plus celle-ci comme une préoccupation marginale. L’an dernier à la même époque, le ministre conservateur James Moore a laissé transparaître son Scrooge intérieurlorsqu’il a laissé entendre que la pauvreté de l’enfant de son voisin ne le concernait pas et qu’il n’appartenait pas non plus au gouvernement de se soucier du sort des plus démunis au sein de notre société. Comme il est réjouissant d’entendre aujourd’hui des propos qui s’accordent beaucoup mieux avec l’esprit des Fêtes, peu importe si le porteur du message est inhabituel. Établi à Saskatoon, Ryan Meili est omnipraticien, expert-conseil auprès du site EvidenceNetwork.ca et auteur de l’ouvrage A Healthy Society: How a focus on health can revive democracy.
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Why the federal government needs to keep its promise to end income-splitting Children’s health more about good social policy than medicine alone By Avram Denburg More of Canada’s children are living in poverty than ever before. A new report reveals that child poverty rates in Canada remain unconscionably high. Almost one-third of children in Toronto live in low-income households. Population measures of child health in Canada are also troubling, including above average rates of infant and under-five mortality and below average marks on indices of child well-being as compared to high-income country peers. We are awash in riches, yet plagued by poverty. Why do we tolerate such disparity? Ironically, our national preoccupation with health care is partly to blame. Our public discourse on health, including child health, has tended to focus on acute medical problems and technological solutions to them. This has blinded us to the disproportionate role of social circumstance – facets of daily life as fundamental as food and housing security – in determining child health and well-being. Greater attention to the social determinants of child health need not crowd out efforts to optimize access to quality health care, which every child surely deserves. But it should direct our gaze upstream, towards the often-remediable sources of childhood illness and suffering. Disparities in child health and well-being in Canada find their source in the values that drive social policy choices for children. The values that shape our political culture, that ground the legislative and policy priorities of government, often matter more to child health than the results of any clinical trial ever will. In this federal election, we bore collective witness to a clash of values with real bearing on the life chances of Canadian children. We witnessed opposing stances on income tax policy – notably, with respect to incomesplitting for couples with children. Since its announcement last fall, this policy has been consistently framed by the Conservatives as a defense of Canadians’ economic freedom – a way for “people to put more money back in their own pockets.” But as numbers from the Parliamentary Budget Office make clear, income-splitting primarily benefits middle- and upper-income families, provides relatively little tax relief for low-income families, and skirts single parents altogether. Just as importantly, it acts to deter both parents from equal engagement in the workforce and devalues family policies that promote dual engagement.
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From the point of view of child health, evidence suggests we should be doing just the opposite. Family policies that favour dual-earner households – universal childcare, enhanced parental leave and robust early childhood education – are associated with gains in child survival. The more generous a country’s policies toward dual-earner families, the lower its infant mortality rate: remarkably, among OECD countries, every increase of one percentage point in dual-earner support correlates with 0.04 less infant deaths per 1000 births. Knowing this, one might reasonably ask what inspired the Conservatives’ resolute defense of income-splitting. Its logic is rooted in values that increasingly suffuse large parts of our political system and society: ones that define social citizenship by degrees of economic liberty and spurn equality and universalism as foundations for social policy. Our ever-deepening ideological commitment to market freedom has obscured the lessons of good science. We’ve become a society that defends a narrow form of liberty at the expense of equality or solidarity. A free and just society depends on liberty; but liberty unchecked abets polarization and social dislocation. If we want to improve the health of Canada’s children, we must begin to re-imagine the values that found our social policies. Prime Minister-designate Trudeau campaigned on a promise to scupper income-splitting, recognizing its inherent inequity. Canadians seem to have recognized this too. Our new government should follow through on this promise. While laudable, promises to roll back this policy represent a very small step toward confronting disparities in child health and well-being in Canada. Income-splitting is one manifestation of a broader set of social values that has come to pervade our political institutions and discourse. Going forward, Canadians should continue to press for values and policies that buoy all our country’s children, rather than leave those most vulnerable among us to be buffeted by rough market seas. Dr. Avram Denburg is an expert advisor with EvidenceNetwork.ca, a paediatric oncologist at Sick Kids and a 2015 Trudeau Scholar. He sits on the Board of Canadian Doctors for Medicare.
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Ending homelessness in Canada receives failing grade Homelessness remains a national crisis By Jino Distasio Homelessness in Canada remains a national crisis despite the best efforts of social groups, housing advocates and all levels of government. In the 2014 State of Homelessness in Canada Report Card released last week, the most startling number remains that on any given night 35,000 Canadians have no place to call home. Even more damning is that throughout the year, an estimated 235,000 different individuals will experience the harshness of having no housing. Among industrialized nations, Forbes ranks Canada among the top 20 richest nations, yet we have failed to tackle homelessness in Canada despite years of sustained effort. The mid-1990s were less than kind to Canadian cities. The economy was stagnant and the federal government shifted its policies on social housing, transferring responsibility from the federal government to the provinces. This period was marked by a significant shortfall in building affordable housing across the country and a lack of supports within a health care system that was already maxed out. A flashpoint was in 1999 when images of Tent City, an encampment of homeless persons in Toronto, thrust Canada into the limelight for the entire world to see that we could not house people in one of our most prosperous cities. In reactionary fashion, the Federal government stepped in amidst an international shaming and growing pubic fervor that something had to be done. The outcome was the establishment of a large-scale intervention big enough to have an immediate impact. Seeded with $750 million, a national program was launched in Canada’s largest cities. While the funding was not enough, the wheels were set in motion to help address the needs of our most vulnerable citizens. Over the next 15 years the emphasis shifted from building homeless shelters to include a much broader focus in areas such as labour reintegration, supportive housing and acknowledging that our mental health care system has failed to address the complex needs of a large number of persons. Today, the Homelessness Partnering Strategy (HPS) is Canada’s main source of federal policy with funds directed toward ending homelessness. HPS funds are deployed to cities via local community entities that are responsible for the implementation and distribution of dollars. This has created an important delivery mechanism by which federal monies are able to flow to local jurisdictions without much complexity. In its most current iteration, the HPS has taken the lead by promoting “Housing First” which is an intervention aimed at ending homelessness by providing specialized supports along with housing. Housing First has been proven to be highly effective in ending homelessness for persons with mental health issues.
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The 2014 Report Card notes the impact of homelessness to the Canadian economy is upwards of $7 billion annually, with a substantive portion attributed to the over consumption of services and supports related to mental health and social services. This includes the overuse of hospital and primary care centres, the deployment of police, as well as other areas of our social safety net that could be better used if more people had decent housing and the supports necessary to succeed. What is needed now is the momentum to deal with homelessness in a more comprehensive manner. Solutions must come from the community, such as the Task Force to End Homelessness in Winnipeg which has penned a plan, to the Canadian Alliance to End Homelessness’s bold announcement of launching the “20,000 Homes Campaign” with the objective to house 20,000 of Canada's most vulnerable by 2018. All levels of government and the private sector must begin to see the tremendous social and economic benefits of doing the right thing. Canada can end homelessness and our elected officials have a duty to work together on funding community based solutions. Jino Distasio is an expert advisor with EvidenceNetwork.ca Associate Professor of Geography and Director of the Institute of Urban Studies at the University of Winnipeg. He is also the co-principal investigator for the Winnipeg site of the At Home Chez Soi Project.
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How doctors can tackle the poverty of their patients without leaving the doctor’s office By Gary Bloch and Sharon Macdonald Can a question asked in a doctor’s office contribute to ending poverty for patients and their families? This is what we asked ourselves 10 years ago, as we set out to convince health providers to tackle poverty. There were two factors that pushed us into this work: first, the evidence shows us that poverty puts people at risk for almost every chronic disease, acute illness, even accidents and trauma. And for kids, poverty affects them from the time they are in the womb, right through adulthood. The second push comes from our patients. We hear stories day in and day out, like that of Nico who, at age 42, has diabetes, heart disease and depression. He told us very clearly that he would not be able to get healthy when he has to struggle to eat and pay his rent on the $1400 a month he earns at minimum wage. For doctors, the need to tackle poverty as a health issue is obvious — and it is urgent. Health providers told us that they didn’t feel comfortable joining protests or writing policy briefs to government. So we decided to find ways for them to tackle poverty for their patients in their offices. This is why we created a “Poverty Tool” that lays out a three step approach for front line doctors, nurses and other health workers to deal with poverty. The steps are simple: ask everyone about their income, learn about how poverty impacts patients’ health and connect patients with key income benefits programs and community resources already available. The critical message to health providers? Helping our patients reduce their poverty is part of our work as health practitioners. The impact has been profound. Since we created the Poverty Tool in Ontario, we have taught this approach to thousands of health providers across the country. We now have versions in development in multiple provinces – in BC, Alberta, Saskatchewan, Manitoba and Nova Scotia. And this is not surprising, because the tool works. Through simple interventions like asking patients to complete their tax returns, we have supported up to a doubling of incomes for highly vulnerable families: Sarah, a mother of two earning $14000 per year through part time minimum wage work in Ontario, gained access to $13,500 in extra tax and child benefits. Agnes saw her income increase from $656 to over $1250 a month when we helped her move from basic social assistance to the Ontario Disability Support Program and related income supplements. 153
In a sign of the Poverty Tool’s acceptance, Manitoba brought together a powerful coalition of supporting community groups in the development of its Poverty Tool, including government, medical organizations, academics and many civil society groups. The Manitoba clinical poverty tool is now being broadly distributed throughout the province in health settings, libraries, schools and community agencies. The push for doctors to treat social issues like poverty is starting to change the way we practice medicine and how we work with community agencies and those with expertise in income benefits, food security and poverty law. Many health organizations now are right in the middle of advocacy for better social conditions. Major medical organizations, including the Canadian Medical Association and the Canadian College of Family Physicians have been vocal in their support for this approach. This demonstrates a real acceptance by the medical mainstream that reducing patients’ poverty is a core part of a doctor’s job. This shift is exciting and profound. But it is not enough. Health providers can provide a push, and can make a real difference in their individual patients’ lives. But like other important public health issues, like smoking or substance abuse, major change will require significant shifts in public policy. It will require action from government and support from the general public. Those who live without an adequate income cannot achieve their health goals without basic social foundations — including a liveable income, affordable housing and access to decent well-paid work. As we take real action to help patients and families, together we can all build those foundations. Gary Bloch is an expert advisor with EvidenceNetwork.ca, a family physician, assistant professor in the Department of Family and Community Medicine, University of Toronto and co-Chair of the Ontario College of Family Physicians’ Committee on Poverty and Health. Sharon Macdonald is a public doctor in the Department of Community Health Sciences at the University of Manitoba. See also our Podcast on the issue: Why Canadian doctors should be on the front lines of the anti-poverty struggle
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Saskatoon's housing crisis is a health emergency By Michael Schwandt and Ryan Meili Recently, a disturbing photo of five people sleeping in a Saskatoon bank lobby became headline news and filled social media feeds. An earlier photo had contrasted the lush yards on the east side of the riverbank with tents in the bushes on the west side. A few days later, homelessness was back in the news, with the fire department discovering a makeshift living space under the closed Traffic Bridge. This spring, the Saskatoon Health Region closed numerous units in a downtown hotel due to conditions unfit for habitation. These disturbing images and events each are part of a larger narrative: despite a strong economy, Saskatchewan has a deficit in access to safe and affordable housing. Such stories put a human face on the state of housing and homelessness in the city. This summer, the Saskatoon Housing Initiatives Partnership performed a "point-in-time" count of people without a home on a given night and found 405 people. The number from these counts has steadily increased, with 260 people without a home identified in 2008 and 379 homeless in 2012. What's especially disturbing is that 45 of the homeless individuals in this year's count were children. Across Canada, an estimated 235,000 people will experience homelessness in the course of a year, with 35,000 homeless on any given night. Beyond those who are homeless, many Canadians struggle to maintain the housing they have. The Canadian Mortgage and Housing Corporation defines core housing need as paying more than 30 percent of household income for housing. In 2014, one in four Canadians were in that situation, with the cost of their dwellings squeezing out the ability to pay for other essentials. The health impacts of homelessness and inadequate housing are well known. A 2007 Wellesley Institute study showed that homeless people in Toronto were 29 times more likely than the general population to have Hepatitis C, 20 times more likely to have epilepsy and twice as likely to have diabetes. These conditions are related to an interplay between the social and personal factors leading to homelessness and the hardships of living in inadequate housing. Lack of shelter means exposure not only to the elements, with risk of heat stroke in summer and hypothermia in winter, but also to violence and other risks. Accessing safe food and clean water becomes a challenge, and healthy social and family dynamics all but impossible. Managing mental health issues, addictions and other illnesses is improbable without a stable living situation. As a result, hospitalization for unmanaged chronic medical conditions rises, as do ambulance pickups to address emergencies. The cumulative effect of these challenges has 155
untold impact on individuals, and costs the Canadian economy more than $7 billion a year. As one of the major upstream determinants of health, if housing is properly addressed we can avoid preventable illness and costs, and promote good health in our communities. In Saskatoon, a "Housing First" pilot program spearheaded by the United Way provided housing to 10 local residents who have challenging health issues and social circumstances. In only six months, the program saved nearly $700,000 through decreased ambulance trips, hospital visits, police calls and detentions. Along with these compelling immediate benefits, safe, stable housing allows people an opportunity to manage health issues, pursue education and employment, as well as develop supportive family environments. The Saskatchewan government's advisory group on poverty reduction recently released recommendations for a provincial strategy. Reflecting the role of housing in both preventing and alleviating poverty, its recommendations include establishing a province-wide Housing First model and strategies to increase affordable housing. All levels of government have a role to play in making safe and affordable housing available to all. As well as the direct development of affordable housing, cities have a variety of tools available to encourage and maintain such housing options in their neighbourhoods. Federally, there is potential for leadership on this issue and practical initiatives such as earmarked funding for affordable housing. Canada remains the only G-8 country without a national housing strategy. The people of Saskatoon have been rightly upset by recent pictures of homelessness. Now is the time for us to demand action from political leaders so that we can instead become the picture of health. Michael Schwandt is a Public health physician and Assistant Professor, Department of Community Health and Epidemiology, University of Saskatchewan. Ryan Meili is an expert advisor with EvidenceNetwork.ca, a practicing family physician in Saskatoon and founder of Upstream: Institute for A Healthy Society and Chair of Canadian Doctors for Medicare.
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Basic income: just what the doctor ordered By Danielle Martin and Ryan Meili What makes people sick? Infectious agents like bacteria and viruses and personal factors like smoking, eating poorly and living a sedentary lifestyle. But none of these compares to the way that poverty makes us sick. Prescribing medications and lifestyle changes for our patients who suffer from income deficiency isn’t enough; we need to start prescribing healthy incomes. Decades of studies have shown that health care accounts for less than 25 percent of health outcomes. The upstream factors that affect health – such as income, education, employment, housing, and food security – have a far greater impact on whether we will be ill or well. Of these, income has the most powerful influence, as it shapes access to the other health determinants. Low-income Canadians are more likely to die earlier and suffer from more illnesses than Canadians with higher incomes, regardless of age, sex, race or place of residence. No wonder doctors and policy-makers are beginning to line up behind the notion of a basic income guarantee. Basic income is an approach to poverty reduction that is much simpler and more streamlined than existing programs. Every year, Canadians file taxes. With basic income, if their incomes fall below a certain level, they get topped up to an amount sufficient to meet basic needs. Basic income is a smart alternative to costly social assistance programs, helping overcome the “welfare wall” that traps too many people in the cycle of poverty. Earlier this month, 194 physicians in Ontario signed a letter calling for a basic income pilot program. Delivered to Minister of Health Eric Hoskins (also a physician), the letter outlines how poverty leads to higher rates of heart disease, depression, diabetes and scores of other illnesses. In the same month, a new report has brought forth the most official look at basic income in Canada in a generation. The Government of Saskatchewan Advisory Group on Poverty Reduction, which included community members and high-level public servants, reviewed the evidence and consulted key groups that work with people experiencing poverty. Their recommendations included the ambitious goal of reducing poverty in Saskatchewan by 50 percent by the end of 2020. To reach such a goal requires putting in place a policy with the power to do so, and the group came to the consensus that a Basic Income pilot project would be an effective and achievable means of doing so. Recommendations included the ambitious goal of reducing poverty in Saskatchewan by 50 percent by the end of 2020. To reach such a goal requires putting in place a policy 157
with the power to do so, and the group came to the consensus that a basic income pilot project would be an effective and achievable means of doing so. A growing body of evidence shows that allowing poverty to continue is far more expensive than investing to help improve people’s economic wellbeing. Currently $3.8 billion dollars – 5 percent of GDP - is lost from the Saskatchewan economy each year due to increased health and social costs and decreased economic opportunities. In Ontario, this cost of poverty has been calculated to be upwards of $30 billion per year. Where more extensive basic income pilots have been tried, both internationally and in Canada, the results have been impressive. The Mincome experiment in Dauphin, Manitoba in the 1970s resulted in higher school completion rates, and a reduction in hospitalization of 8.5 percent largely due to fewer accidents, injuries and mental health admissions. According to the Canadian Institute for Health Information, Canadians spent $63.6 billion on hospital services in 2014, meaning a decrease of 8.5 percent would result in savings of $5.4 billion. This is just one of the many areas where the return on social investment saves public funds, improving the lives of Canadians in the bargain. Some policy changes happen slowly, with incremental movements in public opinion. But every once in a while, an idea that had seemed outside the realm of possibility quite suddenly gathers momentum. The concept of basic income is on a course from the margins to the mainstream. If political leaders have the health of Canadians as their first priority, they’ll turn advice into action and implement basic income. Danielle Martin is a family physician and Senior Fellow at the Women’s College Hospital Institute for Health System Solutions and Virtual Care. Ryan Meili is a family physician, founder of Upstream: Institute for A Healthy Society and an expert advisor with the Evidence Network.
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Will climate refugees in Canada finally spur action on climate change? By Ryan Meili and Mahli Brindamour A young child arrives at the hospital emergency room in respiratory distress, his asthma worsened by smoke exposure. An elder has uncontrolled blood pressure because there wasn't time to get her medications when the evacuation orders came through. Scabies and other illnesses related to crowding spread quickly through the close quarters of the evacuees. Sudden departure from and worry about home bring significant mental stress. These sorts of health problems are commonplace for people in circumstances like the over 13,000 Northern Saskatchewan residents forced to leave their homes due to forest fires. As physicians, we're taught not only to look at the symptoms of an illness, but to seek its root causes. For these patients, the connection is fairly obvious: through smoke and relocation, the fires have hurt their health. And the cause of those fires? Canadian experts are pointing to high temperatures and dry conditions, with climate change a likely factor. The people who have been relocated in Saskatchewan come from Northern communities with higher rates of poverty than the rest of the province. This is the predicted pattern of the repercussions from climate change, as remote communities with less infrastructure are more prone to its effects. Poverty, lower rates of employment, the effects of colonization and other social determinants also lead to higher rates of illness. This means that community members are more susceptible to the health effects of changes in temperature, air quality and diet that come with the disruption of climate. We now have internally displaced people in Saskatchewan, and although they do benefit from state protection, in some ways they are as vulnerable as resettled refugees. The federal response to the forest fire crisis is certainly better, however, than the treatment refugees to Canada have received in recent history, as exemplified by the cuts to the Interim Federal Health Program, reducing health services to this vulnerable population. Natural disasters can bring out the best in our political leaders. They come forward with extraordinary support for people affected or displaced by floods or forest fires. We've seen this in the past couple of weeks in Saskatchewan too, as provincial and federal governments have been assisting evacuees and adding additional resources to fight the fires devastating the North of the province. This action is admirable, a manifestation of the care we provide for each other as a society, and of governments and civil society acting decisively in the public interest. Tragic times can paradoxically be a boon for political leaders. It's a chance for dramatic speeches and fire station photo-ops from government and opposition leaders alike. We say this not to cast doubt on their motivations. A strong performance in times like these demonstrates the dedication the public expects from their elected leaders. However, we 159
should be able to expect more. The point is that talking about climate change is not bringing up politics in a time of tragedy. There are already politics at play. What we need from our leaders is more than a robust response to the downstream effects of climate change. For the health of Canadians, we need to see upstream thinking to prevent this from occurring over and over. Unfortunately, we're hearing nothing of the sort. Quite the opposite in fact; at the same time as the federal government is stepping in to take action to respond to the effects of climate change, they are the subject of international criticism at the Climate Summit of the Americas in Toronto for their inaction on its prevention or mitigation. Premier Wall has been openly resistant to taking any meaningful action to reduce carbon emissions, despite Saskatchewan leading the country in per capita carbon output. Climate change is a massive and complex issue, and can be hard for people to get their heads around, and hard to motivate political leaders to make sacrifices to act. Sometimes what it takes to understand something on this scale is to see its effects on the health of a single person or a community. Saskatchewan today has thousands of climate refugees suffering as a result of climate change. Will that be enough to change minds and spur meaningful action? If our leaders have, as they should, the health and wellbeing of the population as their highest priority, it must. Ryan Meili is a family physician in Saskatoon, founder of Upstream, and an expert advisor with EvidenceNetwork.ca. Mahli Brindamour is a pediatrician in Saskatoon and a member of the steering committee of Canadian Doctors for Refugee Care.
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What I learned as a medical student working with low-income families in Toronto By Lita Cameron and Elizabeth Lee-Ford Jones As a medical student taking part in a Social Paediatrics course at The Hospital for Sick Children (SickKids), I was recently immersed in the lives and health care needs of lowincome families in Toronto. This experience reshaped the lens through which I now view health care and helped me recognize that societal factors greatly influence the emotional and physical wellbeing of children and their families. There were times during this course – which involved working to improve the health of children of young parents, in clinics with multi-disciplinary teams — when I felt overwhelmed by the incredible number of obstacles faced by Toronto families. I met a teenage mother raising her baby in a shelter; I met a refugee who found creative ways to feed herself and her child on $200 a month after escaping an abusive relationship. I learned the source of significant weight loss for a very young teen mother was because her paycheck was used to feed her extended family, not herself. The Toronto Children’s Aid Society recently published a report saying that 30 percent of children in Toronto are from low-income families. Put another way, almost 146,000 children are growing up in low-income families in Toronto. They face higher risks for almost every kind of illness and disease. When a doctor regularly meets patients who face poverty, food insecurity, lack of safe housing, and psychosocial stressors, it reinforces the necessity to ask about their social and living conditions. We don’t know unless we ask. And we don’t ask unless we understand the reality of those living in poverty. I was reminded of this after meeting children and mothers who have experienced physical and emotional abuse, for example. And after meeting families who might not have insurance or access to government subsidies for medications, lotions or treatments. In these instances, asking questions regarding safety and income becomes paramount. By the end of medical school, students should all have a good understanding of what public health experts call the social determinants of health. I was reminded of this on a daily basis during this course. I saw countless examples of strength and resilience as well as the power of acts of generosity. This may not be a part of the physiology we study, but it plays a significant role in health and healing. I realized why an understanding of the social conditions of our patients should shape our approach to health and health care. But to translate our knowledge of the social determinants of health into our practice can be a challenge for medical students and residents. Medical schools teach a lot about patient-centered care. But there is a need for more exposure to the daily struggles of disadvantaged families. There is also a need to integrate patient advocacy into medicine in order to learn practical ways to create meaningful 161
change. This means providing treatment options that are feasible, affordable and practical for families. It requires insight into food and housing insecurity and how poverty may manifest as illness or present challenges to adhere to treatment. My time at SickKids also gave me some insight into the dedication of community organizations and allied health professionals in addressing unmet needs on an individual, community and policy level. I wish more of my fellow medical students could share this experience of immersion into a culture of medical practice where a deep understanding of the experiences of marginalized groups influences not only the questions asked, but the treatment strategy and approach. Many of my peers in social paediatrics have helped me understand a doctor’s role as an advocate — how to address injustice within the health care system and ways to design a medical practice to see health beyond illness. Social determinants of health are no longer an abstract concept. Lita Cameron is a Family Medicine resident at McMaster University. She completed her Masters in Global Health Science at Oxford University. She worked previously for the Public Health Agency of Canada and has been involved in aboriginal health research. Elizabeth Lee-Ford Jones is an expert advisor with EvidenceNetwork.ca, and Professor of Paediatrics at The Hospital for Sick Children and the University of Toronto. See also our Podcast on the issue: How future doctors see social factors shaping their medical practice
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Arrested for Sleeping? The struggle to occupy public space By Jino Distasio As humans, we need to sleep. It is a biologically unavoidable act. Yet, on both sides of the border, “sleeping” can be considered a criminal act, especially if you are homeless and have no place to rest your head other than in public spaces such as parks. How have cities and states been able to impose and enforce by-laws and ordinances that clearly violate one’s right to occupy public space for this very purpose? This summer several cases are putting this longstanding question to the legal test. The outcome might just change the way we view homelessness. In the City of Abbotsford, British Columbia, a civil court case is pitting a group known as the “Drug War Survivors” against the state in a fight over what is being viewed as further evidence of the criminalization of homelessness. The group’s lawyer has argued that his clients (and all persons homeless) have the right to occupy park space for the purpose of temporary dwelling and sleeping. The case argues that a set of by-laws prohibiting such uses of public spaces is unjust given there is no alternative. Perhaps the real fight is also about who is responsible for the provision of adequate shelter in Canada, especially for those most in need. Across the border, the United States Department of Justice has intervened in a case in the District Court of Boise, Idaho by filing a Statement of Interest. The filing clearly articulates that the act of sleeping, when there is no shelter available, should not be considered a criminal act, yet they cite that among the nearly half a million annually homeless, 42 percent slept in unsheltered public locations. The Boise filing may become a landmark case in finally ending the debate on whether it is constitutionally just for any citizen without shelter to seek a public space for the right to sleep — without fear of being arrested. Interestingly, neither the Abbotsford case nor the Boise filing are new as cities have always struggled with the inability to shelter all those in need since the dawn of modern urbanization. However, what is new is the criminalization of homelessness. In the North American context, it was not until the late 1970s when the United States saw a spike in the numbers of citizens without homes, largely attributed to the economy, the deinstitutionalization of persons from mental health facilities and increasing veterans on the streets that actions began to take place. For most jurisdictions, the fight was not about affordable housing but how to deal with the “vagrants” who shuffled about the streets, causing well-minded citizens to demand steps be taken to end public intoxication, curb panhandling and the visibility of poverty, mental health and severe addiction.
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In a case that took place in the winter of 1979, Supreme Court Judge Andrew Tyler delivered a landmark decision in the case of Callahan vs. Carey. Robert Callahan was homeless and resided in the notorious Bowery neighbourhood of New York City. Justice Tyler’s brave decision was clear: the State was obligated to provide shelter to those most in need and his decision also included the clear articulation of necessary shelter standards and intake and monitoring provisions. The decision resulted in the state of New York being required to shelter those in need. The case would also impact other jurisdictions to consider whose responsibility it was to provide temporary shelter. While the decision did not end homelessness, it did place the burden on the State to provide shelter spaces while also setting a strong precedent. In the late 1990s, Toronto’s “Tent City” plight became ground zero for a Canadian resistance movement that drew in many including the late Jack Layton, a then City Councillor, who grappled over the same question: Who is responsible for the provision of adequate shelter in Canada during a time of crisis? The Toronto story ended with a mass eviction on the occupied private lands while a media storm brewed among social housings activists, governments and citizens all fighting over how shelter should be provided and what rights Canadians have to occupy land. The Tent City movement did not result in the legal outcomes of Callahan vs. Carey but it did see the federal government acknowledge the homeless crisis with an investment of nearly a billion dollars in funding to overhaul Canada’s inadequate shelter system. As the North American summer simmers with high temperatures evoking heat warnings, several legal proceedings are quietly brewing. Perhaps the boiling point has been hit — with governments on both sides of the border on the verge of acknowledging the right of people to sleep in public spaces when no other option exists. Let’s hope these legal cases also determine that this fundamental right cannot be deemed a criminal act. And let’s hope what follows is further government investment in the range of supports needed to end homelessness. Jino Distasio is an expert advisor with EvidenceNetwork.ca and Director of the Institute of Urban Studies, University of Winnipeg. See also our Podcast on the issue: Ending homelessness in Canada is possible
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Extreme weather events hit most vulnerable Canadian governments need to be better prepared to tackle climate volatility By Jino Distasio Just off a bustling urban street, in the heart of a middle class Canadian community, I came upon an elderly man wilting in the low lying shrubs, mere feet from heavy traffic and visibility. He appeared unconscious, perhaps brought on by the searing summer temperatures that had pushed the mercury above 30 degrees Celsius. Judging by his appearance and nearby possessions, I made the assumption that he was homeless. As I waited for emergency personnel to be dispatched, I did my best to describe his appearance and condition which seemed dire. As we know, being homeless presents many socioeconomic hardships. Homelessness also increases vulnerability to extreme heat events that can exacerbate health issues brought on by heat exposure, including cardiac events, dehydration and respiratory illnesses. Most often Canadians tend to think of the impact of cold weather in our cities during the winter months when vulnerable persons have too often frozen to death. However, heat is also a killer and cities need to be better prepared to address the risks associated with extreme weather events — not only today, but also as our climate changes and brings forth more volatile weather patterns. This past winter several tragic events occurred in Toronto where deaths related to cold weather hit the homeless community hard. During that same frigid period, on the other side of the world, the Australian city of Melbourne was grappling with a pending heat wave. The city issued a series of measures to support its local vulnerable population with cooling stations. In addition, Melbourne also adopted a strategy to deal with increasing extreme weather. Such government strategies will become even more important as climate volatility is expected to worsen, especially with respect to the frequency and duration of hot days exceeding 30 degrees. To put this in perspective, Environment Canada defines a heatwave in Ontario as three consecutive days of 32 degrees along with high humidity. This past May saw parts of India hit temperatures of 48 degrees Celsius, resulting in an estimated 2000 deaths, many being among the poor and homeless. Closer to home, the Chicago extreme heat event of July 1995 resulted in an estimated 700 heat related deaths. The spike in mortalities took place during a span of about 10 days when temperatures soared past 40 degrees Celsius. The New England Journal of Medicine published an article documenting the Chicago tragedy with the authors citing social isolation, pre-existing medical conditions, poverty and living conditions as being among the key predictors of mortality for such occurrences. Not surprisingly, they conclude that the provision of better housing, frequent 165
interactions with social services and simple access to air conditioning as critical for survival. There are no shortages of examples of how extreme weather events have impacted vulnerable populations on a global scale. Many of these events have caused policy makers to pause and consider the need for careful planning in order to be better prepared for sudden extreme weather occurrences. However, what is now emerging are a series of even more dire predictions as a result of modelling long-term trends in weather. In a recent article published in Nature Climate Change, authors Bryan Jones and colleagues examined long-term weather predictions in the United States. What they contend is that the intensity of days in excess of 35 degrees Celsius will increase dramatically over the coming decades. The outcome could prove devastating if climate adaption strategies are not created to address extreme heat events, especially for vulnerable populations. In Canada, we need more careful analysis of emergency planning focused on extreme heat events for vulnerable persons. Both Environment Canada and Health Canada have developed communications strategies and tools. These resources remain important for building awareness but more concrete actions are needed that have a direct impact. This includes addressing income inequality, ending homelessness and retrofitting our aging housing stock. We must not only build more affordable housing but do so in a much more efficient manner to both cool and heat buildings (while using less energy). Governments of all levels across the country need to consider the mounting evidence for increasing climate variability and create actionable plans for vulnerable persons to ensure that those most likely to be adversely effected by extreme weather events are protected with the right supports. This must start with ending homelessness for as many Canadians as possible and closing the widening income gap that pushes far too many into poor quality housing. Jino Distasio is an expert advisor with EvidenceNetwork.ca and Director of the Institute of Urban Studies, University of Winnipeg.
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Is it finally time for a Guaranteed Annual Income? By Noralou Roos and Evelyn Forget Could the Guaranteed Annual Income – once considered radical notion – now be an idea whose time has come? The Dutch city of Utrecht recently announced it is starting an experiment to determine whether introducing a basic income produces a more effective society. Closer to home, Joseph Ceci, Alberta’s new Finance Minister proposed a guaranteed income program last year on the election campaign trail, and both Calgary Mayor, Naheed Nenshi and Edmonton Mayor, Don Iveson, have also promoted such a program. Now, medical officers of health and boards of health members across Ontario are officially calling for provincial and federal governments to bring in a basic income guarantee. So what exactly is a Guaranteed Annual Income? (GAI) Well it turns out, GAI has been supported by generations of economists and welfare theorists, from the left and the right. One version works like a refundable tax credit. If an individual has no income from any source at all, they receive a basic entitlement. As earned income increases, the benefit declines but less than proportionately. As a result, low income earners receive partial benefits so that they are not worse off than they would be if they quit their jobs and relied solely on income assistance. This means that there is always an incentive to work, and people who work are always better off than they would be if they didn’t work. So why are such a broad group of people – finance ministers, mayors and medical officers of health – pushing such a program? Poverty, substantial evidence now tells us, is one of the best predictors of poor health. And poor health costs everyone. Research on the city of Hamilton, Ontario demonstrated that residents of the city’s wealthy west Mountain neighborhood lived, on average, to 86.3 years of age, while average age at death for residents of one of the poorest Hamilton neighborhoods was only 65.5 years – a shocking gap. Way back in the 1970s, Manitoba tried implementing a Guaranteed Annual Income in Winnipeg and in the small town of Dauphin. In Dauphin, everyone was eligible to participate. A family with no income from other sources would receive 60 percent of the Statistics Canada low-income cutoff (LICO) which varied by family size. Every dollar received from other sources would reduce benefits by 50 cents. Important for an agriculturally dependent town with a lot of self-employment, the GAI offered stability and predictability. Sudden illness, disability or unpredictable economic events would no longer be financially devastating. The project ran for four years, ending in 1979. So did the GAI produce anything to report? Remarkably, even this four year program had strong positive results. Dauphin high school students were more likely to remain in 167
school than had been true in the years before the GAI started (or in the years after the GAI stopped). The health of Dauphin residents also improved, with fewer hospitalizations (8.5 percent reduction), specifically for mental illness, accidents and injuries. So how much would introducing a Guaranteed Annual Income across Canada cost? According to several Queens University professors, the cost of replacing social assistance (which includes welfare and disability support) and old age security (which includes a top-up for low-income seniors) and providing every adult with an annual income of $20,000, and children with an income guarantee of $6000, would be $40 billion. The Fraser Institute calculates the total cost of Canada’s current income support system (the payout plus administrative costs) at $185 billion. Our own estimates, which build on existing social programs, range from a gross annual cost of $17 billion for a program that (in today’s dollars) is slightly more generous than was offered in Dauphin, to a “Cadillac” version costing $58 billion that would guarantee everyone a minimum income equal to the LICO, and pay at least some benefits to people earning well above the LICO. The cost of a Guaranteed Annual Income depends on how generous it is, how quickly benefits are phased out with additional income and how existing social programs are affected. Some of these costs, of course, would be partially recovered from the additional taxes paid by recipients, as well as the lower costs faced by so many other social programs that are driven by poverty. Hospital care alone, for example, costs Canada $63.5 billion in 2014. Bottom line, whether it’s our calculations or those done by other organizations, a GAI is definitely do-able. And it is clear: the potential benefits of a GAI are substantial. Maybe it is time for the rest of Canada to at least look to what Alberta is saying and focus on the health, educational and financial benefits that the Guaranteed Annual Income might offer. Noralou Roos is the Director of EvidenceNetwork.ca and professor in the Department of Community Health Sciences, Faculty of Medicine, University of Manitoba. Follow her on Twitter at @nlroos. Professor Evelyn Forget is a health economist at the University of Manitoba. Her reexamination of Mincome and ongoing work on Guaranteed Annual Income is supported by CIHR and SSHRC.
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Serions-nous enfin mûrs pour le revenu annuel garanti? Par Noralou Roos et Evelyn Forget Se pourrait-il que l’idée d’un revenu annuel garanti – considérée autrefois comme radicale – ait mûri au point où certains envisageraient de l’adopter? Aux Pays-Bas, la ville d’Utrecht a annoncé récemment qu’elle allait tenter l’expérience afin de déterminer s’il pourrait en résulter une société plus efficace. Plus près de chez nous, le nouveau ministre des Finances de l’Alberta, Joseph Ceci, avait lui aussi proposé l’an dernier, pendant la campagne électorale, un régime de revenu garanti. Le maire de Calgary, Naheed Neshi, et celui d’Edmonton, Don Iveson, ont tous les deux donné leur aval à ce genre de programme. Et voilà qu’en Ontario, les médecins hygiénistes et les membres des conseils de santé demandent officiellement aux gouvernements provincial et fédéral d’instaurer un revenu de base. Alors, en quoi consiste exactement le revenu annuel garanti (RAG)? Dans les faits, des générations d’économistes et des théoriciens du bien-être, à droite comme à gauche, ont appuyé ce principe. Dans l’une de ses versions, le RAG prend la forme d’un crédit d’impôt remboursable. Selon celle-ci, un individu qui n’a aucune source de revenus a droit à une prestation de base. À mesure que le revenu gagné augmente, le montant de la prestation diminue, mais dans une proportion moindre. Les salariés à faible revenu reçoivent ainsi une prestation partielle qui fait en sorte qu’ils se trouvent dans une situation plus avantageuse que s’ils avaient quitté leur emploi afin de dépendre uniquement de l’aide sociale. Par conséquent, le RAG est un facteur de motivation; les gens qui travaillent sont toujours en meilleure posture que ceux ne travaillent pas. Qu’est-ce qui explique qu’un aussi grand nombre d’acteurs sociaux (des ministres des Finances, des maires et des médecins hygiénistes) réclament aujourd’hui un tel programme? Des recherches solides nous ont confirmé que la pauvreté est l’un des meilleurs prédicateurs d’un piètre état de santé. Et les gens en mauvaise santé coûtent cher à la société. Ainsi, une étude a démontré que les résidents de West Mountain, un quartier aisé de Hamilton en Ontario, vivaient en moyenne jusqu’à l’âge de 86,3 ans, alors que les résidents d’un de ses quartiers les plus pauvres ne dépassaient pas les 65,5 ans. L’écart est choquant. Il y a bien longtemps, dans les années 1970, le Manitoba avait tenté d’instaurer un revenu annuel garanti à Winnipeg ainsi que dans la petite ville de Dauphin. À Dauphin, toute la population était admissible au programme. Une famille qui ne bénéficiait d’aucune autre source de revenus recevait à l’époque une prestation équivalant à 60 pour cent du seuil de faible revenu (SFR) établi par Statistique Canada, variable selon le nombre de ses 169
membres. Chaque dollar obtenu d’autres sources réduisait cette prestation de 50 cents. Le RAG offrait un certain degré de stabilité et de prévisibilité, un avantage non négligeable dans une ville aussi dépendante de l’agriculture et où une grande proportion de gens sont travailleurs autonomes. Une maladie soudaine, une invalidité ou un événement économique imprévu ne représentaient plus une catastrophe sur le plan financier. Ce projet s’est poursuivi pendant quatre ans et s’est terminé en 1979. L’expérience a-t-elle engendré des retombées dignes d’être rapportées? Fait étonnant, elle a donné des résultats très positifs même si elle n’aura duré que quatre ans. À l’école secondaire de Dauphin, le taux de persévérance scolaire était supérieur à ce qu’il était avant l’instauration du RAG (et après sa disparition). De plus, l’état de santé des résidents de la ville s’est amélioré; les hospitalisations pour cause de problèmes de santé mentale, d’accidents ou de blessures ont diminué de 8,5 pour cent. Alors, combien coûterait l’instauration d’un revenu annuel garanti à l’échelle du Canada? D’après plusieurs professeurs de l’Université Queen’s, le remplacement des régimes actuels de sécurité sociale (comprenant l’aide sociale et le soutien aux handicapés) et de sécurité de la vieillesse (qui prévoit un supplément pour les personnes âgées à faibles revenus) par un revenu annuel garanti de 20 000 $ par adulte et de 6000 $ par enfant coûterait 40 milliards de dollars. Rappelons que l’Institut Fraser estime à 185 milliards de dollars les dépenses actuelles en matière de sécurité du revenu au Canada (incluant les prestations et les coûts administratifs). Selon nos propres estimations fondées sur les programmes sociaux en place, un régime un peu plus généreux que celui qui était offert à Dauphin coûterait 17 milliards en dollars d’aujourd’hui; une version « Cadillac », qui garantirait à toute la population un revenu minimum équivalent au SFR et offrirait au moins quelques prestations aux personnes qui vivent bien au-dessus de ce seuil, coûterait 58 milliards. Le coût total d’un programme de revenu annuel garanti dépend de plusieurs facteurs : son degré de générosité; la vitesse à laquelle les prestations sont compensées par des revenus additionnels; son incidence sur les programmes sociaux en place. Bien entendu, une partie des coûts serait récupérée grâce aux impôts supplémentaires versés par les bénéficiaires, sans parler des économies réalisées dans un grand nombre de programmes sociaux que la pauvreté rend nécessaires. À titre d’exemple, les coûts d’hospitalisation en 2014 au Canada s’élevaient à eux seuls à 63,5 milliards de dollars. Comme on le voit, peu importe leur provenance, les chiffres démontrent que le revenu annuel garanti n’est pas une chimère. Et tout indique que ses avantages sont substantiels. Le temps est peut-être venu pour le reste du Canada de tenir compte des propos émanant de l’Alberta et de réfléchir aux avantages que pourrait offrir un programme de revenu annuel garanti tant sur le plan de la santé que de l’éducation et de l’économie.
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Noralou Roos est directrice du site EvidenceNetwork.ca et professeure au département des sciences de la santé communautaire de la Faculté de médecine à l’Université du Manitoba. Suivez-la sur Twitter @nlroos. Evelyn Forget est économiste de la santé et professeure à l’Université du Manitoba. Ses travaux sur la réévaluation du programme Mincome et sur le revenu annuel garanti sont subventionnés par les IRSC et le CRSH.
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Many of the most complex needs of my patients stem from poverty and not disease alone Why Canadian children need a champion By Laura Stymiest with Elizabeth Lee Ford Jones A young girl is referred to a paediatrician’s office for inability to pay attention in the classroom. The child’s teacher is concerned she has attention deficit hyperactivity disorder (ADHD), and possibly, a learning disability. I am a second year medical student working in the clinic at the time of her visit. I am beginning to establish my approach to patient problems and complex medical illness. As I make my way through the medical history, the child’s parents tell me they are struggling to make ends meet. Despite their best efforts combined with collections from a nearby food bank, the little girl often goes to school hungry. The problem seems clear: how could any child concentrate in the face of hunger? When your groceries consist of the non-perishable offerings of others, how do you nourish a developing brain? How does a physician properly evaluate a learning problem when a child’s basic needs are unmet? I am now paediatric resident, pursuing specialist training in the diagnosis and treatment of childhood illness. Years later, I still can’t help but feel that some of the most complex needs of many of my patients stem from the constraints of poverty and not disease alone. Unfortunately, as physicians, my colleagues and I do not have the therapeutic tools necessary to “cure” the social conditions that so often impact the health of our patients. Beyond anecdotal confirmation, there is strong evidence linking poverty to poor health outcomes for children: higher levels of mental illness, accidental injury, obesity, asthma, poor brain development and more. These problems have a cost that we all bear. When children are exposed to the toxic effects of poverty, the detrimental impacts can be felt for generations – and they impact entire communities. In 1989, the year I was born, Canada’s House of Commons vowed to eliminate child poverty by the year 2000. Twenty-six years later, Canada’s children are still suffering. Current data suggest that over half a million Canadian children live in low in-come households. Provincially and territorially, efforts to curb levels of child poverty have had variable success. Provinces like Quebec and Newfoundland and Labrador have significantly reduced levels of child poverty after introducing poverty reduction strategies that include enhanced early childhood education and child care. Conversely, in Manitoba where a 172
poverty reduction strategy has been in place since 2009, levels of child poverty continue to be some of the highest in the country. The same rate holds true for British Columbia, the only province without a committed poverty reduction strategy. Without a coordinated effort and strong national leadership, we risk leaving too many children behind. The time has come for Canada to adopt a child poverty reduction strategy and to appoint a Commissioner for Children and Young Persons who will guarantee its success. If we succeed in making a federal commitment to our children, we stand to make real change. Let’s hear what our political parties have to say about a cohesive, national child poverty reduction strategy in this election season. A number of evidence-based policy and program solutions, including, but not limited to, guaranteed minimum income and universal childcare, are at our disposal and could inform this effort. But here’s a plea: A strategy without true accountability will put us no further ahead. Canada’s children need a non-partisan, independent, “advocate” or “champion” to represent their best interests. A Commissioner for Children and Young Persons could report on the status of children. They would ensure all sectors consider children in decision-making. A Commissioner for Children and Young Persons could also provide a framework of accountability for a federal commitment to eliminate child poverty. This is not a new concept to wealthy nations like Canada. Countries including Australia, Sweden and France have all established a point person or office representing the interests of the child. This concept is also well known to the Canadian government. After Canada ratified the UN convention on the Rights of the Child in 1991, more than a decade’s effort to establish a Commissioner for Canadian Children and Young Persons was set afoot. Previous governmental reports have also produced recommendations for the appointment of a federal Commissioner Twice, the UN Committee on the Rights of the Child has called on Canada to establish an ombudsman’s office. In 2009 and again in 2012, Parliamentarians’ introduced bills proposing the appointment of a Commissioner. Despite this, we have yet to muster the political will to establish formal representation for Canadian children. The need for a national champion for children is clear. Will our future leaders heed the call? Laura Stymiest is a paediatrics resident at Dalhousie University. She previously completed training at the Coady International Institute and has been involved in research in the area of Social Paediatrics.
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Elizabeth Lee-Ford Jones is an expert advisor with EvidenceNetwork.ca, and Professor of Paediatrics at The Hospital for Sick Children and the University of Toronto. See also our Podcast on the issue: How future doctors see social factors shaping their medical practice
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What I didn’t learn in medical school Sometimes doctors can’t fix what makes their patients sick in the first place By Vivian Tam with Elizabeth Lee-Ford Jones I began medical school optimistic about what becoming a physician meant I could do for my future patients. Naively, I presumed my career would involve treating patients’ illnesses so they could return to lead full and fulfilling lives. Yet for the one in seven Canadians living in poverty, it is often difficult for doctors to achieve this goal. Take Christina, a 64-year old woman with diabetes, who came to me with new-onset numbness in her fingers and toes (a serious and progressive consequence of poorly controlled diabetes). As she struggled to leave on her walker, her prescription fell out of her purse. When I retrieved it for her, she mentioned that it hardly mattered because she would not have enough money to purchase the medication anyway. Then there was Andrew, a 36-year old man who had been physically assaulted while panhandling. He had a prosthetic hip from a work accident that had left him with a pronounced limp, a chronic disability and no job. While I could screen Andrew for fractures and neurologic deficits, I could do nothing for his unemployment or his inability to find safe shelter at night. These are but two of many encounters I have had that starkly contrast the values of social medicine I have learned in medical school. What good is it to treat illness if we can only send our patients back to the conditions that helped make them sick to begin with? Health care is just a small part of what determines our well-being. In fact, our health is strongly influenced by factors such as income, our working environment and affordable housing, over which neither patients nor medical doctors have much control. This is why Canada needs better public policy that safeguards the global health of all Canadians. As the ninth richest country in the world, we have managed to ignore the erosion of social assistance and the rise in income inequality that has taken place over the last decades. While we are one of the countries consistently spending the most on health care, we don’t do a very good job of providing a social safety net for the growing numbers of Canadians who are living paycheck to paycheck or are under or unemployed. We are also one of the few OECD countries without a national housing and homelessness strategy, which the United Nations Committee on Economic, Social and Cultural Rights considers a “national emergency.” For a nation that once prided itself on being ranked “the best country in which to live,” we have a lot to do before warranting the title once again. It does not have to be this way. Public policy decisions, including those that determine the allocation of tax revenue, strongly influence health outcomes. These decisions need to 175
be critically re-examined, particularly when most Canadians have demonstrated their support for policies that improve conditions for the most vulnerable. In 2009, a Nanos research poll reported that most Canadians strongly supported the public health system and strengthening publicly funded health care. In 2014, a poll by the Broadbent Institute found that 77 percent of Canadians recognize the widening income gap as a serious issue for the country, while 71 percent believe this gap undermines Canadian values. The same poll found that most Canadians are in favor of increasing taxes to fund public programs that will reduce the impacts of income inequality. This means that Canadians are far ahead of their governments in supporting solutions to close the gap between the rich and poor, and, often at the same time, the healthy and unhealthy. Canada’s current public policies could better meet both the health needs and social values of its citizens. As a soon-to-be physician I hope to practice medicine in a nation where income is not an obstacle to good health, and where polices and legislation are accountable to Canadians’ priority of health for all. Vivian Tam is a second year medical student at the Michael G. Degroote School of Medicine at McMaster University. Elizabeth Lee-Ford Jones is an expert advisor with EvidenceNetwork.ca, and Professor of Paediatrics at The Hospital for Sick Children and the University of Toronto.
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Setting the conditions for good long-term health Putting children’s health and resiliency on the national agenda By Chris Harper Last year at a camp in southern New Brunswick I met Evan. Before turning eight, he had bounced from foster home to foster home. He was sent to camp without a bathing suit or sufficient lunch. Regardless, Evan smiled constantly, excelled in school and had a striking sense of compassion. I still think about Evan all the time – what allowed him to thrive in spite of the cards he had been dealt? Aaron Antonovsky was a medical sociologist with a similar curiosity. He worked with women who had undergone severe hardship in the past, many of whom survived the Holocaust. He found that some suffered more profoundly while others were more perseverant. He spent his life trying to figure out why. As a medical student, I learn plenty about complex management of disease once it’s started — but rarely do we learn about what keeps people well in the first place. What contributed to those women’s ability to overcome physical and psychological trauma? What keeps Evan so resilient? Antonovsky’s research lead to what he called a “sense of coherence,” a concept just beginning to gain traction outside of academic circles in many countries. He theorizes that it is the most fundamental protective factor against disease. Based on three components, it also provides a valuable framework for how we should approach public policy making in the area of health and wellness in Canada. First, Antonovsky found that whatever stresses you encounter must be comprehensible. Children, for example, must have the basic understanding that an action will often have a predictable, stable reaction. Imagine how difficult this must be when moving homes constantly or not having one at all. In 2010, 52 percent of single-mother households in Canada with children under six years of age were living in unstable housing. Just last year, by the age of seven, 7.5 percent of children in Manitoba had been placed in some form of foster care. How can we expect children to comprehend stress when they don’t even have a home base in which to do it? Secondly, children must have the basic tools to see challenges as inevitable yet manageable. For example, one in six Canadian children have vision problems interfering with their ability to read, yet despite our “universal” health care, just 14 percent receive professional eye care before first grade. I would imagine it’s a lot easier to break the cycle of poverty when you’re able to see the blackboard. Finally, children must be able to find things meaningful. To thrive, it’s pivotal that children have the opportunity to find satisfaction and a sense of purpose. Sadly, even that isn’t guaranteed.
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Jordan River Anderson, a five-year-old aboriginal child with a rare muscular disorder, spent nearly his entire life in hospital while provincial and federal governments fought over who should pay for his at-home care. Unfortunately these inequitable delays are not uncommon experiences for First Nations children; responsibility for their health services is often shared between jurisdictions through complex funding systems (whereas most Canadian children’s care falls solely in the hands of the province/territory). In yet another obvious example of our system failing children, Jordan was denied the opportunity to make meaningful memories outside of his hospital room. This gave birth to Jordan’s Principle, which makes the reasonable request of the department first in touch with the child to cover services in the legal interim. A strong sense of coherence – the cognitive capacity to see challenges as comprehensible, manageable and meaningful – isn’t just a fluffy sociological construct. It has been tied to evidence: better glycemic control in Type 1 diabetics and faster return-to-work following musculoskeletal injuries. In Scandinavian countries, it was found to predict the need for social assistance and unemployment benefits later in life. Such findings present major opportunities for rethinking public policy from an “upstream” perspective — creating the foundation for good health in the first place — and pay off with a more effective use of public funding in the process. Through interacting with underserved kids in New Brunswick and patients in inner-city Toronto, I see first-hand how often we look at health problems in the rear-view mirror instead of creating health from the beginning. So how can we change things? Let’s promote health from a young age and use the resources we have efficiently. The “social determinants of health” — the multitude of non-medical factors like adequate income, stable employment and quality education that impact health – need critical attention, yet tackling them all can sometimes seem insurmountable. So what do our policy makers and politicians need to do in real terms? Here’s a good list to start with that’s achievable: build an effective national housing strategy so kids have a place to call home, institute comprehensive pre-school vision screening across the country so classrooms can have their full impact and cut red tape for First Nations children by committing to Jordan’s Principle. And as parents, educators, neighbours and community members — at the absolute minimum, let’s keep in mind the importance of helping kids like Evan see stressors as comprehensible, manageable and meaningful. Isn’t it time we put children’s long-term health and wellness on the national agenda?
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Chris Harper is a Contributor with EvidenceNetwork.ca, a medical student at the University of Toronto and camp director in his hometown of Saint John, New Brunswick – two cities deeply affected by child poverty. See also our Podcast on the issue: How future doctors see social factors shaping their medical practice
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How to make the social determinants of health matter An Interview with Sir Michael Marmot By Ryan Meili Recently, I was fortunate to attend the Global Symposium on the Role of Physicians and National Medical Associations in Addressing Health Equity and the Social Determinants of Health held in London, England. The meeting was organized by the Canadian, British and World Medical Associations, and had, among other goals, an agenda to assist Sir Michael Marmot in making such issues central to his upcoming role as president of the World Medical Association. I sat down with Sir Michael to explore the stories, the evidence and the politics that come into play when doctors are actors for social change. Ryan Meili: In 2012, you joined me for a Healthy Society book launch in Yellowknife, NWT. You had a lot of nice things to say about the book, but there was one thing you objected to. This was the idea that the social determinants of health reside in a “Phantom Zone” — that the concept is stuck in academia and hasn’t made it into the public discourse. You said that wasn’t true, and that your being the keynote at the Canadian Medical Association annual meeting was one sign that it had changed. What are some of the signs you see of the success of this concept of social determinants of heath reaching a wider population? Sir Michael Marmot: That CMA meeting in Yellowknife is a good example. On my way home I was at the airport in Edmonton and somebody said to me “that was all very good, but I don’t think anything’s going to happen.” And then today, at the World Medical Association meeting on Physicians and Health Equity, we had a presentation from your Canadian Medical Association (CMA) president sharing all that’s been happening with the CMA, including the publication “Healthy Communities” (what makes us sick?). I was speaking with another Canadian physician, Gary Bloch last night. He said “there’s so much activity now. Everybody’s talking about it.” So we go, in the space of less than three years, from that skepticism about whether the idea will go anywhere to it becoming the norm. When I started with the WHO Commission on the Social Determinants of Health, people said to me “What is this ‘social determinants of health?’ What does it mean? No one understands it — why did you choose that language?” I didn’t give it much thought about the language, I just did it, and now everybody’s talking about it, in the most unusual places. You touched there on one of the things we run into frequently: the debate around this term, ‘social determinants of health.’ Some people say it’s not complete, it should be socioeconomic, sociopolitical, etc. We’ve committed to this term with my own 180
organization, Upstream. We really do want to popularize it, but we also realize there may be other ways to get into that concept. What are your thoughts on that criticism, that it’s incomplete, or perhaps a bulky or awkward term? I think it’s the term we happened on, and as long as people know what it means, that’s fine. The concept is to engage the general population, and it’s the concept that’s important. Because, if you ask most people what causes ill health they’ll say, for places like Canada or the UK, that it’s difficulty getting to see the doctor. If they’re talking about low-income countries, they’ll say it’s dirty water or lack of food. And then they might also say smoking and drinking — that sort of thing, is important as well. And then you ask people, “What do you worry about?” and they’ll say, “Oh, what I worry about is the kids getting a good education, and not hanging out with bad company and being in a safe place to live, and being able to have money to meet the weekly bills. I worry about losing my job, or having a lousy job in which I don’t feel fulfilled or I have a terrible boss, and about what am I going to do in my old age.” And that’s what people worry about. I tell them, “You know the things you worry about are the major influences on your health, and they in fact determine whether you’re going to smoke or drink or at least have an important influence on those things.” So what excited me about what Chris from the CMA reported from Canada yesterday, is that it’s a way of engaging people, that these things are practical in their lives: housing, jobs, neighbourhoods, security – they are important for health, and that the social determinants of health will do as an umbrella term. That’s fine, because how else do you describe them? As long as the thing gets translated into the reality of Canadian lives. I think it’s really interesting the way that the CMA has done their Transforming Health Care town halls, with physicians, organized medicine, reaching out to the general public, trying to bridge that gap in understanding, and learn from the public. I’m wondering if your greater involvement with organized medicine in your role as president of the British Medical Association, and now president-elect of the World Medical Association as president-elect has changed your thinking at all about the role of physicians in advancing these determinants of health? It has. When I made my acceptance speech as president of the BMA, and again at the WMA, I appealed to doctors’ better instincts. I said “Why did you go into medicine? Remember why you went in to medicine? You didn’t go into medicine to be a respected member of the community or to make money or to become a medical politician. You came to medicine because you wanted to help people. Remember?” And most doctors like to be reminded of that. That is why they went into medicine. And so my argument is: “You wanted to cure the sick. It’s not a huge leap from there to say, let’s address the condition that made them sick.” So this isn’t a distraction from medicine, it’s the core purpose of it? 181
Exactly. If we want to make our patients well, that means that we want to make our communities and our populations well. And that means prevention, it means addressing the social determinants of illness. This is not to the exclusion of treating sick people, but it means addressing the conditions that made them sick in the first place. How do you see physicians incorporating that concept into day-to-day practice? Well, we need to provide the tools to help them to do so. For example, if you see a woman who doesn’t want to talk about it, but you suspect has been suffering domestic violence, an ordinary physician may think: “I don’t know what to do with this, I’m out of my depth. I suspect she’s not telling me about what’s going on and I don’t know how to deal with it if she does tell me.” Well there are trained professional who do know how to help, so you must learn to make the link between what you do in your day-to-day practice and the supports that are out there, or indeed, to get trained yourself so you do know how to respond. It’s about helping the practitioner who’s got the patient in front of them to ask: “What do I do, how do I deal with this?” And to say, “it’s my problem. I can’t say I don’t deal with domestic violence. I don’t just dish out antidepressants and stitch up wounds; I have a responsibility. I’m not competent to deal with everything, and I recognize my limitations, but I can know who I need to partner with.” That brings to mind a project we’re working on in Canada. Building on the poverty tool designed by Gary Bloch and his group, we’re designing a social determinants of health screening tool. Patients answer a series of questions on a tablet device and then it’s linked to a searchable database of all the social programs within our region. When the physician or other health care provider hits the submit button, up comes all the suggested services to which they could connect their patient. That’s exactly the kind of tool we need. Just as now you could go online and find out what the side effect of drug X is, and that you shouldn’t eat grapefruit when you’re on warfarin or whatever, you can find out what’s available to assist patients with their social circumstances. I mean, it’s very frustrating as a physician to feel that you can’t deal with the real problems that your patients are facing, that all you can do is hand out blood pressure pills or anti-depressants, but can’t actually deal with the cause of the problem. It’s very frustrating. Extremely frustrating. It’s exactly that frustration that’s driving more physicians to question current practices and think upstream. Now that’s a way of addressing the social determinants of health at the level of the individual. How do we get to what you call “the causes of the causes”? I was walking down the street last night, and on the portico of St Pancras Church, just up the street from BMA house, there were wall-to-wall homeless people, out sleeping rough. Is that our job as physicians to be concerned about that? Absolutely. Absolutely it’s our 182
job to deal with homelessness. Now, the homeless numbers went down in Britain, but they’re rising again. It’s a political issue. And we need to speak up about that. Now the line I’ve been taking in Britain, and in other countries, is that I’m not party political. I wrote a little blog about this when I came back from one of my many trips to Sweden. Somebody said, “the word on the street in Sweden is you’re getting more political.” Political, moi? Perish the thought. I argue from the evidence. Not, “You’re a rotten this or a rotten that.” I argue from the evidence. I’ve had right wing politicians say to me, “Isn’t your agenda really closer to social democracy?” And my response is, “if you’re saying your party doesn’t care about people’s suffering, then that’s most unfortunate.” I’m looking at how the conditions in which people are born, grow, live, work, age impact on their health and the evidence for that. There will be different views on the solutions, but to argue that, “Well, who cares, that’s just an unfortunate consequence of how we organize things in this country, but that’s nothing to do with us” — that’s just not acceptable. That’s what I think is so helpful about this lens. If you can get people to agree on a goal of health then the solutions on how to reach that goal can work themselves out. One of the things that’s on Upstream’s agenda is to try to make the social determinants of health a political issue, something that all parties need to address, and are speaking about addressing. Have you seen any progress in terms of getting this on the agenda of the public’s political demands and the platforms of political leaders? As we were saying earlier, it’s harder to get it on the public’s list of demands under the rubric of social determinants of health, but getting it on the public’s demands in terms of homelessness, not being able to afford to rent a house or a flat, having some private equity firm take over a housing association and then expel residents so they can put the rents up, that becomes a political issue, and that’s very much on the minds of the people. We want affordable housing, we want good neighbourhoods, we want good schools, where our kids can go and flourish. That’s very much on people’s minds. And all those things are practical to health, they’re part of the social determinants of health. So yes, I think we do have to engage the public, and the public has to engage the politicians. Speaking of what engages the public. You’re an epidemiologist; you work with data. But the things you actually end up talking about much more are stories. What’s the importance of those stories, or case studies if you want to call them that, in communicating this concept? Somebody wrote to me recently, and they said, “your combination of stories, evidence, passion and urgency are exactly what we need.” That was a very nice thing to hear, because I do think stories are important. I spend my life looking at evidence, combing through the statistical data. Whenever I’m writing something, I have the UNDP reports open on my desktop, looking at WHO or World Bank statistics or looking at the National 183
Office for Statistics in Britain, data on poverty, wealth distribution. I look at evidence and data all the time. Not a day goes by, literally, where I’m not looking at some evidence that’s related to incomes or welfare, expenditures in health or education, and I talk about those things as well. But data is not enough. Logic is not enough. You need the passion, and it’s the stories that bring that passion forward. The stories are what empower us. And it’s not the stories of just the hard facts. Nobody sheds a tear when I talk about people sleeping rough. People do shed a tear when they hear the stories of triumph over adversity, of things betting better. Jeff Turnbull’s power to inspire is not, “Oh, it’s so awful that people are homeless and their health suffers.” His power to inspire is that he’s taken these down-and-out souls and improved their life situation and that’s helped us treat their illness. Those hopeful stories have a huge impact. Now, the evidence that he’s making a difference is vitally important as well. Just being a good fellow is inspiring, but that’s not enough. Being a good fellow is one thing, showing you’re making a difference is another thing entirely. That’s why you need both: evidence and stories. Ryan Meili is an expert advisor with EvidenceNetwork.ca, a practicing medical doctor and founder of Upstream: Institute for A Healthy Society.
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Growing gap poses a health risk to all By Ryan Meili Certain Canadian commentators are bringing forth a strange critique of public health, suggesting that physicians and public health experts, charged with caring for the health of Canadians, should not concern themselves with the root causes of illness and stick to a narrow range of health interventions. Fortunately, Canadian health experts have a broader and more complete understanding of how and why people get sick. They aren’t satisfied with simply pulling drowning kids out of the river; though this is obviously important, they also look upstream to ask why kids are falling in the river in the first place. Decades of studies have shown conclusively that income and its distribution, education, employment, housing, food security and the wider environment have far greater impact on health outcomes than health care. I see this borne out daily in the lives of patients whose life circumstances have limited their ability to be enjoy full health. These upstream factors touch on all aspects of public policy. Our health is determined by political choices. If we want the best for Canadians, shouldn’t our political choices be determined by health? There is a growing international movement, supported by the World Health Organization, toward “Health in all Policies,” an approach that has been adopted by governments around the world. Here in Canada, Quebec has such a policy, and Newfoundland and Labrador is currently exploring this model. The notion that is facing the greatest scrutiny is one that has been expressed most clearly in the British Medical Journal: “The more equally wealth is distributed the better the health of that society.” There are three key ways in which wealth inequality can lead to worse health outcomes. The first, and most obvious, is poverty. In a less equal society, more people live in relative disadvantage, and are less able to afford safe housing and nutritious food or to access educational and economic opportunities. Their health suffers as a result, with people living in poverty often having life expectancies 20 or more years shorter than wealthier citizens. In my inner-city neighbourhood in Saskatoon, that manifests in rates of diabetes, heart disease, STIs, infant and overall mortality many times greater than the rest of the city. The second way that inequality affects health is not confined to the most disadvantaged. As Wilkinson and Pickett described in their 2009 book, The Spirit Level, and further elaborate in a 2015 article for Social Science and Medicine, significant evidence suggests that people living in less equal countries suffer from worse physical and mental health, even if they are at or near the top of the socioeconomic scale. Something about greater inequality – be it higher levels of crime, greater strain on the social safety net, or even higher levels of stress – appears to harm the health of all but the very wealthiest members of a society.
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Thirdly, new evidence suggests that it’s not only the people in unequal countries that are sicker; it's their markets as well. The OECD reported in 2014 that income inequality is at its highest level in 30 years, with economic growth slowed by as much as ten percent in some countries as a result. An IMF study from the same year showed that redistributive policies can improve economic performance in the long term. Many experts, including economists at TD bank, are consequently calling for action on income inequality. Greater levels of inequality damage the economy, worsening the material conditions of all who participate in the economy, and with them their health and wellbeing. Given that inequality has grown significantly in Canada, with the richest 20 percent now holding 67.4 percent of wealth in this country, this is an issue of great concern. This understanding of the connection between inequality and health is growing among the general public. A series of town halls hosted by the Canadian Medical Association on the health of Canadians resulted in a report titled “What Makes Us Sick”, showing that Canadians recognize the influence of income, housing and education on their health. With Canadians increasingly waking up to the need for an upstream approach to health and politics, those who actively oppose social investment and greater equality are sure to take aim at the notion of health as a guiding principle in public policy. This is beyond unfortunate, as addressing the upstream determinants of health can both improve the economy and the ability of that economy to provide for the wellbeing of Canadians. That's a hopeful and compelling idea, and, to some, a dangerous one. The fact that it’s receiving so much press attention suggests it’s an idea whose time has come. Ryan Meili is an expert advisor with EvidenceNetwork.ca, a family physician in Saskatoon and founder of Upstream: Institute for A Healthy Society. Watch our video on the issue: What has the biggest impact on health outcomes? The answer might surprise you, with Dr. Ryan Meili
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Five things we know about economic inequality – and why we need to act By Carolyn Shimmin Certain segments of society encounter persistent disadvantages and lack of opportunity across the country. This can affect everything from health outcomes of individuals and entire communities to social cohesion. It can also impact the economic growth of the country and the social mobility of Canadians. However, the extent of inequality — including what drives it and what to do about it – is hotly debated amongst policy makers, economists and political leaders. So how bad is it and who does it affect? Here are five things we know about economic inequality in Canada: 1. Economic inequality is a matter of life and death. According to a report this month from the Canadian Institute for Health Information, the gap between the health of high and low-income Canadians has widened over the past decade for measures such as smoking, hospitalization for chronic obstructive pulmonary disease (COPD), and how Canadians rate their own mental health. A Statistics Canada report has also found that economic inequality, including income inequality, is associated with the premature death of 40,000 Canadians a year, which is equal to 110 Canadians dying prematurely every day. Comparing the wealthiest 20 percent of Canadians with the poorest 20 percent of Canadians, it was found that a man living in low income has a 67 percent greater chance of dying each year than his wealthy counterpart, and a woman living in low income, a 52 percent greater chance. 2.
Income inequality has grown over the past 20 years in Canada. According to the Gini coefficient (a measurement of the statistical distribution of income between residents across the country), Canada successfully reduced income inequality in the 1980s. However, according to the same measurement, income inequality rose in the mid-1990s and has remained at an all-time high. To put this into perspective, Canada ranks 12th highest among developed countries for the worst income inequality and received a “C” grade on income equality from the Organisation for Economic Co-Operation and Development (OECD).
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Studies suggest that economic inequality is driven by the rising concentration of wealth at the top. In 2012, the top 10 percent of Canadians accounted for almost half of all wealth while the bottom 30 percent of Canadians accounted for less than one percent of all wealth. In fact, the bottom 50 percent of Canadians combined controlled less than six percent of all wealth in Canada. Understood another way, the median net worth (an individual’s assets or wealth minus debts and liabilities) of the top 10 percent of Canadians was a little over $2 million in 2012 – a rise of more than $600,000 (41.9 percent) since 2005. In contrast, the median net worth of the bottom 10 percent of Canadians was negative $5,100 in 2012 — which means individual debt, including credit card debt — increasing more than 150 percent from negative $2,000 in 2005. Maybe the simplest way to understand all these figures is this single statistic: the top 10 percent of Canadians held almost $6 of every $10 of financial assets in the country, excluding pensions.
4.
The roots of economic inequality are often social. Economists frequently make a distinction between inequality due to differences in effort and talent, and those due to differences in circumstances that are seen as beyond an individual’s control, such as gender, race, class, ethnicity, sexuality, geography, age, ability, immigration status and religion. Economists often believe that inequality arises from differences in opportunities combined with talent and effort. But the International Monetary Fund (IMF) has found that economic inequality is more strongly associated with inequality of opportunities than with talent and effort – refuting the strongly held belief that wealth is tied to hard work. Other data also suggest the belief that effort equals wealth is misguided. Indigenous people earn only 70 cents for every dollar versus non-Indigenous peoples; and women make 67 percent of what men make. These income gaps partly stem from disparities in the distribution of good paying and more secure jobs.
5. Income inequality slows the overall economic growth of the country. Benefits do not trickle down. The IMF and the OECD have found that an inverse relationship exists between increasing the income share of those living in the highest income group and overall economic growth of the country. If the income share of the top 20 percent of income recipients increases by one percent, GDP growth actually slows.
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However, a similar increase in the income share of the bottom 20 percent – a country’s poorest — is associated with a rise in economic growth. This positive relationship continues when increasing the income share of the middle class, resulting in higher economic growth. Carolyn Shimmin is a Knowledge Translation Coordinator with EvidenceNetwork.ca and the George and Fay Yee Centre for Healthcare Innovation.
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Five things everyone should know about the relationship between poverty and health in Canada By Carolyn Shimmin With a federal election on the horizon, certain high level policy topics are bound to make the headlines beyond the personalities of the political leaders: the economy, energy prices, jobs prospects even climate change. But what seems surprisingly absent from the political hustings so far has been a fulsome discussion of the health of everyday Canadians, and how we can improve it. Health for many pundits is all about health care. And while health care deserves its place in the political spotlight, what should be a central concern for Canadian voters is the human and economic costs of poverty on health. These costs aren’t just personal — affecting those unfortunate many beneath the poverty line — but affect our economy and our communities as a whole. Fail to address poverty, and you fail to address health. Fail to address both, and your discussions about the economy or jobs or markets (which rely on healthy Canadians and healthy communities) are not really complete. Over three million Canadians struggle to make ends meet — and what may surprise many is the devastating influence poor income, education and occupation can have on our health. Research shows the old adage, the “wealthier are healthier,” holds true, as the World Health Organization (WHO) has declared poverty the single largest determinant of health. According to WHO, social and economic conditions and their effects on people’s lives determine their risk of illness, the actions they are able to take in order to prevent themselves from becoming ill and treating illness when it does occur. We know that income provides the prerequisites for health — including housing, food, clothing, education and safety. Low income limits an individual’s opportunity to achieve their full health potential (i.e., physical, psychological and social well-being) because it limits choices. This includes the ability to access safe housing, choose healthy food options, find inexpensive childcare, access social support networks, learn beneficial coping mechanisms and build strong relationships. Here’s what everyone needs to know: 1. In Canada, there is no official measure of poverty. The way in which we measure and define poverty has implications for policies developed to reduce poverty and its effect on health. Statistics Canada does not define poverty nor does it estimate the number of families in poverty in Canada. Instead, they publish statistics on the number of Canadians living in low-income, using a variety of measurements including the LowIncome Measurement (LIM); the Low-Income Cut-Offs (LICOs); and the Market Basket Measure (MBM).
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Following the federal government’s cancellation of the mandatory long-form census in favour of a voluntary National Household Survey, long-term comparisons of income trends over time have been made difficult because the voluntary survey is now likely to under-represent those living in low income. 2. There is a social gradient in health. Substantial and robust evidence confirms a direct link between socioeconomic status and health status — meaning people in the lowest socioeconomic group carry the greatest burden of illness. This social gradient in health runs from top to bottom of the socioeconomic spectrum. If you were to look at, for example, cardiovascular disease mortality according to income group in Canada, mortality is highest among those in the poorest income group and, as income increases, mortality rate decreases. The same can be found for conditions such as cancer, diabetes and mental illness. 3. Poverty in childhood is associated with a number of health conditions in adulthood. More than one in seven Canadian children live in poverty — this places Canada 15 out of 17 similar developed countries, and being at the bottom of this list is not where we want to be. Children who live in poverty are more likely to have low birth weights, asthma, type 2 diabetes, poorer oral health and suffer from malnutrition. But also children who grow up in poverty are, as adults, more likely to experience addictions, mental health difficulties, physical disabilities and premature death. Children who experience poverty are also less likely to graduate from high school and more likely to live in poverty as adults. 4. People living in poverty face more barriers to access and care. It has been found that Canadians experiencing low-income are more likely to report that they have not received needed health care in the past 12 months. Also, Canadians in the lowest income groups are 50% less likely than those in the highest income group to see a specialist, and 40% more likely to wait more than five days for a doctor’s appointment. Individuals in low income are also twice as likely as those in the highest income group to visit the emergency department for treatment. Researchers have reported that Canadians in the lowest income groups are three times less likely to fill prescriptions and 60% less able to get needed tests because of costs. 5. There is a profound two-way relationship between poverty and health. What this means is people with limited access to income are often more socially isolated, experience more stress, have poorer mental and physical health and fewer opportunities for early childhood development and post-secondary education. In the reverse, it has been found that chronic conditions, especially those that limit a person’s ability to maintain viable stable employment, can contribute to a downwards spiral into poverty. Studies show the former — people living in poverty experiencing poor health — occurs more frequently than poor health causing poverty. Carolyn Shimmin is a Knowledge Translation Coordinator with EvidenceNetwork.ca and the George and Fay Yee Centre for Healthcare Innovation.
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Cinq faits incontournables sur le rapport entre santé et pauvreté au Canada Par Carolyn Shimmin Avec l’élection fédérale qui se pointe à l’horizon, certains enjeux de haut niveau ne devraient pas manquer de faire les grands titres, outre les personnalités des chefs politiques : l’économie, les prix de l’énergie, les perspectives d’emploi et même les changements climatiques. Étonnamment, un thème semble jusqu’ici absent des plateformes électorales, soit la nécessité d’un débat en profondeur sur l’état de santé du Canadien moyen et des moyens à prendre pour l’améliorer. Pour bien des experts, la santé se résume aux soins de santé. Même si cette question mérite une place dans l’actualité politique, l’enjeu qui devrait préoccuper les électeurs canadiens au premier chef devrait être celui des conséquences, sur le plan humain et économique, de la pauvreté sur la santé. Elles ne se limitent pas aux répercussions de nature personnelle sur les individus ayant la mauvaise fortune de vivre sous le seuil de la pauvreté; elles touchent notre économie et l’ensemble de nos régions. Ignorez le problème de la pauvreté et vous échouerez à régler celui de la santé. Omettez les deux et vos discussions sur l’économie, l’emploi ou les marchés (qui dépendent de la bonne santé des Canadiens et des communautés) seront incomplètes. Plus de trois millions de personnes au Canada, dont 900 000 vivent au Quebec, peinent à boucler leur budget. Bien des gens seraient surpris de constater les effets désastreux sur la santé d’un salaire médiocre, d’un faible niveau de scolarité et d’un emploi au bas de l’échelle. Les recherches confirment en effet que les riches sont en meilleure santé que les autres couches de la population; l’Organisation mondiale de la Santé (OMS) a d’ailleurs déclaré que la pauvreté était le déterminant le plus important en matière de santé. Toujours selon l’OMS, les conditions socioéconomiques et leurs effets sur la vie des gens déterminent le risque de tomber malade et les moyens à notre disposition pour prévenir la maladie ou la traiter lorsqu’elle survient. Nous savons que le revenu permet de réunir les conditions préalables à une bonne santé, dont le logement, la nourriture, l’habillement, l’éducation et la sécurité. En raison des choix limités qu’il impose, un faible revenu réduit nos chances d’atteindre notre plein potentiel en matière de santé (c.-à-d. le bien-être physique, psychologique et social). Cela concerne la capacité de se payer un logement sécuritaire, de faire des choix santé en matière d’alimentation, d’accéder à des services de garderie peu coûteux, de disposer de réseaux de soutien social, d’apprendre des mécanismes d’adaptation bénéfiques et d’établir des liens solides. Voici ce qu’il faut savoir au sujet du rapport entre santé et pauvreté : 1. Le Canada ne dispose pas de mesure officielle de la pauvreté. La façon dont on la mesure et la définit a des répercussions sur les politiques de réduction de la pauvreté et de ses effets sur la santé. Statistique Canada ne 192
donne pas de définition de la pauvreté ni d’estimation sur le nombre de familles touchées au Canada. Le bureau publie plutôt des statistiques sur le nombre de personnes qui vivent avec un bas salaire, établi au moyen d’un éventail d’instruments comme la mesure de faible revenu (MFR), les seuils de faibles revenus (SFR) et le mesure du panier de consommation (MPC). Depuis l’abolition par le gouvernement fédéral du recensement long obligatoire au profit de l’Enquête nationale auprès des ménages, il est difficile désormais de comparer les tendances à long terme en matière de revenus. En effet, le caractère volontaire de l’enquête risque d’aboutir à une sousreprésentation des personnes à faible revenu. 2. Il existe un gradient social en santé. Des données substantielles et solides confirment l’existence d’un lien entre statut socioéconomique et niveau de santé : ce sont les personnes au bas de l’échelle qui portent le fardeau de maladie le plus lourd. Ce gradient social en santé concerne toute l’échelle socioéconomique de haut en bas. À titre d’exemple, si l’on examine le taux de mortalité cardiovasculaire au Canada en fonction de l’échelle des revenus, on constate que c’est dans le groupe où les revenus sont les plus faibles qu’il est le plus élevé; de plus, à mesure que le niveau de revenu augmente, le taux de mortalité diminue. Le même constat s’applique à des maladies comme le cancer, le diabète et la maladie mentale. 3. Le fait de vivre dans la pauvreté durant l’enfance prédispose à un certain nombre de maladies à l’âge adulte. Plus d’un enfant sur sept vit dans la pauvreté au Canada, ce qui place le Canada au 15e rang sur 17 pays développés comparables – un classement loin d’être enviable. Les enfants qui grandissent dans la pauvreté sont plus susceptibles d’avoir un faible poids à la naissance et de souffrir d’asthme, de diabète de type 2, de mauvaise santé buccale et de malnutrition. Ils risquent aussi de connaître à l’âge adulte des problèmes de toxicomanie et de santé mentale, des déficiences physiques, ainsi qu’une mort prématurée. Les enfants qui font l’expérience de la pauvreté sont moins enclins que les autres à obtenir leur diplôme d’études secondaires et plus susceptibles de vivre dans la pauvreté à l’âge adulte. 4. Les obstacles à l’accès et aux soins de santé sont plus nombreux lorsqu’on vit dans la pauvreté. On constate que les Canadiens à faible revenu sont plus nombreux à rapporter qu’ils n’ont pas reçu les soins dont ils avaient besoin au cours des 12 derniers mois. De plus, si l’on compare les membres des groupes aux revenus les plus faibles à ceux dans la tranche la plus élevée, les premiers sont 50 pour cent moins susceptibles de consulter un spécialiste que les seconds; 40 pour cent sont plus susceptibles d’attendre plus de cinq jours avant d’obtenir un rendez-vous chez un médecin. De plus, les premiers sont deux fois plus susceptibles de se rendre à l’urgence pour être soignés. Les chercheurs rapportent que les Canadiens qui gagnent les plus faibles salaires sont trois fois moins portés,
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en raison des coûts, à faire remplir leurs ordonnances que les autres; 60 pour cent moins nombreux à pouvoir se prévaloir des examens médicaux requis. 5. Il existe un lien réciproque étroit entre pauvreté et santé. Cela signifie que les personnes dont l’accès aux revenus est limité sont souvent plus isolées que les autres sur le plan social; elles vivent davantage de stress et sont en moins bonne santé sur le plan mental et physique; elles profitent moins des services de développement de la petite enfance et de l’éducation postsecondaire. À l’inverse, les maladies chroniques, en particulier lorsqu’elles restreignent la capacité d’une personne à conserver un emploi fiable et stable, peuvent provoquer une spirale descendante vers la pauvreté. Les études montrent que la première situation (des gens vivant dans la pauvreté en mauvaise santé) se produit plus souvent que la deuxième (se retrouver dans la pauvreté à cause d’un mauvais état de santé). Carolyn Shimmin est coordonnatrice du transfert des connaissances pour le site EvidenceNetwork.ca et le George and Fay Yee Centre for Healthcare Innovation.
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Why does Canada do so poorly on children’s health rankings? Studies show early childhood education and family supports yield excellent return on investment By Nicole Letourneau Something is amiss in Canada. A 2014 UNICEF report compared the health and development of children in Canada with 28 other wealthy nations. In spite of being a G8 country, Canada’s children rank number 17th, a status that has not budged in the last 10 years. When measuring the quality of children’s relationships with their parents, Canada came in 25th. Canadian data support these facts: In 2014, the Canadian Institute of Health Information (CIHI) reported that 26 percent of Canadian children demonstrate a developmental problem in communication, language, cognition, social-emotional or physical health by the time they reached school age. The question is, why are these problems still so widespread? One answer –and something we can readily do something about — may be stressful early experiences, in the absence of supportive relationships with a caregiver. The Harvard Centre on the Developing Child has published at least a dozen reports outlining the extensive evidence on how unmitigated stress changes children’s brain development in ways that don’t prepare them well for today’s knowledge economy. If we wish to fight crime, poverty, disease, or any number of woes our society faces, the research tells that we must go straight for the root of these issues. And that root is found in early childhood and in supporting parents to provide the best environments for children. Children do better, families do better, and countries do better when nations invest in early childhood programs. In just one of many examples, a study by the Minneapolis Reserve Bank compared the effectiveness of preschool education programs to other common state investments, such as subsidies for private businesses. The study found that in terms of return on investment, early childhood education yielded $8 for every $1 spent in terms of cost savings associated with reduced remedial education, juvenile justice involvement, health and social services use and increased school completion. Even more incredible, programs that target not only children but also their mothers and other caregivers appear to have the most profound and persistent effects on children’s health and development. Nobel prize-winning economist James Heckman released a report entitled, The Productivity Argument for Investing in Young Children, which argues for allocating public funds to support developmental programs for young children and their families, especially (but not exclusively) those in low-income or otherwise underprivileged 195
households. Heckman argues that productive workforces rely on a skilled and educated society, and the early childhood environment provides the foundation on which future skills and education rest. Children from disadvantaged, stressed homes fare disproportionately poorly in obtaining these vital skills, and catching up can be extremely difficult—and expensive. In the long run, providing opportunities for programs to support child development and reduce family stress are far cheaper options, as they prevent children from falling back in the first place, and consequently, let them earn more and rely less on costly health, social, education and justice programs. With all this evidence, we should be outraged that our Canadian children are doing so poorly. Yet despite their proven benefits, children’s programs face a number of significant challenges. First, from a politician’s perspective, children’s programs are tough to sell and easy to overlook. They take years or decades to truly pay off—a timeframe poorly calibrated to election cycles—and most directly benefit vulnerable, marginalized families who lack political clout. Other issues such as the “silver tsunami” of aging Canadians are perceived as much larger and more pressing, and benefit from a large and engaged voter base. Second, effectively investing in children’s programs involves careful coordination between multiple sectors, including health, education, justice and social/human services. This renders them vulnerable to logistical problems and lack of coordination. These problems are amplified when these sectors fall under different jurisdictions—regional, provincial and federal—resulting in a patchwork of poorly resourced, under-accessed and unevaluated programs for families and children, for whom there are no dedicated and potent national advocates. Finally, I think Canadians need a shift in understanding to acknowledge that Canada’s children are our children and that they and their parents all are worthy of our support through better programs and policies. What’s more, a smarter, happier, and more successful generation benefits all of us, not just those who use early childhood education programs. With moral and mathematical imperatives both pointing towards a greater focus on early childhood and family support, it is unconscionable that we have left it for so long. For 10 years we have been failing the grade. It’s time to make a change. Nicole Letourneau is an expert advisor with EvidenceNetwork.ca and a professor in the Faculties of Nursing and Medicine. She also holds the Norlien/Alberta Children’s Hospital Foundation Chair in Parent-Infant Mental Health at the University of Calgary.
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Pourquoi le Canada fait-il mauvaise figure en matière de santé infantile? Selon les études, la présence d’une éducation et d’un soutien familial de qualité pendant la petite enfance génère d’excellents résultats. Par Nicole Letourneau Il y a quelque chose qui cloche au Canada. Un rapport publié par UNICEF en 2014 comparait la santé et le développement des enfants canadiens à ceux de 28 autres pays nantis. Bien qu’il fasse partie du G8, le Canada se classe au 17e rang en ce qui a trait à ses enfants, et sa position demeure la même depuis 10 ans. Pour ce qui est de la qualité de la relation parents-enfants, le Canada se classe au 25e rang. Ces faits sont confirmés par des données canadiennes. En 2014, l’Institut canadien d’information sur la santé (ICIS) révélait que 26 pour cent des enfants canadiens affichaient, avant d’atteindre l’âge scolaire, un problème de développement sur le plan de la communication, du langage, de la santé socio-émotionnelle ou physique ou sur le plan cognitif. À quoi ces troubles si fréquents sont-ils dus? Entre autres, à la présence d’événements stressants au stade précoce combinée à l’absence d’une relation positive avec une personne qui prodigue des soins. Or, nous pouvons certainement agir pour corriger de telles situations. Le Harvard Centre on the Developing Child [Centre Harvard sur le développement de l’enfant] a publié au moins une douzaine de rapports présentant des données probantes exhaustives sur l’influence qu’exerce un taux de stress élevé sur le développement du cerveau d’un enfant. Un enfant qui vit trop de stress ne développe pas les capacités nécessaires pour participer à l’économie du savoir qui caractérise notre ère. Si nous souhaitons combattre le crime, la pauvreté, la maladie ou toutes les autres misères qui pèsent sur notre société, nous devons nous attaquer aux sources des problèmes. Celles-ci remontent à la petite enfance, une étape du développement où il importe d’avoir des parents aimants qui assurent aux enfants des environnements sains. Les enfants, les familles et les pays se portent mieux lorsque les États investissent dans des programmes de soutien à la petite enfance. L’une des nombreuses études sur le sujet réalisée par la Minneapolis Reserve Bank a comparé l’efficacité des programmes d’éducation préscolaire à d’autres investissements gouvernementaux courants, comme l’octroi de subventions aux entreprises privées. L’institution a fait le constat suivant. En termes de rendement du capital investi, l’éducation à la petite enfance génère 8 $ pour chaque dollar dépensé. Ceci est dû à l’économie de coûts liée à la réduction de mesures d’enseignement correctif et la
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diminution des démêlées avec la justice pour mineurs et de l’utilisation de services de santé et de services sociaux, ainsi qu’à l’augmentation du taux d’achèvement d’études. Encore plus surprenant, les programmes qui ciblent non seulement les enfants, mais aussi leur mère et d’autres personnes qui prennent soin d’eux semblent produire les effets les plus importants et les plus durables en matière de santé et de développement infantiles. L’économiste James Heckman, lauréat d’un prix Nobel, a publié un rapport intitulé The Productivity Argument for Investing in Young Children [L’argument de la productivité justifiant l’investissement de ressources pour l’aide à la petite enfance]. Ce rapport souligne la nécessité d’allouer des fonds publics au soutien de programmes de développement ciblant les enfants et leur famille, surtout (mais non seulement) de milieux à faible revenu ou défavorisés. M. Heckman soutient que la création d’une maind’œuvre qualifiée s’appuie sur une société compétente et scolarisée. L’environnement dans lequel se déroule la petite enfance constitue les fondements sur lesquels reposent les futures habiletés et le niveau d’éducation. Les enfants vivant dans des familles défavorisées et stressées éprouvent de façon disproportionnée des difficultés à acquérir des habiletés essentielles. Les mesures destinées à combler les retards peuvent s’avérer très exigeantes et coûteuses. À long terme, les initiatives visant à offrir des programmes de soutien au développement des enfants et de réduction de stress familial sont des avenues beaucoup moins coûteuses. Dès le départ, elles préviennent les retards chez les enfants et augmentent chez ceux-ci la capacité d’accéder à un revenu supérieur et de s’affranchir des onéreux programmes de santé, de services sociaux, d’éducation et de justice. À la lumière de toutes ces données probantes, les nombreuses difficultés que vivent les enfants canadiens devraient soulever notre indignation. Malgré leurs retombées confirmées, les programmes de soutien aux enfants font face à des obstacles importants. Premièrement, du point de vue politique, ces programmes sont difficiles à implanter et il est facile d’en ignorer l’importance. Les résultats qui découlent de ces initiatives ne se manifestent qu’après des années ou des décennies et ces délais cadrent peu avec les cycles électoraux. Les retombées touchent surtout les familles vulnérables et marginalisées, un groupe qui a peu de poids politique. D’autres dossiers, comme celui du tsunami d’une population vieillissante au Canada, sont perçus comme beaucoup plus importants et urgents et suscitent l’intérêt d’un grand nombre d’électeurs avertis. Deuxièmement, pour assurer l’efficacité des investissements liés à ce type de programmes, il faut mettre en place une coordination minutieuse entre les multiples secteurs, y compris la santé, l’éducation, la justice, les services sociaux et les services à la personne. Les risques de difficultés logistiques et de problèmes de coordination sont réels et ils sont amplifiés si ces secteurs relèvent de compétences différentes, soit régionales, provinciales et fédérales. Peut s’ensuivre alors un rapiéçage de programmes d’aide aux
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familles et aux enfants qui bénéficient de peu de ressources, à l’accès difficile, non évalués et orphelins de défenseurs pancanadiens puissants et convaincus. Pour terminer, il faut, à mon avis, améliorer les programmes et les politiques de manière à sensibiliser davantage la population canadienne au fait que les enfants du pays sont les enfants de la collectivité et qu’ils méritent tous,ainsi que leurs parents, le soutien de tous. De plus, une génération plus intelligente, plus heureuse et qui réussit mieux est un atout non seulement pour ceux qui utilisent les services d’éducation à la petite enfance, mais aussi pour la population entière. La négligence qui entoure ce dossier depuis si longtemps est inadmissible et les impératifs moraux et statistiques nous indiquent l’importance de se pencher davantage sur ces questions. Depuis 10 ans, nous n’avons même pas obtenu une note de passage. Le temps est venu de faire des changements. Nicole Letourneau est experte-conseil à EvidenceNetwork.ca. Professeure aux facultés des sciences infirmières et de médecine de l’Université de Calgary, elle est également titulaire de la chaire de la Fondation Norlien/Hôpital pour enfants de l’Alberta en santé mentale des parents-enfants de la même université.
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Canada needs to rethink approach to early childhood development Supports children receive in infancy have a profound influence on their intellectual and social development By Nicole Letourneau and Justin Joschko UNICEF recently released a report card ranking child well-being in the 29 richest countries on earth. Canada came 17th, placing us in the bottom half of the pack on factors such as child poverty, emotional well-being and life satisfaction. Clearly, we can do better. It’s time to have a frank conversation about how our country approaches early childhood: what we get right and what we need to change. For example, our education system does a good job of promoting cognitive development and helping children develop the skills they need to excel academically. International rankings have placed Canada near the top of the heap when it comes to educational achievement, and even the very same UNICEF report card mentioned earlier, cites us as above average in this category. But school is only part of the picture. Learning starts far before children enter a classroom, and the foundational brain architecture laid down during those crucial first few years determines the stability of an entire lifetime. Studies show that the support and stimulation children receive in infancy has a profound effect on their intellectual and social development, influencing everything from educational achievement, to mental health, to risk of heart disease. It is here, in this critical juncture, that we most need to improve. And the best way to do that is to borrow from those who seem to be succeeding. For instance, Norway, Sweden, and Germany – countries which ranked far higher than Canada on UNICEF’s report card — have significantly more generous parental leave policies than Canada. In these countries, parents on leave receive between 85 percent and 90 percent of their annual salaries, compared to Canada’s 50 percent. And parents with the means to do so can take between 150 and 170 weeks — upwards of three years and three months — off to raise a young child, with the guarantee that their job will be there for them when they return. Meanwhile, the Netherlands, which ranked first place in UNICEF’s report card, provides a host of benefits to new parents, including subsidized childcare, special outreach programs for at-risk families, and comprehensive postnatal support from maternity nurses specially trained to assist new mothers in the transition to parenthood. These individuals, called kraamverzorgster, often put in as much as six to eight hours a day for a single family, doing everything from offering breastfeeding instruction to diagnosing and dealing with tongue ties. They’ll even do light housework. 200
These policies seem luxurious to us, maybe even decadent, but they are actually a wellresearched and pragmatic response to the costliness of poor early childhood experience, which takes a heavy toll, not just on the affected individual or family, but on society as a whole. While often beneficial, adopting individual programs and policies to support early childhood development can only make so big an impact. Where countries like Sweden and the Netherlands really get it right — and where we really need to focus our attention — is in reframing early childhood development as an issue worthy of our attention. When it comes to early childhood in Canada, a national vision is sadly lacking. In 2004, the federal government proposed a comprehensive action plan for a Canada-wide early childhood system called A Canada Fit for Children, which focused on supporting families, building communities, and promoting education. However, this plan was scrapped in 2006 in favor of a taxable universal payment of $100 per child under six years old. This policy has a certain innate appeal — who doesn’t love getting a cheque in the mail? But while a little extra money can make a difference for a lot of families, such payments are at best a Band-Aid strategy, quick fixes that do nothing to address the deeper limitations of our early childhood strategy and ignore the systemic inequalities between wealthy and poor families. This is not to say that Canada hasn’t made significant strides. Our parental leave policy, though less generous than some countries, still provides new families with financial support during that vital first year, when a parent’s presence matters most. And more recent initiatives, like the new parental tax benefits, can make a big difference when budgets are tight. But cutting cheques has its limitations. The money allocated from ‘baby bonuses’ can be used on unregulated childcare services, some of which provide dubious supports for families. If pooled into a common resource, the same amount of money can go much farther, providing effective and evidence-based postnatal support. Nicole Letourneau is an expert advisor with EvidenceNetwork.ca and a professor in the Faculties of Nursing and Medicine. She also holds the Norlien/Alberta Children’s Hospital Foundation Chair in Parent-Infant Mental Health at the University of Calgary. Justin Joschko is a freelance writer currently residing in Ottawa. Their co-authored book, Scientific Parenting, has been released with Dundurn Press.
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Le Canada doit repenser son approche en matière de petite enfance Le soutien que reçoivent les enfants en bas âge a une profonde influence sur leur développement intellectuel et social Par Nicole Letourneau et Justin Joschko L’UNICEF a publié récemment un classement des 29 pays les plus riches de la planète en fonction du bien-être des enfants. Le Canada figure en 17e position, ce qui le place dans le peloton de queue en ce qui touche certains facteurs comme la pauvreté chez les enfants, le bien-être affectif et la satisfaction de vivre. De toute évidence, nous pouvons faire mieux. Le temps est venu de tenir une discussion franche sur les orientations de notre pays en matière de développement de la petite enfance : sur ce qui marche, et sur ce qui doit changer. Notre système d’éducation fait du bon travail lorsqu’il s’agit de favoriser le développement cognitif et d’aider les enfants à développer les habiletés nécessaires pour exceller à l’école. En effet, les classements internationaux placent le Canada aux premiers rangs en matière de réussite scolaire; même le bilan de l’UNICEF nous situe au-dessus de la moyenne dans cette catégorie. Or l’école ne représente qu’une partie du tableau. L’apprentissage débute bien avant que l’enfant ne fréquente les salles de classe. L’architecture du cerveau, qui se façonne durant cette période fondamentale qu’est la première enfance, détermine la stabilité d’une vie entière. Les études démontrent que le soutien et la stimulation ont un effet profond sur le développement intellectuel et social du jeune enfant; ils ont une incidence sur tous les plans, depuis la réussite scolaire jusqu’à la santé mentale, en passant par le risque de maladie du cœur. C’est précisément à ce stade primordial que le Canada doit s’améliorer. Et le meilleur moyen d’y parvenir est d’imiter ceux qui semblent avoir du succès en la matière. La Norvège, la Suède et l’Allemagne – des pays qui affichent des résultats bien supérieurs à ceux du Canada dans le bilan de l’UNICEF – offrent notamment des congés parentaux beaucoup plus généreux que les nôtres. Dans ces trois pays, les parents en congé parental reçoivent 85 pour cent à 90 pour cent de leur salaire annuel, comparativement à 50 pour cent au Canada. De plus, les parents qui en ont les moyens peuvent prendre de 150 à 170 semaines de congé pour s’occuper d’un enfant en bas âge (soit plus de trois ans et trois mois), avec la garantie qu’ils pourront récupérer leur emploi à leur retour au travail. De leur côté, les Pays-Bas, classés au premier rang dans le bilan de l’UNICEF, offrent aux nouveaux parents toute une gamme d’avantages sociaux : services de garde subventionnés; programmes spéciaux pour les familles à risque; services postnatals 202
complets dispensés par des infirmières spécialement formées pour aider les mères à apprivoiser leur nouveau rôle. Appelées kraamverzorgster, elles passent souvent jusqu’à six à huit heures par jour dans une seule famille; elles donnent des conseils en matière d’allaitement et détectent les cas d’ankyloglossie (brièveté du frein de la langue). Elles font même parfois de menus travaux ménagers. Vu d’ici, ces services peuvent nous paraître comme un luxe, voire décadents. Il s’agit toutefois d’une intervention pragmatique, aux résultats avérés, qui vise à prévenir les conséquences coûteuses d’une mauvaise expérience durant la petite enfance, non seulement pour l’enfant et sa famille, mais pour l’ensemble de la société. Même s’ils sont souvent bénéfiques, les programmes axés sur les individus ne peuvent avoir en fin de compte qu’une portée limitée. Si des pays comme la Suède et les Pays-Bas montrent d’aussi bons résultats, c’est qu’ils ont redonné à la petite enfance toute l’attention qu’elle mérite. C’est précisément là-dessus que nous devrions nous concentrer. Malheureusement, nous n’avons pas au Canada de vision digne de ce nom. En 2004, le gouvernement avait proposé un plan d’action exhaustif intitulé « Un Canada digne de ses enfants », axé sur le soutien aux familles, le développement communautaire et la promotion de l’éducation. Toutefois, ce plan a été abandonné en 2006; il a été remplacé par une prestation universelle imposable de 100 $ par enfant âgé de moins de six ans. Cette prestation a un certain attrait en soi : en effet, qui n’aime pas trouver un chèque dans sa boîte aux lettres? Néanmoins, même si quelques dollars de plus font parfois une grande différence pour bien des familles, ce genre de politique n’est qu’une mesure insignifiante – un pansement de fortune qui ne compense en rien les limites de notre stratégie en matière de petite enfance. Par ailleurs, elle ne tient aucunement compte des inégalités systémiques entre familles riches et familles pauvres. Cela ne signifie pas que le Canada n’a pas fait de grands progrès. Notre congé parental, même s’il est moins généreux que dans d’autres pays, offre malgré tout aux jeunes familles un soutien financier bienvenu pendant cette première année si déterminante où la présence des parents compte plus que tout. De plus, certaines initiatives récentes, comme le crédit d’impôt pour les familles, peuvent faire une énorme différence lorsque le budget est serré. Remettre des chèques a toutefois ses limites. Les sommes consacrées aux allocations familiales servent parfois à payer des services de garde non réglementés, dont certains offrent aux familles un soutien de qualité douteuse. Si on les réunissait dans une seule cagnotte, ces fonds pourraient être dépensés à meilleur escient et servir à financer des services de soutien postnatals dont l’efficacité a été démontrée. Nicole Letourneau est experte-conseil auprès du site EvidenceNetwork.ca et professeure aux facultés de sciences infirmières et de médecine de l’Université de Calgary. Elle est également titulaire de la Norlien/Alberta Children’s Hospital Foundation Chair in 203
Parent-Infant Mental Health. Justin Joschko est rédacteur à la pige et vit à Ottawa. Ils ont cosigné un ouvrage, Scientific Parenting, paru chez Dundurn Press.
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We need a radical new approach for kids in care Families seeking support services should not have to worry their children will be taken away from them By Marni Brownell and Neeta McMurtry Six advocates for First Nations children have gone on a symbolic hunger strike at the Manitoba Legislature to try to raise awareness across the country about Manitoba’s broken child welfare system. Why? Well, here’s one fact that should make most Canadians sit up and take notice: Over one in five First Nations children in Manitoba spends some time in care before their 15th birthday. And kids in care are in crisis. The Manitoba Centre for Health Policy recently released a report on the educational outcomes of children in the care of Manitoba Child and Family Services. Spoiler alert: kids in care do not do as well in school as kids who are not in care. But the reality of how far kids in care are falling behind the rest of the population is a shock. The report compares kids from kindergarten all the way to high school graduation. Even when things like socioeconomic status are considered, the kids in care, as a group, are struggling. For example, over half of the kids in care entering school are not ready to learn compared to less than a quarter of their counterparts, because many of their basic emotional and physical needs are not being met. Only a third of kids who have been in care graduate from high school versus a 90 percent graduation rate for kids who have never been in care. So what’s the solution? You might be surprised to learn that the report findings have less to do with fixing the education system than paying attention to the recommendations of the Truth and Reconciliation Commission (TRC). That’s because Manitoba has a very high number of children in care – over 10,000 on a single day in 2014 – but almost 90 percent of these kids are Indigenous. This over-representation of Indigenous kids in the care system has at its roots the intergenerational trauma of the residential school system, which forcibly separated children from their families and subjected many children to maltreatment. The long-term impact of these experiences is at the root of many of the difficulties experienced by Indigenous families today. This includes alarmingly high rates of suicide, family violence, substance abuse, mental health issues and parenting challenges. These are the very challenges that often contribute to children going into care and also doing poorly in school. North American child welfare agencies generally favour child-protection strategies – removing kids at risk from the home – and there are historical reasons why. High profile tragedies such as the Phoenix Sinclair case in Manitoba, for example – where 5-year-old Phoenix suffered unspeakable abuse and died at the hands of her mother and step-father after falling through the cracks of the child welfare system – influence well-intentioned social workers to err on the side of caution. As a result, they may opt to remove a child 205
from a family where his or her safety may be in jeopardy, particularly if community support resources are inadequate. But it is time to start questioning the wisdom of apprehending kids from their families. Other countries, such as Sweden, which has a substantially lower rate of children in care, have implemented family welfare policies instead, providing intensive in-home resources to help address the family’s challenges while they stay together. Canada’s resources could be better invested trying to tackle the root causes of child abuse and neglect. The root causes are not a mystery. We know that child maltreatment is prevented when families have adequate housing, adequate income, employment opportunities, access to addictions treatment, and access to mental health services, parenting skills training and parenting support. Resolving these issues would reduce the need for foster care placements and improve outcomes for entire families. One of the TRC recommendations calls on the federal and provincial governments to report annually on total spending on prevention and care services by child welfare agencies. In a report released a year ago, the Assembly of Manitoba Chiefs called for the dismantling of the current child welfare system and the development of a completely new system. While this idea may seem radical, child welfare as it exists now in Manitoba is failing our children and our families, particularly our Indigenous children and families. And here’s how we could re-construct the system: What if we separated prevention and care services so that they are not delivered by the same agencies? This would encourage families in need to seek support services without worrying that admitting their challenges will result in their children being taken away from them. Perhaps what is needed is nothing short of a revolution in the way we think about addressing the high numbers of kids in care. Marni Brownell an expert advisor with EvidenceNetwork.ca, a Senior Research Scientist with the Manitoba Centre for Health Policy (MCHP) and Associate Professor in the Department of Community Health Sciences, Faculty of Medicine, University of Manitoba. Neeta das McMurtry is a freelance writer. She specializes in making academic and scientific writing accessible to broader audiences. See also our Podcast on the issue: How can Canada reduce the number of children in care?
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Canada has too many kids in care – and the situation is not improving It’s time for national leadership By Marni Brownell and Neeta McMurtry What happens to kids who authorities determine can't live safely with their own parents or caregivers? Thousands of Canadian children are in this situation right now. Many go into foster homes, while others go into other types of out-of-home care on behalf of child welfare agencies. But we don’t know how many, nor do we know how well they are doing. Why? Canada does not keep reliable national statistics on kids in care, instead relying on provincial reporting. But each province has its own child welfare policy and its own definition of children in care, which may not include other types of out-of-home care, such as care from family relatives (kinship care) or group homes. This matters, because it is difficult to know what to do — how to improve outcomes for Canadian kids — if we are not keeping track of what is going on. Some analysts say child welfare systems suffer from underfunding, staffing cuts and not enough foster families or resources to support them. But policy makers have a hard time deciding what to fund without statistics to measure possible outcomes. Also, reliable numbers can help provinces compare best practices for child welfare. Instead, Canada’s foster children story is a patchwork of data and news headlines reporting foster care crises where some children have died while receiving child services. Here’s what we do know: Back in 2011, the National Household Survey counted approximately 30,000 foster kids in Canada. This figure is based on a single-day count that does not include children in other types of out-of-home care, such as group care. Also, statisticians caution that this survey is voluntary, which often results in less accurate data from low-responding groups such as Indigenous peoples, new immigrants and low-income families. In 2007, the Canadian Child Welfare Research Portal reviewed provincial annual reports and counted over 65,000 Canadian children in care on a single day. More recent provincial data tell us that Canada has one of the highest rates of kids in care in the world. Let’s take Manitoba, which has reliable statistics on the issue. In 2014, Manitoba Family Services reported more than 10,000 children in care. And here’s a fact that should alarm every Canadian: by the age of seven years, 7.5 percent of all Manitoba children have been placed in care at some point in their lives. 207
When compared to other countries, Manitoba’s data become even more startling: Manitoba’s rate of out-of-home care for children under 11 years of age was 10 times higher than that of Western Australia. Our rates of care for children during the first year of their lives are higher than Sweden, Western Australia, England, New Zealand, and the U.S. Manitoba is not alone. Though we can’t do province to province direct comparisons because the data measure different things, the total numbers of children are still alarming. In 2013, Association des Centres Jeunesse de Quebec reported 11,250 children in kinship care, foster care and group care. In 2012, the Saskatchewan government reported 6,738 children in out-of-home care. We also know that not all Canadian children are equally likely to be placed in care. The First Nations Child and Family Caring Society of Canada estimates that Indigenous children comprise 30-40 percent of kids in care even though aboriginal population is less than five percent of the total population of Canada. So why does Canada have so many kids in care? The answer largely lies in the approach. Canada (as well as the U.S.) favours a “child safety” approach to children’s welfare. This means that if a welfare agency identifies a child at risk, he or she is removed from the home. Child welfare agencies rely on foster homes and other types of placements to provide temporary, day-to-day care for children until the risks of abuse or neglect are resolved. But with so many kids in care, securing quality out-of-home care is a challenge across Canada. Australia and several European countries take more of a “family welfare” approach. This means that when a child is at risk, the whole family is given intensive home support to try and remove risks while the child stays with the family. Sweden’s child and family wellbeing policy has made remarkable progress in reducing child poverty and family violence, which are two major risk factors for child welfare. It’s time we took a dramatic new approach to kids in care and overhauled our system to focus on preventing rather than reacting to child maltreatment. It’s time we had some federal leadership on a national strategy to make sure some of our most vulnerable citizens are not left by the wayside, but instead treated as valued and respected members of our communities. There’s no greater folly as a nation than wasting the potential of our children. Or worse, putting them at risk. Marni Brownell is an expert advisor with EvidenceNetwork.ca, a Senior Research Scientist with the Manitoba Centre for Health Policy (MCHP) and Associate Professor in
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the Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba. Neeta das McMurtry is a freelance writer. She specializes in making academic and scientific writing accessible to broader audiences.
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Le nombre d’enfants placés en structures d’accueil au Canada est trop élevé Une action à l’échelle du pays s’impose, car la situation est loin de s’améliorer Par Marni Brownell et Neeta McMurtry Qu’arrive-t-il aux enfants lorsque les pouvoirs publics décident qu’ils ne peuvent plus vivre en toute sécurité auprès de leurs parents ou de leurs gardiens? Au Canada, des milliers d’enfants se trouvent actuellement dans cette situation. Un grand nombre sont placés en famille d’accueil et les autres dans des structures hors de la famille parrainées par les services d’aide à l’enfance. Toutefois, nous ne savons pas combien ils sont, ni comment ils se portent. La raison? Le Canada ne recueille pas de statistiques nationales fiables sur les enfants pris en charge; il s’appuie plutôt sur celles des provinces. Or chacune a sa propre politique en matière d’aide à l’enfance et sa propre définition de la prise en charge, pouvant comprendre ou non d’autres types de dispositions comme un placement chez un membre de la parenté ou dans un foyer de groupe. La question est importante, car si l’on n’a aucune idée de ce qui se passe, comment savoir ce qu’il faut faire pour améliorer les résultats de nos interventions auprès des enfants? Certains analystes affirment que les services d’aide à l’enfance souffrent de sousfinancement et des réductions de personnel et que les familles d’accueil et les ressources dont ils disposent sont en nombre insuffisant. Mais en l’absence de statistiques pour évaluer les résultats éventuels, il est difficile pour les décideurs de déterminer où il faut investir. Par ailleurs, des chiffres fiables permettraient aux provinces de comparer leurs meilleures pratiques en matière de protection de l’enfance. La seule information dont nous disposons pour brosser un portrait de la situation se résume à un amalgame de données parcellaires et à des reportages qui font état de crises ayant provoqué le décès d’enfants mis sous la protection de l’aide à l’enfance. Voici ce dont on peut être sûr : En 2011, l’Enquête nationale sur les ménages a dénombré environ 30 000 enfants placés en famille d’accueil au Canada. Ce chiffre se fonde sur un recensement d’une journée qui ne tient pas compte des enfants pris en charge par d’autres structures, comme les foyers de groupe. De plus, les statisticiens rappellent qu’il s’agit d’un sondage volontaire, lequel produit souvent des données moins précises sur les groupes dans lesquels le taux de réponse est faible, comme les Autochtones, les nouveaux immigrants et les familles à faible revenu.
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En 2007, le Portail canadien de la recherche en protection de l’enfance a étudié les rapports provinciaux annuels et déterminé que plus de 65 000 enfants se trouvaient cette année-là en famille d’accueil. Des données provinciales récentes indiquent que le Canada compte l’un des taux de placement en famille d’accueil les plus élevés au monde. Prenons par exemple le Manitoba, qui dispose de statistiques fiables sur la question. En 2014, le ministère des Services à la famille du Manitoba dénombrait plus de 10 000 enfants en famille d’accueil. De plus, 7,5 pour cent des enfants manitobains ont été placés à un moment ou à un autre avant l’âge de sept ans, un chiffre qui devrait alarmer tous les Canadiens et Canadiennes. Lorsqu’on les compare à celles d’autres pays, les données du Manitoba sont encore plus saisissantes. Dans cette province, le nombre d’enfants de moins de 11 ans placés dans des structures hors de la famille est dix fois supérieur à celui que rapporte l’AustralieOccidentale. En ce qui concerne les enfants de moins d’un an, le taux est supérieur à ceux de la Suède, de l’Australie-Occidentale, de l’Angleterre, de la Nouvelle-Zélande et des États-Unis. Le Manitoba n’est pas seul dans sa catégorie. Même s’il est difficile de faire des comparaisons directes entre provinces parce que les données mesurent des choses différentes, les chiffres sont très préoccupants. En 2013, l’Association des centres jeunesse du Québec rapportait que 11 250 enfants étaient placés chez des proches, en famille d’accueil ou en foyer de groupe. En 2012, le gouvernement de la Saskatchewan rapportait pour sa part 6 738 placements hors famille. Nous savons également que les enfants canadiens ne risquent pas tous au même degré d’être placés en famille d’accueil. La Société de soutien à l’enfance et à la famille des Premières nations du Canada estime que les enfants autochtones comptent pour 30 à 40 pour cent des placements, et ce, même si les Autochtones représentent moins de 5 pour cent de la population canadienne. Alors, pourquoi place-t-on autant d’enfants dans des structures d’accueil au Canada? La réponse réside en grande partie dans l’approche. Au Canada (comme aux États-Unis d’ailleurs), on préconise une intervention fondée sur la « sécurité de l’enfant ». Ainsi, lorsqu’on juge que la sécurité d’un enfant est compromise, on retire celui-ci de son milieu familial. Les services d’aide à l’enfance s’appuient sur les familles d’accueil et d’autres structures pour prendre en charge les enfants temporairement jusqu’à ce que le risque d’agression ou de négligence disparaisse. Or avec le nombre actuel d’enfants pris en charge, il devient de plus en plus difficile de trouver des structures d’accueil de qualité d’un bout à l’autre du pays. L’Australie et quelques pays européens ont adopté une approche qui est davantage axée sur « la protection de la famille ». Lorsqu’on craint pour la sécurité d’un enfant, la famille 211
entière bénéficie de mesures de soutien intensif à domicile pour tenter d’éliminer les risques tandis que l’enfant reste auprès de sa famille. Les politiques suédoises en matière de protection de l’enfance et de la famille ont permis d’accomplir des progrès remarquables sur le plan de la pauvreté infantile et de la violence familiale, deux facteurs de risque majeurs pour la protection de l’enfant. Il est grand temps de révolutionner notre approche en matière de prise en charge des enfants et de remanier en profondeur le système pour se concentrer sur la prévention plutôt que sur l’intervention en cas de maltraitance. Le temps est venu pour le fédéral d’adopter une stratégie nationale afin de faire en sorte que nos citoyens et citoyennes les plus vulnérables ne seront pas laissés pour compte, mais plutôt traités comme des membres appréciés et respectés de notre société. Il n’y a rien de plus insensé pour un pays que de gaspiller le potentiel que ses enfants représentent. Ou pire encore, de leur faire courir des risques. Marni Brownell est experte-conseil auprès du site EvidenceNetwork.ca, chercheuse principale au Centre manitobain de politiques en matière de santé (MHCP) et professeure associée au département des sciences de la santé communautaire de l’École de médecine, Faculté des sciences de la santé, Université du Manitoba. Neeta das McMurtry est rédactrice pigiste. Elle se spécialise dans la vulgarisation des travaux universitaires et scientifiques.
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Alcohol use in pregnancy part of a complex set of issues Winnipeg program provides social supports instead of judgement — with positive results By Chelsea Ruth In my work as a neonatologist, I’ve looked after many, many babies. I’ve seen families of all ages, cultures and circumstances. But I’ve never seen a mother who wanted to harm her growing baby. Yet too often I still see mothers who use alcohol during pregnancy despite extensive educational campaigns about its harmful effects on the growing fetus. Alcohol use in pregnancy can result in Fetal Alcohol Spectrum Disorder (FASD). FASD is a lifelong disability which may include intellectual and learning disorders, facial differences and social and emotional difficulties. Not all babies exposed to alcohol in utero develop FASD, but many do. It’s easy to judge, but the truth is, consistently practicing healthy behaviours is not as simple as it sounds. There are often many barriers which may affect a person’s ability to do what they know they should. Studies show that women who use alcohol in pregnancy often deal with many other problems at the same time – physical and mental health disorders, an abusive partner, addictions, homelessness and food insecurity, among other possible issues. So designing programs to adequately support women in such situations can be challenging. This is where InSight comes in. Insight is a Manitoba-based program where mentors work with women at risk of having an infant with FASD. Participants work with a mentor for three years to set and achieve goals for small, positive behavioural changes. The good news – it works. In a recent report from the Manitoba Centre for Health Policy, my colleagues and I demonstrate that women involved in the InSight program made many important gains. They accessed prenatal and other health care at greater rates, they reduced their use of alcohol, both in and outside of pregnancy, and they had greater connections to social supports such as housing, income assistance and postnatal family support programs. Their children were also more likely to be assessed for FASD which likely results in connection to appropriate services, and ultimately, improved outcomes for the child. Importantly, we also found that due to the women’s behavioural changes with mentor support, the children born to women during the program were less likely to be taken into the care of Child and Family Services. But it wasn’t all good news. The report also showed some unexpected findings, which identify areas to change or expand the supports offered through InSight.
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Our report indicates some of the benefits that were seen during the program did not persist after the women left the program. Some women previously engaged in InSight reported increased social isolation, most likely because they lost previous networks of support after changing their behaviours. Going forward, we must find a way to ensure that before an InSight mentor is removed, appropriate other social supports are in place. Lasting positive change shouldn’t be expected to happen overnight. Also, despite having fewer children taken into foster care overall, more newborns were taken into care during the Insight program than in our (lower risk) control group. This can be prevented. The risk of having their babies taken away is a fear that can stop women from accessing supports to reduce their alcohol use during pregnancy. And separating mothers and their newborns increases the risk for postpartum depression and decreases breastfeeding, among other detrimental effects. The solution? It’s a systems problem. We have an opportunity here for child protection agencies to work directly with the InSight program to reduce the occurrence. Insight participants are already attending prenatal care and receiving other supports. Child protective services should allow time for participants to benefit from the program before assessing the home situation. Insight could help provide whatever is needed to allow participants to take their newborns home wherever possible with appropriate surveillance to ensure the safety of the family. When faced with complex problems requiring complex solutions many people don’t know where to start. Our evaluation suggests that the women in InSight know themselves where to start — but they need support to get there and stay there. Addressing poverty, intimate partner violence and mental health issues may take a while, but until we make progress on these pressing issues, expecting there to be quick fixes for reducing alcohol use in pregnancy is unrealistic. Programs like InSight are critical because they are non-punitive in addressing substance use and addictions and address the underlying determinants of disease. When we encounter families and patients affected by drug and alcohol use, we should ask why they got there and how we can help instead of judging them. Steps to provide food security, housing and safety from violence go a long way towards solving the problem for mother and baby. Chelsea Ruth, MD, MSc, FRCPC is an advisor with EvidenceNetwork.ca, a Neonatologist working in the Newborn Intensive Care Units within Winnipeg and a Research Scientist at the Manitoba Centre for Health Policy. Her research focuses on how the outcomes for Manitoba’s children is affected by their newborn circumstances.
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Missed opportunities Jail and prison are a chance to improve health By Fiona Kouyoumdjian with Stephen Hwang The Correctional Investigator of Canada – Canada’s top prison watchdog, Howard Sapers – will soon be leaving his post at the request of the federal government as they exercise their right to appoint a replacement. During his decade-long tenure, Sapers has often been a vocal critic of Canada’s prison system, including the treatment of mentally ill and aboriginal inmates, as well as the use of solitary confinement, among other issues. Canadian prisons, his many reviews have flagged, are often unhealthy spaces. It doesn’t have to be this way. It surprises most people to know that about 1 in 200 Canadians is detained or incarcerated in jail or prison every year, and that the average length of stay in these facilities is only a few weeks. Most of these individuals are dealing with both serious medical problems and difficult social situations, and they lack good access to health and social services in the community. Time spent in jail or prison can serve as an opportunity to improve health. But achieving this goal will require a change in attitudes about health care in custody and reforming health care in correctional facilities. In Fiona’s work as a physician providing health care at a jail in southern Ontario, she often hears patients describe something good about being in jail (as well as lots of bad things about being in jail), like having a chance to “detox” from drinking or drug use, or to get away from unhealthy relationships. These are incidental consequences of being in custody. But we could be more purposeful in using time in custody to help people improve their lives. We have good evidence about ways to do this. With colleagues, we recently reviewed the scientific literature on interventions to improve health in people in custody and in the year after release, and we identified more than 50 interventions that clearly improve health. Some of these interventions seem obvious, for example, linking people with chronic medical and psychiatric problems to a family physician when they are released from jail. Others are treatments that are available for people in most communities in Canada, such as pharmacological therapy and counselling for people with addictions. But these interventions have not been implemented in many correctional facilities across Canada.
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Transforming jails and prisons into places where people can improve their health and where we integrate evidence on best practices will require changing our attitudes and changing how health care is delivered. We need to recognize that people in custody have the right to the same standard of care and level of service as people in the community, regardless of what crimes they may have committed or what lifestyle choices they have made. We need oversight of health care in correctional facilities by people with expertise in health and not only those with expertise in security. This important change may be best achieved by transferring the responsibility for health care from Ministries responsible for corrections to Ministries responsible for health. Where not already in place, health care services in correctional facilities should be accredited as a means of ensuring quality and consistency of care across institutions and jurisdictions. Does it make sense to focus on the health of people in jails and prisons? We firmly believe, yes. Jail and prison offer a unique opportunity to access an often marginalized population, to provide needed treatment and services, and to link people with communitybased care and programming. Improving health in this population would also benefit the general population. Better health and health care for people who are detained or incarcerated could reduce health care costs, for example, by linking people with family physicians we could reduce expensive and unnecessary use of emergency departments. Appropriately diagnosing and treating infectious diseases such as hepatitis C and HIV could lead to less transmission of these diseases to others in custody and to the general population after release from custody. Effective treatment of mental illness and substance use disorders could lead to less crime, which would positively affect public safety and reduce re-incarceration and associated costs. A focus on improving health and health care for our most vulnerable populations is an important agenda that we need to advance. Innovation and excellence should be integral to the provision of health care and services for persons in jails and prisons, with potential benefits for all Canadians. Fiona Kouyoumdjian is a Postdoctoral Fellow at the Centre for Research on Inner City Health at St. Michael’s Hospital and a Family Physician at a provincial correctional facility in Hamilton, Ontario. Stephen Hwang is an expert advisor with EvidenceNetwork.ca and a practicing physician in general internal medicine at St. Michael’s Hospital and a research scientist at the Centre for Research on Inner City Health in Toronto. See also our Podcast on the issue: Using incarceration as an opportunity to improve inmates’ health
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Is it fair to make a public appeal for a live organ donor? By Jennifer Chandler The public response to the appeal on behalf of Eugene Melnyk, owner of the Ottawa Senators hockey team, for a liver donor has been a heart-warming demonstration of the generosity of our community. Fortunately, a donor was found and the transplant was performed in time to save his life. But is it fair that he received a donation when many others are waiting, and dying, on the waitlist for a transplant? This is one of the common themes in the commentary in the news over the past few days. It is entirely understandable for those in desperate need to give up on the waitlist for a deceased donor and to reach out to their friends and family, and, if they are able to do so, to the public to find a live donor. There is perhaps an inescapable unfairness in all such appeals for live donors. Those with larger families and social circles may have a higher chance of locating a suitable donor. As for appeals to the public, those with wealth, fame, charisma or a particularly compelling story are likely to do better than those without these attributes because they are more appealing to the public or because they have better access to the means of effective mass communication. Although some are critical of public appeals for live organ donors, it is important to note that refraining from launching these appeals does nothing to help anyone. In fact, it may actually harm both people like Mr. Melnyk who hope to find a donor, as well as others on the waitlist as well. There are several ways in which public appeals to help one specific individual might indirectly benefit others waiting for a transplant. When the topic of organ donation and transplantation attracts the public’s attention as it has done this week, more people tend to register their willingness to donate after death and to speak to their families about donation. This benefits everyone by increasing the availability of organs from deceased donors. It is important to remember that wealth and fame do not play a role in the allocation of organs from deceased donors in Canada, even if these factors might offer a platform from which to launch more successful appeals for live donors. Second, some of those who have come forward to help Mr. Melnyk may be willing to help one of the other unknown Canadians facing a similarly desperate plight. In other words, Mr. Melnyk’s public appeal may well save the lives of others who are less wellplaced than Mr. Melnyk to command public attention. According to the most recent annual statistics from the Canadian Institute for Health Information, 374 Canadians were awaiting a liver transplant in 2012. In the same time period, 111 in need of a liver transplant died or were removed from the waitlist. It is hard not to notice that in only a couple of days this past week, 2,000 people responded to the
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appeal on behalf of Mr. Melnyk, and more than 500 sent in donor applications. This level of support could go a long way toward meeting the need for liver transplants in Canada. The ideal outcome in this case is a healthy recovery for Mr. Melnyk and for the person who donated to him, as well as – and as important – spill-over benefits for the many others awaiting a transplant. This could be in the form of increased registration for deceased donation and perhaps live donation from some of the many people who stepped forward for Mr. Melnyk. In fact, 20 of the many potential donors who stepped forward are reported to have told surgeons they would like to donate to others in need. It is in our hands as members of the public to act to help the many unknown Canadians who are living among us desperately but quietly and anonymously awaiting a transplant. If we are troubled that the overwhelming response to celebrity appeals for live donors leaves these others unaided, there are steps we can take to help them too. It is a simple matter to register to donate after one’s death (a couple of clicks at https://beadonor.ca in Ontario). Jennifer Chandler is an advisor with EvidenceNetwork.ca, holds the Bertram Loeb Research Chair in Organ and Tissue Donation, Canadian National Transplant Research Program and is an Associate Professor, Faculty of Law, University of Ottawa.
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Three things the federal government can do to improve the Registered Disability Savings Plan By Kathleen O’Grady Many of us in the disability community were pleasantly surprised when the Liberal party promised to create a National Disabilities Act that would safeguard disability rights, reduce systemic barriers and establish a foundation of opportunity for those affected by disability. Canada is an outlier among developed nations for not having one – the U.S. has had theirs for 25 years – so it could not arrive soon enough. But the federal Conservative government did make some positive contributions of their own for the disability community during their decade in power – most notably, The RDSP was the brainchild of non-profit organization, PLAN and was championed by the late Finance Minister, Jim Flaherty, who made it a reality in the 2007 budget. Flaherty had first-hand experience with disability; one of his sons contracted encephalitis as an infant with lasting health consequences. The RDSP is Flaherty’s legacy to Canadians with disability and it remains an important and valuable program – at least in theory. According to a 2014 study, only about 15 percent of eligible Canadians take part in the program, meaning almost half a million eligible Canadians are losing out. With a wave of teens with autism reaching adulthood in the coming years, helping families affected by disability help themselves has never been more important. So what is it and what needs to be done to make it work better for Canadians? The RDSP is a savings plan that helps parents and caretakers of those with a disability save for their loved one’s long-term financial future with some financial contributions coming directly from the government – free money, in other words. There are two components to the RDSP in addition to personal contributions: a federal grant and a federal bond. The grant is based on family income and how much a family contributes privately to the RDSP. It can equal as much as $3,500 in contributions from the government each year. The bond is based solely on family income (those making less than $43,953) and can be as much as $1,000 in contributions from the government per year. Over the lifetime of an RDSP, an individual can receive as much as $70,000 from the federal grant, and if eligible, as much as $20,000 from the federal bond. So why are so few using the RDSP?
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In 2014, a cross-party Senate Committee undertook a study to answer this very question. It’s time our new federal government dusted off the report and put some of the recommendations into action. Here are three quick ways the federal government can improve the RDSP and help families affected by disability now: 1. Establish an RDSP automatically once an individual is eligible for Revenue Canada’s Disability Tax Credit. When I initiated my son’s RDSP, I was required to provide his Disability Tax Credit status, a Social Insurance Number, proof of age and residency in Canada. It’s a lot of intimidating bureaucratic paperwork that could put off families who may have time, language or educational barriers. 2. In the meantime, raise the awareness and understanding of the RDSP program. I regularly encounter families in the disability community who have never heard of the RDSP program or don’t know how to initiate it. Others have told me they don’t have the money to start one – unaware they’d be eligible for free government bonds just for opening the account without requiring a penny of savings from them. The Senate report recommends the federal government should partner directly with advocacy groups to help spread the word. This makes good sense since it’s often the front-line non-profit groups who are directly engaged with disability families and know best how to reach them and could help them with administrative hurdles. Another promising model is to have health practitioners work directly with their patients. Recently, a coalition of health care providers, researchers and community agencies based in Ontario and Manitoba have created a Get Your Benefits! Toolkit to help health care workers improve the wealth – and thus the health – of their patients by helping them access income and other supports they may be entitled to. 3. Allow other family members and friends to more easily contribute to an existing RDSP This recommendation isn’t in the Senate report, but it’s one that comes from my own experience and from others I know in the disability community. If you have a disabled child, ‘extra money’ is not always easy to tuck away. But birthdays and other special events are an opportunity for loved ones of the child to contribute meaningfully to their future. 220
Financial institutions should work with the federal government to find an easy way for those who are not plan holders to contribute to an individual RDSP in small or significant amounts. (In theory it is permitted now, but in practice, it is almost impossible in some plans). It takes a community to raise a child after all. The RDSP really is an excellent program and needed as much today as when it was created. The federal government just needs to give it wings to make it fly. Kathleen O’Grady is the Managing Editor of EvidenceNetwork.ca, a Research Associate at the Simone de Beauvoir Institute, Concordia University, Montreal, and the mother of two sons, one with autism.
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Trois mesures que peut prendre le fédéral pour améliorer le régime enregistré d’épargne-invalidité Par Kathleen O'Grady Bon nombre d’entre nous qui œuvrons dans le milieu avons été agréablement surpris d’apprendre que le parti libéral avait promis d’adopter une loi nationale sur les handicaps afin de protéger les droits des personnes handicapées, d’aplanir les obstacles systémiques et de promouvoir l’égalité des chances. L’absence de loi à cet égard est une aberration lorsqu’on se compare aux autres pays développés – les États-Unis ont adopté la leur il y a 25 ans –, si bien que l’on peut dire que l’annonce n’arrive pas trop tôt. Au cours des dix années où ils ont détenu le pouvoir, les conservateurs ont adopté néanmoins quelques mesures de leur cru qu’on peut qualifier de bonnes pour l’ensemble des personnes handicapées, dont la plus remarquable est le régime enregistré d’épargneinvalidité (REEI). Le projet, fruit des travaux du Planned Lifetime Advocacy Network (PLAN), un organisme à but non lucratif, avait été mis de l’avant par feu Jim Flaherty, ancien ministre des Finances, qui l’avait concrétisé dans son budget de 2007. Celui-ci avait une expérience directe du handicap, l’un de ses fils ayant contracté à un très jeune âge une encéphalite qui avait entraîné des conséquences à long terme sur sa santé. Le REEI représente l’héritage laissé par Jim Flaherty à ses concitoyens qui vivent avec un handicap. Il s’agit toujours d’un programme essentiel et très utile ‒ du moins en théorie. Selon une étude publiée en 2014, seulement 15 % des Canadiens admissibles participent au programme, ce qui signifie que près d’un demi-million de personnes ne s’en prévalent pas. Avec la vague d’adolescents autistes qui atteindront l’âge adulte dans les années à venir, l’idée d’aider leurs familles à s’aider elles-mêmes n’a jamais semblé d’une aussi grande actualité. En quoi consiste le programme et que peut-on faire pour l’améliorer? Le REEI est un régime d’épargne visant à aider les parents et les personnes qui s’occupent d’une personne handicapée à mettre de l’argent de côté dans le but d’assurer sa sécurité financière à long terme. Une partie des sommes sont versées directement au régime par le fédéral; c’est de l’argent gratuit, en somme. Les cotisations individuelles versées dans un REEI sont complémentées par une subvention ainsi qu’un bon (versés par le fédéral). La subvention, qui peut atteindre jusqu’à 3500 $ par an, est calculée selon le revenu familial et le montant de la cotisation du particulier au REEI. Le calcul du bon est basé uniquement sur le revenu familial 222
(aucun bon n’est accordé si celui-ci dépasse 44 701 $); le montant peut atteindre jusqu’à 1000 $ par an. La limite à vie de la subvention que peut recevoir un bénéficiaire grâce au REEI est fixée à 70 000 $; celle du don, à 20 000 $ pour les bénéficiaires admissibles. Dans ce cas, comment expliquer que le nombre de cotisants à un REEI soit si faible? En 2014, un comité sénatorial interpartis a entrepris une étude pour se pencher justement sur cette question. Il serait temps que notre nouveau gouvernement dépoussière le rapport qui en découle et mette en œuvre certaines des recommandations qu’il renferme. Voici trois mesures que le fédéral pourrait instaurer rapidement en vue d’améliorer le REEI et venir immédiatement en aide aux familles touchées par le handicap: 1. Établir automatiquement un REEI au nom des personnes qui deviennent admissibles au crédit d’impôt pour personnes handicapées. Lorsque j’ai ouvert un compte REEI au nom de mon fils, on m’a demandé de fournir son certificat pour le crédit d’impôt pour personnes handicapées, son numéro d’assurance sociale ainsi qu’une preuve d’âge et de résidence au Canada. Toute cette paperasse peut décourager les personnes qui manquent de temps, ne maîtrisent pas la langue ou ont un faible degré de scolarité. 2. Dans l’intérim, faire la promotion du programme et en expliquer le fonctionnement. Je rencontre souvent des familles qui n’ont jamais entendu parler du REEI ou qui ne savent pas comment s’inscrire. D’autres m’ont dit qu’ils ne disposaient pas de fonds suffisants, sans savoir qu’ils sont admissibles aux sommes versées gratuitement par le gouvernement simplement en ouvrant un compte, sans avoir à y verser un sou. Les auteurs du rapport sénatorial recommandent au gouvernement de s’associer avec les groupes de défense des personnes handicapées pour faire connaître le programme. Une proposition sensée, puisque ce sont souvent les associations à but non lucratif qui interviennent auprès des familles en première ligne. Elles savent comment les joindre et peuvent les assister dans leurs démarches administratives. Une autre avenue prometteuse consisterait à demander aux professionnels de la santé d’intervenir directement auprès de leurs patients. Récemment, une coalition de prestataires de soins, de chercheurs et d’associations en Ontario et au Manitoba a conçu une trousse d’outils destinée à aider les patients à améliorer leur situation financière ‒ et leur état de santé par le fait même ‒, en les renseignant sur les prestations auxquelles ils pourraient avoir droit. 3. Faciliter le versement de cotisations au REEI par l’entourage du bénéficiaire
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Cette recommandation ne figure pas dans le rapport du Sénat; elle se fonde sur ma propre expérience et celle d’autres personnes que je connais dans le milieu. Si vous avez un enfant handicapé, il n’est pas toujours facile de se constituer un pécule. Les anniversaires et d’autres événements du même genre peuvent constituer une occasion pour l’entourage de contribuer de façon tangible à l’avenir d’un être cher. Les institutions financières pourraient collaborer avec le fédéral afin de trouver un moyen, pour les particuliers non titulaires d’un compte, de verser des sommes modestes ou importantes au REEI d’un bénéficiaire (il est possible de le faire, en principe, mais dans la pratique, cela est presque impossible dans certains régimes). Après tout, il faut une collectivité pour élever un enfant. Le REEI est indéniablement un excellent programme, aussi nécessaire aujourd’hui que lors de sa création. Il ne reste plus qu’à lui donner les ailes nécessaires pour qu’il prenne son envol. Kathleen O’Grady est associée de recherche à l’Institut Simone de Beauvoir de l’Université Concordia et rédactrice en chef du site EvidenceNetwork.ca. Elle est mère de deux garçons, dont l’un est autiste.
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It shouldn’t matter where you go to school, but for kids with diabetes, it does Provinces, school districts need to adopt comprehensive diabetes policies now By Jan Hux Summer is a time to put thoughts of school aside, but some families are already worrying about September. For parents of kids with diabetes, the beginning of each new school year brings not only the usual preparations, but also fears for their child’s health and safety. This is especially true if their school or school district does not have a policy to ensure staff are knowledgeable about diabetes, know how to prevent emergencies, and are able to assist students with daily diabetes tasks, when needed. Type 1 diabetes affects more than 34,000 Canadian children under the age of 19; another 1,800 have type 2 diabetes. Type 1 diabetes is when the body is unable to produce insulin, a hormone that controls blood sugar. It has no known cause or cure and usually begins in childhood. Type 1 diabetes is the most common diabetes in children. Type 2 diabetes is the most common among all people with the disease, where the body either cannot effectively use or produce enough insulin. Type 2 diabetes usually develops in adulthood, although more children and adolescents are being diagnosed. Most students can manage their diabetes independently or with minimal support, and they can fully participate in school activities, including gym, field trips and celebrations. However, some, especially very young children with type 1 diabetes, may need trained personnel to help administer insulin, monitor blood sugar levels or supervise food intake and activity. Students with diabetes may also need flexibility in school rules to prevent low or high blood sugar, and, in some cases, may also need help with recognizing “lows” and “highs.” A supportive school environment is critically important for keeping children with diabetes safe and healthy. Proper diabetes management reduces the risk of life-threatening emergencies, prevents or reduces the risk of serious long-term complications such as heart disease, limb amputation, kidney failure and blindness and ensures that students with diabetes are able to learn and participate fully in all school activities. Yet only five provinces have guidelines for children with diabetes at school: Newfoundland and Labrador, New Brunswick, Nova Scotia, Quebec and British Columbia. Ontario recently formed a working group to address this issue and other jurisdictions have signaled their interest in forming such policies, but change has not been implemented as of yet. At the school-board level, some boards and even individual
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schools have developed policies, leading to a patchwork of different care standards among school districts, and even among schools in the same district. Many schools and districts have no diabetes policies in place at all. It is important that all children with diabetes be afforded the same protections and given the same opportunities to succeed, no matter where they live or attend school. It is a team effort to enhance the health, safety, emotional well-being and participation of each student with diabetes. There is a role to play for everyone involved in the care of the student to ensure a safe and healthy school experience. Parents and guardians need to notify the school of the diagnosis and meet with the school to develop an Individual Care Plan (ICP) so the necessary supports are arranged. School personnel need to participate in annual diabetes education, training and resource review to learn how to manage diabetes, including emergency procedures. Health care providers act as resources to the schools and assist in creating the student’s ICP. But perhaps, most importantly, our provincial governments need to make proper diabetes management at school a priority now. Every province and territory should establish clear standards of care that school boards can follow to ensure the safety, health and optimal education for children with diabetes. In the interim, school boards can begin the process of creating pragmatic guidelines such as those outlined by the Canadian Diabetes Association so that diabetes care across regions is equitable, safe and organized. Clear and consistent policies are better for the schools, better for families and provide an open and transparent process for communities to work with. Finally, everyone should work to prevent students with diabetes from experiencing stigma and discrimination by promoting a positive, caring and inclusive learning environment through communication, education and cooperation. Dr. Jan Hux is an expert advisor with EvidenceNetwork.ca and Chief Science Officer for the Canadian Diabetes Association.
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Rethinking diabetes It’s time to stop blaming individuals for poor eating choices, and move toward community action By Jan Hux Journalist H.L. Mencken wrote that “for every complex problem there is a solution that is clear, simple and wrong.” That observation aptly describes a prevailing attitude toward type 2 diabetes, which characterizes diabetes as a problem that could clearly be fixed if people would simply move more and eat less. Such a suggestion ignores much of what is known about the causes of the most prevalent and rapidly growing form of diabetes in Canada, and places an unwarranted burden of blame on those affected by it. Type 2 diabetes is a complex problem with roots in genetics, the environment and individual behavioural choices. The role of genes is evident in the epidemiologic patterns of the disease. It is a condition that runs in families and few individuals diagnosed with type 2 diabetes do not have at least one relative who is affected. It is also more prevalent in certain population groups, most notably First Nations. For some of those who carry a potent genetic risk for diabetes, no amount of physical fitness or healthy eating will protect them from developing the disease. A second, less appreciated contributor to the growing diabetes epidemic is the role of the environment, specifically factors such as the walkability of neighbourhoods, food security and local access to health-related facilities and services. Recent research in Toronto [http://care.diabetesjournals.org/content/36/2/302.short] has demonstrated that, all else being equal, men living in the least walkable parts of the city are 32 percent more likely to develop diabetes than those living in the most walkable neighbourhoods. For recent immigrants to Canada (many from parts of the world where the genetic risk is higher), the effect is even more striking, with a risk 58 percent higher in the least walkable neighbourhoods. Similar results were found in women, with risk increases of 24 percent for long-term residents and 67 percent for recent arrivals. It is also true that for people who are at risk of developing diabetes, behavioural choices that promote obesity increase that risk. Improving the diet and physical activity level of persons at high risk has been shown to reduce the risk by nearly 60 percent. Studies documenting the impact of behavioural changes are noteworthy because small changes in weight – on average, a loss of only five to 10 percent — has significant benefits. Such findings have been widely promoted by public health agencies and practitioners in an attempt to empower individuals to reduce their risk of developing diabetes. However, over-emphasizing the importance of weight reduction may have contributed to unbalanced messaging to the public around the causes of the disease. It’s time to right the balance. 227
To simply blame individual behavioural choices as the root cause of the diabetes epidemic does a disservice to those with the disease by creating stigma (a stigma which can even spill over to those with type 1 diabetes, a disease that it is not linked to obesity). But there is an even greater danger with a simplistic understanding of diabetes that focuses exclusively on individual choice – it diverts attention and resources from other approaches which may be more effective at addressing the diabetes epidemic. It is projected that by the year 2020, one in three Canadians will have either diabetes or pre-diabetes, a statistic that crystalizes the need for more emphasis on prevention, and illustrates why individual interventions alone are unlikely to be enough. We can turn to Finland for inspiration. In the late 1960s, North Karelia, a province in Finland, was found to have the world’s highest documented rate of cardiovascular death among middle-aged men. In response, provincial representatives signed a petition to the Finnish government for urgent assistance to reduce the high burden of disease. Within a year, a multi-stakeholder community-based approach engaged food retailers, the food products industry and even the agricultural sector where, for example, a drop in demand for high fat milk products was managed by supporting dairy farmers to become berry farmers. What was the outcome? Over the next three decades, death rates from heart disease fell by 80 percent and significant reductions were also seen in rates of stroke and cancer. This comprehensive approach that sought to address the whole population had a remarkable impact. Can this experience be reproduced in Canada? There will be a number of challenges, but perhaps the first step is to effectively confront the misconception that diabetes is exclusively the fault of those who eat too much and move too little. Diabetes is a complicated problem and that simple response has delayed real action. Dr. Jan Hux is an expert advisor with EvidenceNetwork.ca and the Chief Science Officer at the Canadian Diabetes Association. She has broad experience as a physician, researcher, educator and executive.
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Repenser le diabète Il faut cesser de juger les individus et leurs habitudes alimentaires et prôner une action collective Par Jan Hux Le journaliste H.L. Mencken a écrit qu’à tout problème complexe il y a une solution simple, mais mauvaise. Cette réflexion décrit bien l’attitude prédominante à l’égard du diabète de type 2, à savoir qu’on pourrait facilement endiguer le problème si les gens se décidaient enfin à bouger davantage et à manger moins. Cette conception fait fi d’un grand bassin de connaissances actuelles sur les causes de cette forme de la maladie, qui est la plus courante au Canada et en croissance rapide. Ainsi, ses victimes sont culpabilisées sans raison. Le diabète de type 2 est une affection complexe, associée à des facteurs génétiques et environnementaux ainsi qu’aux comportements individuels. Lorsqu’on étudie le profil épidémiologique de la maladie, on constate que les gênes jouent un rôle évident. En effet, il est rare de trouver une personne atteinte qui ne compte pas un membre de sa famille qui en souffre également. Sa prévalence est plus élevée dans certaines populations, notamment chez les Premières Nations. Chez certaines personnes qui présentent un risque génétique élevé, l’activité physique ou une saine alimentation ne seront jamais un facteur de protection, quel que soit leur degré d’adhésion à cet égard. Un second facteur, moins connu, contribue à l’épidémie de diabète : le rôle que joue l’environnement, en particulier des éléments comme l’accessibilité piétonnière des quartiers, la sécurité alimentaire et l’accès aux installations et aux services de santé près de chez soi. Des recherches menées à Toronto montrent que, toutes choses étant égales, les hommes qui vivent dans les quartiers les moins propices à la marche ont 32 pour cent plus de chances de souffrir de diabète que les hommes qui vivent dans les quartiers où l’on peut facilement se déplacer à pied. Le phénomène est encore plus frappant chez les immigrants récents (dont un grand nombre sont originaires de parties du monde où le risque génétique est élevé): le risque atteint 58 pour cent dans les quartiers où l’accessibilité piétonnière est moindre. Les résultats sont semblables chez les femmes : le risque augmente de 24 pour cent chez les résidentes de longue date et de 67 pour cent chez celles qui s’y sont établies depuis peu. Il est vrai que chez les personnes à risque, les comportements qui favorisent l’obésité font augmenter celle-ci. On sait que celles qui sont à risque élevé, le fait d’améliorer son alimentation et son niveau d’activité peut réduire d’environ 60 pour cent les chances de souffrir de diabète.
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Les études sur les effets des changements de comportement méritent d’être soulignées, puisqu’une légère modification du poids (une perte de 5 pour cent à 10 pour cent seulement en moyenne) apporte des bienfaits significatifs. Ces conclusions ont fait l’objet d’une large médiatisation par les organismes et les médecins de la santé publique, qui ont vu dans ces résultats un moyen d’amener les individus à réduire le risque de diabète. Toutefois, le fait d’avoir trop insisté sur l’importante de réduire son poids pourrait avoir contribué à fausser le message sur les causes de la maladie. Le temps est venu de rétablir l’équilibre. En se contentant d’imputer les causes de l’épidémie de diabète aux comportements des individus, on nuit aux personnes qui en souffrent, car on les stigmatise (cela touche parfois même aux personnes atteintes de diabète de type 1, une maladie qui n’est pas associée à l’obésité). De plus, en ciblant exclusivement les comportements individuels, les explications simplistes sur les causes du diabète comportent un danger plus grand encore. En effet, elles contribuent à détourner l’attention des approches susceptibles d’être plus efficaces et des ressources qu’on pourrait y investir. On prévoit que d’ici l’an 2020, un Canadien sur trois souffrira de diabète ou de prédiabète. Ce chiffre montre à quel point il est important de mettre l’accent sur la prévention, tout en rappelant que des interventions individuelles ne suffiront pas à régler seules le problème. L’exemple de la Finlande pourrait nous inspirer. Vers la fin des années 1960, la Carélie du Nord, une province finlandaise, affichait le taux de mortalité cardiovasculaire le plus élevé jamais répertorié chez des hommes d’âge moyen. Les représentants provinciaux signèrent une pétition adressée au gouvernement national en lui demandant d’agir de toute urgence pour réduire le lourd fardeau de la maladie. Au bout d’un an, les responsables avaient instauré un programme local faisant appel à de multiples intervenants, dont les épiceries, l’industrie alimentaire et même le secteur agricole. Entre autres, on a compensé la baisse de la demande en produits laitiers à forte teneur en matières grasses en encourageant financièrement leurs producteurs à se tourner vers la culture des petits fruits. Quel fut le résultat de cette initiative? Le taux de mortalité cardiovasculaire a chuté de 80 pour cent en 30 ans. On a constaté en outre une réduction importante du taux d’accident vasculaire cérébral et de cancer. Ce programme exhaustif qui s’adressait à l’ensemble de la population a produit des retombées remarquables. Serions-nous capables de répéter cette expérience au Canada? Les défis seront nombreux; il faudra peut-être, en premier lieu, combattre l’idée erronée voulant que les personnes
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atteintes de diabète soient seules responsables de leur sort parce qu’elles mangent trop et ne bougent pas assez. Le diabète est une maladie complexe; les approches simplistes ne font que retarder la mise en œuvre d’un véritable programme d’intervention. La Dre Jan Hux est experte-conseil auprès du site EvidenceNetwork.ca et conseillère scientifique en chef à l’Association canadienne du diabète. Elle possède une vaste expérience comme médecin, chercheuse, pédagogue et gestionnaire.
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Learning to walk What will be the legacy of the Truth and Reconciliation Commission? By James Wilson As Cree youngsters in the north, we are taught the tradition of how to walk on the land and in the bush – with each foot fall carefully and quietly placed so as not to disturb the food sources that have always meant the difference between thriving and starvation. It is a hard won but essential skill for those living off the land and it takes many years of practice to master. Sadly, like so many of our traditions, this one was almost swept away during the tragic Indian Residential Schools period, described by Justice Murray Sinclair, Chair of the Truth and Reconciliation Commission, as Canada’s greatest shame. On June 2, after the Commission’s findings and final recommendations were released, the baton will be passed to people like Ry Moran, director of the National Research Centre at the University of Manitoba. Here, the many hours of deeply personal testimony will be housed and a plan struck to foster further research and to decide how best to pass on all that has been learned. As he reflects on the many tears that were shed during the thousands of hours of disclosures, the horrors that still haunt many Canadians, and all that was lost, Moran said, “At its core, kids were denied the right to be children and to feel the love of their parents in their lives. At the same time, parents were denied the right to give love – an attack on the most fundamental and sacred elements of any society." When I think back on the role my own parents played in our lives and in Moose Lake, Manitoba where they both began their careers as teachers, how very different things could have been. Though they arrived separately to a reserve that was accessible only by boat, snowmobile or dog team back then, they left together and their story is nothing short of remarkable in the way it paints what life in a Cree community used to be like. Yes, they witnessed first-hand the chasm created by residential schools, but, as the community’s first Cree teacher, my Dad fell in love with another young teacher, the daughter of a Scottish couple who no doubt feared their girl was entering the unknown. Together, their time there was impactful and not only in romantic ways but in how they helped hold the community together. I love to hear their stories about Moose Lake, back when teachers used to smoke at the front of their classrooms, and Physical Education entailed cutting wood and hauling water.
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They both spent most every evening visiting the families in the reserve. Mum says they had a calendar mapping out who they would have tea with on which night, so they could eventually spend time with all of the community. Now and then I still run into people who used to be their students, and I am proud to say the relationships they built there are still cherished. My parents often talk about the people from the reserve who lived off the land. There was no such grandiose a title as “Elder” back then, only people who held themselves with the confidence of spending years being solely responsible for their own and their family’s existence. When young people began returning from residential schools, it is fascinating that what struck those who lived off the land the most is that these ‘students’ had to be taught how to walk all over again. Not with the harsh heel strike they had learned in the towns and cities but with the gentle foot fall of their early childhoods. Maybe that will be the lasting legacy of the Truth and Reconciliation Commission – that we can face the truth of our past, see a way forward that is hopeful, and learn how to walk gently together so that, as Justice Sinclair so eloquently said, “we can turn our greatest shame into our greatest source of pride” as peoples and as a nation. James Wilson is an advisor with EvidenceNetwork.ca and commissioner of the Treaty Relations Commission of Manitoba, a neutral body mandated to encourage discussion, facilitate public understanding, and enhance mutual respect between all peoples in Manitoba.
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Apprendre à marcher Quel héritage durable la Commission de vérité et réconciliation laissera-telle? Par James Wilson J’ai appris à me déplacer sur la terre et dans les bois selon la tradition, telle qu’on l’enseigne aux jeunes Cris des régions nord. L’idée consiste à poser le pied sur le sol délicatement et sans faire de bruit, afin de ne pas perturber les sources de nourriture qui, depuis toujours, représentent cette ligne de démarcation entre abondance et disette. Une aptitude durement acquise, mais essentielle pour ceux qui tirent leur subsistance du territoire; la maîtriser exige des années de pratique. Malheureusement, cette tradition a pratiquement disparu, comme beaucoup d’autres d’ailleurs, durant la période tragique des pensionnats indiens, que le juge Murray Sinclair, président de la Commission de vérité et réconciliation, a décrite comme la plus honteuse de l’histoire du pays. Le 2 juin, après la publication des conclusions et des recommandations de la Commission, des personnes comme Ry Moran, directeur du Centre national pour la vérité et la réconciliation à l’Université du Manitoba, auront repris le flambeau. C’est là que seront préservés des milliers d’heures de témoignages des plus personnels. Un programme sera mis sur pied afin de promouvoir les recherches et déterminer le meilleur moyen de transmettre tout ce qui aura été appris. Ry Moran réfléchit au poids des larmes qui ont été versées au fil des confidences livrées pendant les séances de la Commission, aux horreurs qui hantent jusqu’à aujourd’hui un grand nombre de Canadiens et à tout ce qui a été perdu : « Essentiellement, on a privé ces petits du droit d’être des enfants et de ressentir l’amour de leurs parents. Et l’on a privé leurs parents du droit de donner de l’amour. C’est une violation des principes les plus fondamentaux et sacrés de toute société. » Lorsque je repense au rôle que mes propres parents ont joué dans nos vies et dans la communauté de Moose Lake, au Manitoba, où ils avaient tous deux entamé leur carrière d’enseignant, je mesure à quel point les choses auraient pu évoluer différemment. Ils étaient arrivés chacun de leur côté dans une réserve qui n’était accessible à l’époque que par bateau, motoneige ou traîneau à chiens, mais ils en sont repartis ensemble. Leur histoire est proprement remarquable, en ce sens qu’elle dépeint la vie dans une communauté crie telle qu’elle se déroulait en ce temps-là. Mes parents ont été des témoins directs du gouffre créé par les pensionnats. Mon père fut le tout premier enseignant d’origine crie à s’établir sur la réserve; il s’est épris d’une autre jeune enseignante, la fille d’un couple écossais qui devait sans doute éprouver des craintes face à l’inconnu vers lequel s’avançait leur fille. Ensemble, mes parents ont laissé leur marque dans la communauté, non seulement d’un point de vue sentimental, mais aussi dans ce qu’ils ont accompli pour aider ses membres à se serrer les coudes. 234
J’adore écouter mes parents raconter des histoires sur Moose Lake, des récits qui remontent à une époque où les enseignants fumaient devant leur classe et où les cours d’éducation physique comportaient des activités comme bûcher du bois et transporter de l’eau. Mes parents consacraient presque toutes leurs soirées à visiter des gens sur la réserve. Ma mère m’a dit qu’ils avaient préparé un calendrier sur lequel ils annotaient le nom de la famille avec laquelle ils prendraient le thé chaque soir, de telle sorte qu’ils puissent rencontrer tout le monde. De temps à autre, je croise encore de leurs anciens élèves et je suis fier de dire que les gens se souviennent avec affection des liens que mes parents avaient tissés. Mes parents parlent souvent des habitants de la réserve qui tiraient leur subsistance du territoire. En ce temps-là, on ne portait pas de titres pompeux comme celui d’« aîné »; on avait l’assurance de ceux qui ont pourvu seuls pendant des années à leurs propres besoins et à ceux de leur famille. Lorsque les jeunes ont commencé à revenir des pensionnats, ceux qui vivaient des produits de la terre ont été étonnés de constater qu’il fallait réapprendre à ces « élèves » à marcher correctement. Non pas en frappant le talon sur le sol comme ils l’avaient appris à la ville, mais en posant le pied tout doucement, comme ils le faisaient quand ils étaient petits. Voilà peut-être quel sera l’héritage durable de la Commission de vérité et réconciliation : le fait d’avoir réussi à affronter les vérités du passé, d’entrevoir l’avenir avec espoir et d’apprendre à marcher doucement ensemble de façon à pouvoir, comme l’a dit de façon si éloquente le juge Sinclair, « transformer notre honte incommensurable en source de fierté immense », en tant que peuples et en tant que nation. James Wilson est conseiller auprès du site EvidenceNetwork.ca et commissaire à la Commission des relations découlant des traités du Manitoba, un organisme neutre ayant pour mandat de nourrir le dialogue, de sensibiliser le grand public et de promouvoir le respect mutuel entre tous les peuples du Manitoba. @JamesBWilson_
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Social change: at the heart of medicine An Interview with Canadian Medical Association President, Chris Simpson By Ryan Meili Recently, I was fortunate to attend the Global Symposium on the Role of Physicians and National Medical Associations in Addressing Health Equity and the Social Determinants of Health held in London, England. The meeting was organized by the Canadian, British and World Medical Associations and had, among other goals, an agenda to assist public health pioneer Sir Michael Marmot in making such issues central to his upcoming role as president of the World Medical Association. Among the attendees was Canadian Medical Association president Dr. Chris Simpson. I sat down with Dr. Simpson to explore the stories, the evidence and the politics that come into play when doctors are actors for social change. Ryan Meili: You have an interest in the social determinants of health (SDOH) — you’ve been talking about it in your presidency, as have the last few Canadian Medical Association (CMA) presidents. On a personal level, why does that matter to you? In your own history, what has drawn you to the idea? Chris Simpson: There’s one reason that’s more altruistic and noble than the other, but I’ll give you both. I grew up in rural New Brunswick, in a town that was a “model” town. It was created because a pulp mill was built there, and there was a hydroelectric dam that basically flooded the entire community and they had to build a new community above it. It was populated with a disproportionate number of teachers and engineers and professionals, and there was a time when I was a kid when it was the community with the highest per capita family income in the country, right in the middle of rural New Brunswick. But around it were very poor rural communities, and the contrast was incredible. When I went to school we all were together, so you'd have these children of university educated engineers and managers making high wages next to more socioeconomically disadvantaged kids. And the contrast, I can remember as a kid, struck me as just absurd. It was almost a caricature of the income gap in Canada. I didn't understand at the time what it was, of course, but I remember being very acutely aware that there was something very odd about the dichotomy. My father was a teacher, so I was one of the more privileged kids, grew up in a stable home, I had everything you could possibly need to build a good me. But the contrast really informed my views of the world and helped me to develop a sense of responsibility, so that's maybe the more noble reason. From a health care perspective, it occurred to me recently that as a sub-sub-specialist who 236
does high-tech, very expensive care that probably delivers very little incremental value to a small number of people for a very high price, and, having been very privileged because that's always been valued very highly in our society, the fact of the matter is that, increasingly, I realize that I'm not going to be able to do any of that high-tech medicine unless we find a way to better support the larger number of patients who need low-tech, but equally important care. I'm not going to be able to do my part of things unless we address the social determinants of health as well, because it ties in critically to the sustainability of our health care system. So that's why I say it's less than noble, because it seems a bit selfish to say. But I recognize that in a system of finite resources we're investing far too much proportionately in the stuff that I do and in doing so we're going to create an unsustainable system where we're not going to have the upstream stuff or the downstream, it's just all going to collapse. It didn't take very much for me to see that addressing the social determinants is a critical part of a plan to achieve stability in the health care system, which gives me some hope that it's an easily translatable message — if we could just find a way to get it out to the population better than we have. Ryan Meili: Are you seeing some of that uptake? In the work you do through the CMA, are you seeing that idea of the determinants of health and the importance of it for our patients catching on? I don't, and I think part of the problem is we're travelling in groups that largely have drunk the Kool Aid, but I know if I go back to my hospital-based colleagues, if I mention any of this at all, they typically do not see how an appreciation of the SDOH ties into their jobs or how it links into their role in caring for patients. We have a lot of work to do. Family Physicians, I think, get the message very quickly, they don't have to be told or directed or instructed, they just inherently feel it. But in the specialist and hospital-based community, it's still largely a foreign concept. They understand poverty, they understand nutrition, they understand all of that intellectually, but I don't think they always feel it politically or in their gut as something that is or could be their responsibility as physicians. Ryan Meili: What do you think would be ways that we could make physicians aware of their role in addressing the social determinants of health, and make it easier to act? Part of it is the silos; we talk about teams, but in hospitals we're still not there yet. We try to have more interdisciplinary rounds but they're very difficult to organize. As long as we still have a silo mentality, those kinds of questions are going to be someone else's responsibility. 237
I like the idea of clinical tools and checklists. The surgical world and the procedural world intuitively get the notion of a checklist with safety in mind. I think you could pull out the same kind of sensibility from people if you said, “ok we're going to have a checklist that will pull out the social determinants and barriers.” It could be just a list of four or five things, that's the kind of thing that could tweak the surgical mindset. In a very insulated hospital environment, if those issues, like inability to pay for drugs, do come to light by whatever means, then the fix is the social worker. They're right there, you call them up, so you have access to support — it should be an easy gap to close. After a heart attack, there are five drugs that you have to take — the aspirin, the statin, the anti-platelet, the beta-blocker and the ACE-inhibitor. I've had on more than one occasion, a conversation with patients saying that, if money concerns come up: “If you have to ration these, if you've got to stop some, this is the order with which I would peel them off.” It seems ludicrous to say that, but to me that's a very practical intervention that is doing some good…It's less good, of course, than an approach that would find a way for them to get all five drugs. Ryan Meili: So that's a real-world solution versus an ideal world solution like Pharmacare. I’m wondering what your thoughts are on a first dollar system, with universal coverage removing the necessity for patients to pay for prescriptions at the point of care. The CMA position has been supporting the Kirby approach — which is some sort of catastrophic coverage. This would perhaps be a good start. But I find the arguments in favour of first-dollar coverage very compelling, personally. I was impressed by the Gagnon report and I love the paper from Danielle Martin and Steve Morgan. First dollar coverage makes much more sense to me from an effectiveness point of view at the bedside. I've seen just a $12.99 dispensing fee dissuade people from filling their prescription. It's hard enough to get people to take their drugs, let alone having a financial barrier of a few bucks. I'm encouraged by the suggestion and the widespread belief by a lot of people that it can be economically viable to have a first dollar coverage system. Ryan Meili: I'm curious about your experience as a physician and your relationship to the CMA. What changes have you seen in the organization? One incredible turning point, which has certainly influenced my involvement with the CMA, was Jeff Turnbull's presidency. I don't think people fully appreciate yet how fundamentally that changed the organization in a way that I think is really progressive. I believe really strongly that if we just simply reflect back to our membership what we think they already think and know, that's not even remotely leadership. This isn’t to say that the CMA does not have a proud history – because it does. Nor is it saying we haven’t had great presidents, because we have. But the consistency we have seen over the past few years in moving ahead with a progressive agenda is what has changed. 238
In five short years, it's turned around completely where we're actually actively bringing along the membership – we’re talking about things that are important to society and we’re no longer afraid to take risks. It's become a very progressive organization because, although we've got 1300 policies dating back to about 1921, I think the heart of the organization is definitely in a very progressive space. I've been pleasantly surprised that the membership is very happy with that change of direction. And I think it's affected the type of people who are seeking the presidency too. People who hold a different view about the role of private investment and so on who used to have quite a strong voice in the organization are now much less influential. That may be good or that may be bad, but it's certainly reflective of the type of people that are being attracted to leadership positions in the CMA; the committees, the board, in elected positions — they've been, on the whole, more progressive and equity-minded individuals, in my opinion. There is room, of course, for all views in the CMA, but the balance we have now more accurately reflects the distribution of views of our membership, I believe. Ryan Meili: There are two ways a medical association can see itself: As advocating for its members almost uniquely vs. seeing health as our primary goal & a healthy society. What do you see is the value of that conversation? I think it's critical. I don't know if you noticed the sign on the wall somewhere here at the British Medical Association; it says something to the effect of “We put doctors at the center of everything we do.” We recently went through a rebranding of our mission and values. I argued very strongly that we needed to leap from being doctor-centred to being very explicitly patient-centred and we kind of landed on “Helping doctors help patients” which is fair enough, but it's sort of that middle ground. I think our legitimacy in society, which is really going to be the only way we're ever going to be truly effective as change agents, is going to be determined by whether or not people truly believe that they are our first priority. Not just individual patients, but society at large. The CMA is well on its way to getting there. And we're partially helped by the fact that all of the negotiation stuff is at the provincial level (unlike in some countries), so we're a little more free to be in that patient advocacy space instead of doctor advocacy/negotiation. They shouldn't be mutually exclusive, but physician pay can be a polarizing issue during stressful times. And as important as these issues are, it sometimes serves to distract from the advocacy piece. Take the recent dispute between the OMA and the provincial government, for example. The OMA has laid out a compelling case for why the government’s imposed solution will reverse several years of funding and structural reforms designed to get better care for patients; work done between the OMA and government as a partnership. This most recent dispute reverses a lot of that good work and the OMA rightly points this out. But the issue has been reduced to soundbites in the press about a dispute over physician’s pay when it’s not really that at all. We support our Provincial and Territorial Medical 239
Associations one hundred percent but our mandate to pursue advocacy is largely unencumbered by the thorny issues surrounding physician pay, and that gives us a different kind of platform from which to pursue our advocacy agenda. Our core work is advocacy, and the other thing that's really helped us, is that we've spun off this new co-organization – Newco - the products and services stuff, and MD Financial Management. Those two entities (though they're wholly owned by the CMA) now have their own boards, their own CEOs. So now the CMA is all about patients, the public, and the profession’s role in the service of patients and the public. We can be very much in that space. It's a very comfortable spot to be in. Since the Turnbull presidency, the CMA has really started to own an advocacy mandate. We’re feeling more and more comfortable in our own skin in that role with every passing year. You can feel it. Even at the board level — the things they're proud of are the ones where CMA has really been out in front on an issue and helped shape society’s discussion. The recent and still ongoing national conversation on end-of-life care is a great example. Ryan Meili: One of the things that I've been seeing happen lately is a series of articles suggesting that public health professionals are commenting on the economy when they shouldn't, and that we should stick to our needles. You talked about that legitimacy of physician voice. Should we stick to our needles, or is there a role for us to be talking beyond health care, to the causes of ill health and the causes of the causes? I see it a little differently than has been expressed by others. I think we need to earn the right to be in that space. We earn the right from the people we serve. So if we have expertise, and our hearts are in the right place, then civic Canada will confer the legitimacy we need to speak from that perspective. I think we are truly servants, public servants, and we need to earn that trust. I see it less as a matter of should we or shouldn’t we but rather can we earn the right to speak on these broader issues. I think we have to do a lot of hard work to really belong there – to be authentic advocates for patients and the public. I think we're well on our way, though. Essentially, whatever affects the health of Canadians should concern us. Things like the economy and tax policy and public policy in general certainly qualify as health influencers, so those of us who feel strongly about this and who have expertise can make their case to Canadians that they can help lead the discussion. Canadians will return that authenticity with their trust. Ryan Meili: There definitely is some past baggage to overcome and some existing problems within the profession to overcome, but I think that's something the public will want from us if we approach it – as you say – consistently and legitimately. And it has to be about coming at it from an altruistic perspective. Yes, we can see the link to our core business – the practice of medicine — but I think there's also a more general leadership role in society that — whether we have deserved it or not — we've been given 240
historically. It's a trust. Even the right to self-regulate is a huge privilege that we have and with that comes the responsibility to do it well. If you think about history — physicians and their organizations have been brought along reluctantly on too many issues of progressive social change. But now we have an opportunity to provide leadership to support and develop a progressive and healthy society and further cement the trust that Canadians place in us as a profession. The stuff we're talking about here today – the role of physicians and their organizations in addressing the social determinants of health, actually has us a bit out in front of general society. Ryan Meili: We had the refugee actions in the last few years. It was the 50th anniversary of medicare — physicians were out with placards — and this time in support of universal health care for all instead of against it. I'm sure you know the story of how Tommy Douglas came to really believe in medicare was his own experience as a kid. He received what he regarded at the time as a charitable donation of services by a doctor and in many ways, I think that kind of sensibility in the profession shares a lot of commonality with some of the core principles of most of the world’s great religions; the sense that we have a responsibility to advocate for people who are less well advantaged. That sense of duty to society’s most vulnerable people is deeply-rooted in our profession. Somehow, along the way, though, we've taken the privilege we've been given and we've perhaps not always lived up to the responsibility – at a societal level — that goes with it. This is really all about bringing that duty and that responsibility to a whole new level. I love to see physicians with placards – being not only advocates but activists. That’s the kind of leadership that demonstrates tangibly to the people we serve that we are with them and that we will work alongside them to achieve the change our country needs. I think we know what the right thing to do is, we just have to have the bravery and put the hard work in to make it happen. Ryan Meili is an expert advisor with EvidenceNetwork.ca, a practicing family physician in Saskatoon and founder of Upstream: Institute for A Healthy Society.
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Canadian researchers call on fellow scientists to be more vocal in the media By Mélanie Meloche-Holubowski In a time when many government scientists in Canada are being muzzled, talking to the media may be a scary prospect for many researchers. Yet some academics are calling on their peers to have their voices heard in the media and cut through the noise coming from think thanks and lobbyists. “The research community is an essential part of an open society that values truth and ideas over interests and preferences. The time is now for researchers to get involved in the public debate. It is absolutely central,” believes Damien Contandriopoulos, an associate professor in nursing and researcher at the Public Health Research Institute at the University of Montreal. Panel debate: Public engagement Contandriopoulos organized a public panel debate on the issue last week in Montreal with participation from both the research community and journalists. The conversation between panelists highlighted the interdependence of the media and researchers, and flagged the way in which many scientific and health topics are often one-sided in media coverage — and how too many public policies decisions are taken without proper evidence. “I’m sick and tired of seeing that think thanks, with specific commercial interests, are driving the political agenda, publishing reports, trying to frame the debate in a specific way,” added Marc-André Gagnon, an expert in political economy and health policy and assistant professor at the School of Public Policy and Administration at Carleton University. “My role as a researcher is to bring forth evidence and to ensure that political decisions are evidence-based.” Scientific studies and reports are rarely communicated to the general public and most people don’t read scientific journals, reminds Contandriopoulos. But scientists should not only be speaking to the already converted, he stresses; they have a responsibility to put forth their results and ideas to the general public. Rapid media cycles News moves fast and is in opposition to the more lengthy process that is science, the panel noted. Add into the mix, companies and organizations who have vested interests in framing public policy, along with researchers who are not media-savvy, and it is easy to see why good studies and ideas by many Canadian researchers are drowned out.
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Researchers by themselves might not have the same type of resources as some lobbyists or think thanks in reaching out to the media. But the panel encouraged researchers to send out press releases, write op-eds, take to social media and email a journalist or a local paper. Gagnon gets editorial help from EvidenceNetwork.ca, a non-partisan resource that links journalists with health policy experts. “They help edit my op-eds and have them published in most major newspapers — something I couldn’t do on my own.” Other resources include the communication departments for those researchers affiliated with Universities; they are often ready and willing to provide media training and op-ed assistance to the research community. Taking the time to explain, in a non-abstract way, why evidence matters to people in their daily lives is the best way to have an influence on decision-makers and politicians, the panel emphasized. It might take a bit of legwork to establish a relationship with a journalist or a news organization, but “knowledge transmission remains necessary,” says Gagnon. Fighting zombie ideas This might all seem like a David against Goliath fight, but researchers should not be discouraged if they need to repeat their message ad nauseum, in order to counter biased or erroneous information, the panel informed the audience. Tongue in cheek, Contandriopoulos compares it to fighting zombies, an idea put forth by public health researcher, Morris L. Barer. “It’s the notion that ideas, no matter how many times they have been proven false, still come back to life again and again, like zombies. This happens because behind a dead idea, there is that zombie master that has an interest in pushing the idea forward. Even though it’s a long-term battle, as a publicly funded researcher, it’s your responsibility to try to get the truth out.” Talking heads In Quebec, with the recent revelation that a prominent journalist, François Bugingo, may have fabricated some of his media content, the increasing use of experts who are called upon for commentary on a multitude of topics is also being questioned. The panel warned against ‘talking heads’ that are ready to comment on every subject under the sun. “What is the value of having them analyze a report that they have not yet read or having them comment on a subject that is not their expertise?” says Gagnon. “The purpose is not about researchers having their face in the media more often – it is about helping the construction of a more rational public debate on societal issues,” adds Gagnon.
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Public engagement and education is why the duo are encouraging more researchers to take the leap and speak up in the media and help tip the balance towards more evidencebased decisions in the public policy domain. Mélanie Meloche-Holubowski was the 2014 journalist intern at EvidenceNetwork.ca and is now the Podcast and Social Media Editor. She is also a journalist with Radio-Canada. See also our Podcast on the issue: Why Canadian researchers need to be more vocal in the media
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Des chercheurs canadiens sollicitent une plus grande présence dans les médias de leurs pairs Par Mélanie Meloche-Holubowski Au moment ou plusieurs scientifiques se disent muselés par leur employeur et par le gouvernement, plusieurs d’entres eux évitent les sorties médiatiques. Mais, certains chercheurs plaident auprès de leurs pairs pour qu’ils prennent leur place dans les médias afin de réduire l’influence des groupes de pression et des lobbyistes. « La communauté scientifique est une partie importante d’une société ouverte, qui donne plus d’importance à la vérité qu’aux intérêts. Il est temps que les chercheurs prennent davantage part au débat public », estime Damien Contandriopoulous, professeur à la Faculté des sciences infirmières de l’Université de Montréal et chercheur à l’Institut de recherche en santé publique de l’Université de Montréal. Trop souvent, le débat entourant la santé ou les sciences est biaisé et de nombreuses décisions politiques sont prises sans réellement tenir compte des données probantes, a dénoncé M. Contandriopoulous lors d’un panel qu’il a organisé sur l’interdépendance entre les médias et chercheurs. Si les lobbyistes et groupes des pression disposent d’importantes ressources pour faire passer leur message et sont surreprésentés dans les médias, la communauté scientifique a le pouvoir d’être entendue, croit-il. « Je suis découragé de voir comment les lobbyistes façonnent l’agenda politique en publiant des rapports dans le but d’influencer l’opinion publique », affirme Marc-André Gagnon, professeur et chercheur à la School of public policy and administration de l’Université Carlton. « Mon rôle en tant que chercheur est de rapporter les faits et de m’assurer que les décisions politiques soient prises en tenant compte de données probantes. » Trop peu d’études scientifiques sont médiatisées et la majorité des gens ne lisent pas les revues scientifiques, rappelle Damien Contandriopoulos. Les chercheurs ont la responsabilité de faire connaître leur travail et leurs idées au grand public, et non seulement aux autres scientifiques. La rapidité de la nouvelle L’actualité bouge à une vitesse frénétique et les chercheurs hésitent lorsqu’on leur demande de résumer des années de travail en deux minutes. Ajoutez à cela des services de relations publiques qui contrôlent le message et des chercheurs qui n’aiment pas les caméras, et voilà, en partie, pourquoi les études de nombreux de chercheurs sont noyés dans une mer d’information. Les chercheurs n’ont peut-être accès aux mêmes ressources que les lobbyistes pour attirer l’attention. Mais les deux chercheurs encouragent leurs pairs à envoyer des communiqués 245
de presse, à écrire des textes d’opinion, à discuter sur les réseaux sociaux ou à envoyer un courriel à un journaliste ou à leur journal local. Par exemple, Marc-André Gagnon obtient de l’aide d’Evidence Network, un organisme non-partisan qui fait le lien entre les experts en santé publique et les médias. « Ils m’aident à éditer mes textes et ont les ressources pour diffuser mes idées dans tous les grands médias, ce que je ne réussirais pas à faire. » Prendre le temps d’expliquer, de façon non-abstraite, pourquoi les données probantes sont essentielles est la meilleure façon de contrer les informations biaisées et ainsi avoir une réelle influence. Établir une relation avec un journaliste ou un média n’est pas facile, mais les chercheurs doivent s’y mettre, sans quoi le public ne pourra jamais se faire une opinion juste. Se battre contre des idées « mortes-vivantes » Si faire valoir ses idées dans les médias peut semble comme une bataille de David contre Goliath, les chercheurs ne doivent pas se décourager, disent Marc-André Gagnon et Damien Contandriopoulos. Il ne faut pas hésiter à répéter son message ad nauseum afin de contrer les informations erronées qui circulent déjà. Damien Contandriopoulos aime comparer cet exercice à une bataille avec des mortsvivant, une idée qu'il reprend de Morris L. Barer, un chercheur en santé publique. « Peu importe le nombre de fois qu’une idée est prouvée comme étant fausse, elle revient à la vie, fois après fois, comme des morts-vivants. Et ça continue, parce qu’il y a toujours quelqu’un avec certains intérêts, qui continue de pousser l’idée à l’avant-plan. Même s’il s’agit d’une bataille long-terme, en tant que chercheur financé publiquement, c’est notre devoir de faire valoir la vérité. » Attention aux experts « touche-à-tout » L’affaire Bugingo a soulevé de nombreuses questions quant à la véracité des propos de journalistes, commentateurs et experts. Qui contre-vérifie tous les faits des experts qui commentent à chaud l’actualité? Trop souvent, les médias s’accrochent à certains experts simplement parce qu’ils communiquent bien. Mais quelle est l’utilité d’avoir un expert qui analyse un rapport qu’il n’a pas lu ou qui commente un sujet qui est hors de son champ de compétence? demande Marc-André Gagnon. « Le but n’est pas de voir des chercheurs partout dans les médias, c’est plutôt d’aider à construire un débat public plus rationnel sur divers enjeux sociaux », ajoute-t-il. C’est pourquoi ces deux chercheurs disent aux scientifiques qu’il est grand temps d’apprivoiser le cirque médiatique afin de s’assurer que le débat public ne soit pas seulement basé sur des messages bien ficelés par les relations publiques. 246
Mélanie Meloche-Holubowski est la journaliste attrité aux balladdiffusions et aux réseaux sociaux pour EvidenceNetwork.ca; elle était la journaliste-stagiaire 2014. Elle est aussi journaliste pour Radio-Canada.
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Five things every Canadian should know about obesity By Carolyn Shimmin There has been a dramatic increase in the number of Canadians living with obesity over the past few decades and it is often cited as a risk factor for other chronic health conditions. This means that obesity is a topic frequently in the news. But media stories often miss the mark when they address obesity, neglecting to mention the complex factors that lead to obesity. Obesity is both a chronic and often progressive condition, not unlike diabetes and hypertension. It is defined by the World Health Organization as the abnormal or excessive fat accumulation that presents a risk to health. Obesity is said to increase the risk of a number of chronic conditions, including type 2 diabetes, hypertension, cardiovascular disease and some forms of cancer. Research has identified a number of factors associated with obesity including: physical activity; diet; socioeconomic status; ethnicity; immigration and environmental factors, which all interconnect in complex ways and patterns. Experts agree that early intervention will require a holistic approach that not only identifies the causes of weight gain but also the barriers to weight management. What this means is that while the root cause of weight gain may be a reduction in metabolic rate, overeating or a reduction in physical activity, secondary factors such as biological (e.g., genetics), psychological (e.g., depression) and/or socioeconomic (e.g., poverty) may also pose significant barriers to weight management. This also means that the short term, ‘quick-fix’ solutions often espoused by shows like The Biggest Loser that are focused on maximizing weight loss are generally unsustainable in the long term and associated with high rates of weight regain. Experts point to the fact that successful obesity management requires realistic and sustainable treatment strategies. Here’s what everyone should know: 1. The prevalence and severity of obesity in Canada has increased dramatically in the past three decades while fitness levels are decreasing. Research shows that one in four Canadian adults and one in 10 children are clinically obese. Between 1981 and 2007/2009, obesity rates roughly doubled among both males and females in most age groups in both adult and youth categories. Since the late 1970s, increases in the prevalence of obesity have been proportionately greater for the heaviest weight classes. On top of this, evidence demonstrates a trend toward decreased fitness for children, youth and adults.
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2. Obesity is a costly epidemic. It has been estimated that obesity cost the Canadian economy approximately $4.6 billion in 2008, up $735,000 or 19 percent from $3.9 billion in 2000. 3. Measurement of obesity is not straightforward. The Body Mass Index (BMI) should be considered a rough guide for predicting health risk in individuals. The distribution and amount of body fat are also crucial determinants of some obesity-related health risks. For example, visceral fat around the abdominal region, has a stronger association with type 2 diabetes and cardiovascular disease than BMI. Hence measures of central obesity such as waist circumference alone provide more robust indices of overall obesity-related health risk than BMI. 4. Experts are looking to government regulations and food industry. Similar to smoking and alcohol abuse, obesity is not simply the result of individuals making bad decisions, but is strongly influenced by the social and commercial environments that puts some individuals at higher risk for certain behaviours. Some risk factors include: the promotion and availability of high-calorie food, limited access to healthy foods, lack of time for meal preparation and barriers to physical activity. Experts point to promising government regulatory approaches such as: discouraging higher calorie consumption by enforcing serving sizes; banning food and beverage advertisements targeting children; zoning laws prohibiting fast food sales near schools; regulating nutrition claim packaging; tax credits for fitness activities; more affordable recreational activities and better walking paths. 5. Weight bias is associated with significant inequities in employment, health, health care and education and is often caused by widespread untrue negative stereotypes that persons with obesity are lazy, unmotivated and lacking willpower and self-discipline.
Carolyn Shimmin is a Knowledge Translation Coordinator with EvidenceNetwork.ca and the George and Fay Yee Centre for Healthcare Innovation.
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Cinq faits pour mieux comprendre le phénomène d’obésité au Canada Par Carolyn Shimmin En quelques décennies, le nombre de personnes touchées par l’obésité a augmenté dramatiquement au Canada. L’obésité est considérée comme un facteur de risque pour les maladies chroniques, comme le diabète de type 2, l’hypertension, les maladies cardiovasculaires et certaines formes de cancer. Au Québec, 53 % de la population a un excès de poids. Voilà pourquoi l’obésité défraie souvent les manchettes dans l’actualité. Or lorsqu’il s’agit de bien expliquer les facteurs complexes qui mènent à l’obésité, les articles sur le sujet contiennent souvent des informations erronées. Nous savons que l’obésité est une maladie à la fois chronique et évolutive. Les recherches ont cerné certains facteurs qui contribuent au phénomène. L’activité physique, l’alimentation, la situation socioéconomique, l’origine ethnique, l’immigration et l’environnement interagissent selon des modèles complexes. Ainsi, si la cause principale d’un surplus de poids est généralement due à un ralentissement du taux métabolique, à un manque d’activité physique ou à l’hyperphagie, de nombreux facteurs secondaires d’ordre biologique (génétique), psychologique (dépression) et socioéconomique (pauvreté) entrent aussi en compte. Par conséquent, les solutions « miracles » que préconisent souvent des émissions de télévision comme The Biggest Loser (Qui perd gagne) – qui promettent une perte de poids maximale en peu de temps – n’offrent pas de résultats durables. Ces méthodes de perte de poids sont, en fait, associées à un taux élevé de reprise de poids. Les experts soulignent qu’une bonne gestion de l’obésité nécessite des stratégies réalistes et durables en matière de traitement. Voici ce qu’il faut savoir au sujet de l’obésité : 1. La prévalence et la gravité de l’obésité ont augmenté dramatiquement au Canada depuis 30 ans, alors que les niveaux de condition physique diminuent. Les recherches montrent qu’un adulte sur quatre et un enfant sur dix sont cliniquement obèses. Au cours de cette même période, les taux d’obésité ont presque doublé chez les hommes et les femmes dans la plupart des groupes d’âge des catégories jeune et adulte. Depuis la fin des années 1970, l’augmentation du taux d’obésité est proportionnellement plus importante dans les catégories des poids les plus lourds. Par ailleurs, les données montrent que le niveau de condition physique des enfants, des jeunes et des adultes diminue. 2. L’obésité est une épidémie coûteuse. On estime que l’obésité a coûté à l’économie canadienne 4,6 milliards de dollars en 2008, soit 735 millions de dollars de plus (19% de plus) qu’en 2000. 250
3. Mesurer l’obésité n’est pas une science exacte. Il faut considérer l’indice de masse corporelle (IMC) comme un indicateur imprécis pour prédire les impacts sur la santé. La répartition des tissus adipeux et leur quantité sont aussi des facteurs déterminants dans la prise de poids. Par exemple, la graisse située dans la région abdominale est associée plus fortement au diabète de type 2 et aux maladies cardiovasculaires que l’IMC. En fait, la mesure du tour de taille dresse un portrait plus exact des risques de santé globaux associés à l’obésité que l’IMC. 4. Les experts se tournent vers la réglementation et l’industrie alimentaire pour trouver des solutions. Tout comme le tabagisme et la consommation excessive d’alcool, l’obésité n’est pas simplement le produit de mauvaises décisions individuelles. L’environnement social et commercial joue un rôle prédominant et fait en sorte que certaines personnes sont plus à risque d’adopter certains types de comportements. Parmi les facteurs de risques, citons: la promotion et la disponibilité des aliments hypercaloriques; un accès limité aux aliments santé; le manque de temps pour la préparation des repas; et les obstacles à l’activité physique. Les expertspréconisent certaines mesures législatives prometteuses: décourager la consommation des aliments hypercaloriques en imposant des portions déterminées; interdire la publicité sur les aliments et boissons destinée aux enfants; adopter des règlements de zonage interdisant les établissements de restauration rapide à proximité des écoles; encadrer l’information nutritionnelle sur les emballages; instaurer un crédit d’impôt pour activités de conditionnement physique; améliorer l’accès aux activités récréatives ainsi que les circuits de randonnée pédestre. 5. Les préjugés à l’égard du poids engendrent une discrimination à l’égard des personnes touchées par l’obésité dans les secteurs de l’emploi, de la santé et de l’éducation. Ils découlent souvent de stéréotypes négatifs, qui perpétuent de fausses notions selon lesquelles ces personnes seraient paresseuses et manqueraient de motivation, de volonté et de discipline. Carolyn Shimmin est coordonnatrice du transfert des connaissances pour le site EvidenceNetwork.ca et le George and Fay Yee Centre for Healthcare Innovation.
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Most Canadians don’t understand food nutrition labels How simplifying and standardizing food labels can help with better food choices By John Millar and Mélanie Meloche-Holubowski As January comes to an end, those who vowed to eat better in 2015 have probably already given up. Not very surprising, considering that most people grossly underestimate the amount of calories they consume, and underestimate their fat, salt and sugar consumption, even after consulting nutrition labels. According to Statistics Canada, half of women and about seven in 10 men in Canada consume more calories than needed and as many as 25 percent have fat intakes above the recommended value. The truth is, even when Canadians want to make healthier choices, many don’t know how to begin. And our food labels don’t help. Studies show that most Canadians don’t comprehend the percent daily value or the variety of units (g, ml, percentages) common on food nutrition labels. One Canadian study showed that less than half of participants could identify the number of calories in a soft-drink bottle even after consulting the nutritional labels. Half of participants who saw a “110 calories per serving” label believed this was the number of calories for the entire bottle, when, in fact, the bottle in question contained several servings (264 calories). Pre-packaged foods in Canada are required to display a nutrition facts table. But regulation does not apply to foods served in restaurants, and serving sizes are not standardized and front-of-packaging logos and health claims are mostly unregulated. Nutrition labels are relatively inexpensive to implement and give consumers the autonomy to choose what they will eat, while being informed. Small changes could go a long way to improving public understanding, and possibly, public health. Modifying regulations to simplify nutritional information on food products and imposing standardized and nutrition labelling at restaurants could increase consumer understanding, positively affect food choices and reduce caloric consumption. However, we need governments to ensure that these claims are evidence-based and easily understood. In a step in the right direction, the federal government recently asked Canadians what they would like to see on food product labels. It turns out, quite a lot. Canadians want easier-to-read labels, more legible fonts, simpler terms and the use of colours and symbols. The government is considering making adjustments, such as regrouping all sugars, changing font sizes and standardizing portion sizes. These are welcome changes, but more comprehensive solutions are needed.
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The U.K. adopted a colour coded-system: traffic lights colours indicate if a product contains a little or a lot of a certain nutrient. As a result, supermarkets noticed an increase in the sale of fruits and vegetables. One study showed that putting the number of minutes of walking it would take to burn off calories consumed on product packages helped reduce caloric consumption. Unfortunately, in Canada, front-of-package symbols and health claims are mostly designed by the food industry, are often confusing and some are not based on proper scientific evidence. Seven years ago, the Canadian Standing Committee on Health asked the federal government for a mandatory, standardized, simple, front of package labelling. They are still waiting. Instead, in 2012 the government chose to stop policing nutrition claims on food labels for budgetary reasons. Regulations for restaurant nutrition information also needs policy reform. Consider this: Canadians consistently underestimate the calories in restaurant meals, sometimes by up to 900 calories, says one study. Even registered dieticians underestimated the calories in a restaurant meal by 200 to 600 calories. With nearly 40 percent of Canadians eating out a few times per week, regulating menu labels should be a priority. In November, Ontario introduced new menu labelling legislation. If passed, all restaurants, convenience stores and groceries with more than 20 locations would be required to post calories on menus and menu boards. Will other provinces follow suit? The food industry is in business to make money. Many are constantly creating and marketing products that encourage overconsumption of sugar, fat and salt that are contributing significantly to the obesity epidemic. Mandatory labelling will possibly be helpful to motivated, educated consumers who want to make healthier choices, but there is also a need for stronger environmental ‘nudges’ such as increased pricing on sugar sweetened beverages and reduced portion sizes to more fully address the obesity epidemic. But we can at least begin with proper food nutrition labels so Canadians can make informed decisions about their food choices. John Millar is a Clinical Professor at the School for Population and Public Health at the University of British Columbia where he is involved in teaching and research in public health leadership, health policy and international health. Mélanie Meloche-Holubowski was the 2014 journalist intern at EvidenceNetwork.ca and is now the Podcast and Social Media Editor. She is also a journalist with Radio-Canada.
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La majorité des Canadiens ne comprennent pas le contenu des étiquettes nutritionnelles Simplifier et uniformiser les étiquettes des aliments pourraient mener à de meilleurs choix alimentaires Par John Millar et Mélanie Meloche-Holubowski En cette fin de janvier, plusieurs personnes qui ont pris la résolution de mieux manger en 2015 ont déjà probablement abandonné. Pas surprenant, compte tenu du fait que la plupart des personnes sous-estiment grandement la quantité de calories, de gras, de sel et de sucre qu’elles consomment, même après avoir consulté les étiquettes nutritionnelles. Selon Statistique Canada, la moitié des femmes et environ sept hommes sur 10 consomment plus de calories que nécessaire, et jusqu’à 25 pour cent d’entre eux consomment des gras en quantités supérieures à la valeur recommandée. À vrai dire, même si les Canadiens veulent mieux manger, nombre d’entre eux ne savent pas comment s’y prendre, et les étiquettes alimentaires n’aident en rien. Des études démontrent que la majorité des Canadiens ne comprennent pas les valeurs quotidiennes ou la panoplie d’unités de mesure (g, ml, pourcentage) figurant généralement sur les étiquettes nutritionnelles. Moins de la moitié des participants d’une étude canadienne ont pu déterminer le nombre de calories contenues dans une boisson gazeuse, même après avoir lu l’étiquette nutritionnelle. La moitié des personnes qui ont lu « 110 calories par portion » sur l’étiquette croyaient qu’il s’agissait du nombre de calories par bouteille, alors qu’en fait, la bouteille en question contenait plusieurs portions (264 calories). Les fabricants canadiens d’aliments préemballés ont l’obligation d’afficher un tableau des valeurs nutritives. Or, la réglementation ne s’applique pas aux aliments servis dans les restaurants. Les portions recommandées ne sont pas uniformisées, et les logos au recto des emballages et les allégations relatives à la santé sont pour la plupart non réglementés. La mise en place d’un processus d’étiquetage est pourtant relativement peu coûteuse et autonomise les consommateurs en leur offrant la possibilité de s’informer et de faire des choix alimentaires. Grâce à de petits changements, le public peut accéder à l’information et possiblement améliorer sa santé. La modification de la réglementation en vue de simplifier l’information nutritionnelle et les produits alimentaires ainsi que l’imposition de normes en matière d’étiquettes nutritionnelles dans les restaurants pourrait favoriser chez le public une meilleure compréhension, de meilleurs choix alimentaires et une réduction de la consommation de calories. Les gouvernements doivent aussi s’assurer que les allégations sont fondées sur des données probantes et faciles à comprendre.
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Le gouvernement fédéral a récemment demandé aux Canadiens ce qu’ils souhaiteraient voir sur les étiquettes des produits alimentaires, ce qui constitue un pas dans la bonne direction. La population canadienne exige un système d’étiquetage plus facile à lire, des polices plus lisibles, des termes plus simples et l’utilisation de couleurs et de symboles. Le gouvernement envisage la possibilité d’introduire des changements, comme regrouper tous les sucres, modifier la grosseur des polices et normaliser la taille des portions. Ces initiatives sont positives, mais il faut aussi mettre en place des solutions plus exhaustives. Le Royaume-Uni a adopté un système de codage couleur. Des « feux de circulation » indiquent la teneur de certains éléments nutritifs dans un produit. Par conséquent, les supermarchés ont remarqué une augmentation des ventes aux comptoirs des fruits et légumes. Une étude démontre que l’ajout sur l’étiquette du nombre de minutes de marche requises pour éliminer les calories consommées contribue à réduire la consommation de calories. Malheureusement, au Canada, les symboles au recto des emballages et les allégations relatives à la santé sont généralement conçus par l’industrie alimentaire. Ils sont souvent nébuleux et parfois non fondés sur des données scientifiques probantes. Il y a sept ans, le comité permanent de la santé du Canada a demandé au gouvernement fédéral d’imposer l’étiquetage et le recours à des étiquettes normalisées, simples et apposées sur la partie recto des emballages. Le comité attend toujours. En fait, au lieu d’aller de l’avant, le gouvernement a choisi en 2012 de ne plus surveiller les allégations figurant sur les étiquettes, pour des raisons budgétaires. Les politiques portant sur la réglementation en matière d’information nutritionnelle dans le milieu de la restauration nécessitent également une réforme. Selon une étude, les Canadiens sous-estiment constamment le nombre de calories contenues dans les repas aux restaurants, parfois jusqu’à 900 calories. Même les diététistes professionnels sousestiment de 200 à 600 le nombre de calories présentes. Or, près de 40 pour cent des Canadiens mangent au restaurant plusieurs fois par semaine. La mise en place d’une réglementation concernant l’étiquetage dans les menus devrait donc constituer une priorité. En novembre, l’Ontario a présenté un projet de loi en matière d’étiquetage nutritionnel des menus. Si la loi est adoptée, tous les restaurants, les dépanneurs et les épiceries comptant plus de 20 emplacements devront afficher dans les menus et sur les tableaux d’affichage le nombre de calories dans les aliments. Les autres provinces emboîterontelles le pas? L’industrie alimentaire a pour objectif de réaliser des profits et de nombreuses compagnies créent et introduisent constamment des produits qui mènent à la surconsommation de sucre, de gras et de sel, lesquels contribuent de façon importante à l’épidémie d’obésité. L’étiquetage obligatoire aidera peut-être les consommateurs motivés et scolarisés qui désirent améliorer leur alimentation. Il faut cependant mettre en 255
place des incitatifs environnementaux plus musclés, comme l’augmentation des prix des boissons édulcorées au sucre et la réduction de la taille des portions, afin de combattre de manière plus efficace l’épidémie d’obésité. Nous pouvons au moins commencer par donner accès à des étiquettes nutritionnelles adéquates pour que les Canadiens choisissent leurs aliments de façon éclairée. John Millar œuvre à titre de professeur clinique à la School for Population and Public Health de l’Université de la Colombie-Britannique. Il enseigne et fait de la recherche dans les domaines du leadership en santé publique, des politiques sanitaires et de la santé internationale. Mélanie Meloche-Holubowski est la journaaliste attitrée aux réseaux sociaux et aux balladodiffusions pour EvidenceNetwork.ca; elle était la stagiaire en journalisme en 2014. Elle est également édimestre et journaliste à Radio-Canada, à Montréal.
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Chapter 4: Pharmaceutical Policy
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Toward a true health accord By Ryan Meili Later this month, Canada's Minister of Health, Dr. Jane Philpott, will meet with her provincial and territorial counterparts in Vancouver. This is no ordinary get-together. In his letter to the Minister, Prime Minister Trudeau tasked Philpott with "engaging provinces and territories in the development of a new, multi-year Health Accord with long-term funding agreement." This is a distinct change in tone; the previous federal government had refused to meet with provinces to negotiate a new agreement after the accord ran out in 2014. The top-down approach by the Harper government was greeted with two distinct reactions. There were those that saw the cancellation of the Health Accord as a step backward that would further reduce the federal portion of funding for health care, offloading costs to the provinces. Others criticized the past accord, billed as "a fix for a generation," because it didn't buy the intended change. While progress was made on wait times for certain services, other innovations in home care, primary care, prevention and health promotion, and the development of a national pharmaceutical strategy were not achieved in any meaningful way, with most of the increased funding getting absorbed into regular health budgets. Both of these perspectives hold merit. There is a strong case to be made for a return to the original 50/50 funding arrangement, which is one of the key reasons the provinces signed on to medicare in the first place and has steadily been eroded in the decades since. There is also a fair criticism that increased funding should have been used more deliberately to attempt to achieve the intended change. An increase in private and public health spending in Canada from $124 billion in 2003 to $207 billion in 2012 bought little in the way of meaningful change in system performance or health outcomes for Canadians. So as the health ministers meet in Vancouver this month, how can they bend the curve toward a less costly and more effective health care system? How can they ensure the funds invested this time around will buy real improvements in health? Some of the directions for this can be found in the Prime Minister’s mandate letter to the Minister of Health, which included an exhortation to "support the delivery of more and better home care services." Investment in quality home care has been shown to improve patient experience while easing pressure on acute and long-term facilities. The letter also encouraged Minister Philpott to "encourage the adoption of new digital health technology.” If done right, electronic medical and health records can greatly expand our ability to effectively treat individuals and the population.
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A third major element described in the mandate letter was a call to "improve access to necessary prescription medications" by "joining with provincial and territorial governments to buy drugs in bulk,” and “exploring the need for a national formulary." This falls short of a national pharmacare program, but does not close the door to the possibility. Canada is the only nation with a universal health care system that doesn't include drug coverage; one in five Canadians reports being unable to afford to take necessary medications as prescribed. A national pharmacare program would eliminate that problem while saving Canadians approximately $6 billion per year in excess costs. Half measures in this area will not achieve the desired savings or accessibility. The directives from Trudeau to Philpott are helpful, but there are two key ingredients missing. The first is that the flow of health care funds needs to be connected to clearly articulated goals. Indiscriminately increasing fund transfers with no accountability for how they will be used is a recipe for continually increasing costs without improving the quality and accessibility of care. The second is that all levels of government need to move toward a Health in All Policies approach that understands all areas of government – policies affecting income, education, housing, food security, for example – impact health outcomes. Health care is the greatest cost driver in provincial governments, but it isn't the area in which spending has the greatest impact on health – and it’s not where those costs can best be controlled. The decisions emerging from this upcoming summit could change the landscape of health care policy in Canada. We can only hope that Dr. Philpott will be practicing "medicine on a larger scale," looking first and foremost to improve the health and well-being of Canadians.
Ryan Meili is a family physician in Saskatoon, vice-chair of Canadian Doctors for Medicare, an expert with EvidenceNetwork.ca and founder of Upstream: Institute for A Healthy Society.
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Ontario spends more than $11 billion a year on prescription drugs Why an income-based drug plan would not be good for Ontario’s economy or its seniors By Steve Morgan Ontario spends $11-billion per year on prescription drugs. Nearly half of this is spent on medicines used by senior citizens, a group that receives public subsidies for nearly all of their prescription drug costs in Ontario. With the population aging, seniors’ entitlement to public drug coverage creates a big strain on government budgets. This is because people under age 65 receive very little subsidy for prescription drugs. The day someone turns 65 years old in Ontario, their prescription drug costs suddenly become a public liability. To avoid this strain on government budgets, several other provinces have discontinued comprehensive drug benefits for seniors and implemented income‐based programs that provide all residents public subsidies for prescription drug costs exceeding a given percentage of household income. Sounds like a good idea for Ontario, right? Except it isn’t. In a report published this week by the Institute for Research on Public Policy my colleagues and I assess the performance of Ontario’s age-based drug plan against the best of the income-based drug plans in Canada: that of British Columbia. Three important results indicate that income-based drug benefits programs are not good for seniors anywhere in the country, and certainly not something that should be replicated in Ontario. First, deductibles under income-based drug plans act as a barrier to seniors’ accessing necessary medicines. Perhaps not surprisingly then, residents of British Columbia are about twice as likely to report such cost barriers to their medications as residents of Ontario – which means many seniors don’t get the drugs they need. If Ontario had the same rate of access barriers among its elderly population as British Columbia does, a further possible 68,000 elderly Ontarians would forgo their prescriptions because of financial barriers. For many of those seniors, stopping treatment could result in worse health outcomes and higher rates of hospitalization. In the end, this would cost both patients and taxpayers. Second, deductibles under income‐based plans impose considerable direct costs on patients. This is of particular concern for seniors, most of whom have chronic needs for prescription drug treatment. In effect, the deductibles under income-based drug benefit programs are tantamount to imposing a specific income tax on people with high medical needs – including most seniors. 260
Though it is true that many seniors today are wealthier than seniors were a generation ago, it's not clear they should be penalized by bearing more costs for their health care than younger Ontarians, especially if there are equitable, alternative models. This raises the third problem with income‐based drug benefit programs: they undermine efforts to control drug costs and promote efficiency for society as a whole. Income-based drug plans do not reduce the total cost of prescriptions filled by seniors. They simply shift those cost onto patients or the sponsors of private insurance – primarily, employers and unions (who may eventually pass these costs on to employees via stagnating salaries and reduced benefits packages). It is estimated that the change toward an income-based drug benefit program in British Columbia increased costs to the private sector – born by patients, employers and unions – by $134-million per year. A similar shift would not be welcome news for Ontario's private sector. Making matters worse, having multiple payers involved in drug coverage for seniors increases administrative costs and reduces the purchasing power of government drug plans. In this regard, existing age-based public drug benefit programs have a similar flaw to income-based drug benefit programs: multiple payers means the system costs everybody more than it needs to. The result is that Canada spends nearly twice as much per capita on prescription drugs as do countries with single-payer systems for prescription drugs, such as the United Kingdom. Moving toward a single-payer system for Ontario could save the province, patients, employers and unions $4-billion per year. Ontario should learn from the experience of British Columbia and other provinces, and not move towards an income-based drug benefit program for seniors. Rather than placing a tax on health needs – as income-based drug plans do – Ontario should consider a more positive road to universal pharmacare. Specifically, it should consider tax financing a universal drug benefit program that would give non-seniors the same coverage elderly residents enjoy today. Doing so would ensure better access to medicines at far lower cost to all involved. Steve Morgan is an expert advisor with EvidenceNetwork.ca and professor and Director of the Centre for Health Services and Policy Research at the University of British Columbia.
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Compulsory insurance does not create affordable access to prescription drugs New Brunswick has opportunity to reduce pharmaceutical drug prices dramatically with a single payer system By Steve Morgan The Liberal government of New Brunswick appears to be stepping back from the brink of mandatory prescription drug insurance. And so they should. The Conservatives had pitched the drug plan as a better model than “catastrophic” drug coverage under which people would only receive public subsidies for prescription drug costs exceeding a given percentage of their household income. In a report published this month by the Institute for Research on Public Policy, my colleagues and I explain why such income-based drug benefits programs are not good for seniors or for the economy. That part the Conservatives got right. But the drug plan chosen by the Conservatives was designed on a false premise: that the private sector can better manage things than government can. In many sectors, that might be true. But not in health care. And certainly not with respect to purchasing prescription drugs on the world market. The Conservatives designed their drug plan to maximize the number of New Brunswickers covered by private insurers. To do this, they required employers offer such coverage to employees or face penalties if they didn’t. Perhaps to remove the temptation of using a more efficient government program, they also and made the premiums for the public drug plan staggeringly expensive. To participate in this program, most New Brunswick households would have faced monthly premiums representing about 3 percent or more of household incomes. And that is on top of taxes they would still have to pay to subsidize the cost of medicines for lower-income families – not to mention taxes paid for private drug coverage for public sector employees. Couples with a gross income of $50,000, for example, would pay $2,800 per year in premiums under the compulsory program. That’s more than 5 percent of household income! And they would still have to pay up to $30 per prescription under the program – which for many would still represent a barrier to filling prescriptions. The problem with this is not that people shouldn’t contribute in proportion to their incomes toward prescription drug needs in the province. The problem is that a well-run, single-payer government program could cover all New Brunswickers at much lower cost. In our IRPP report, we make the case that any system having multiple payers involved in drug coverage will unnecessarily increase administrative costs and reduce the purchasing 262
power of government drug plans. This costs everybody more than the system ought to cost. New Brunswick is home to some of the longest serving, hardest working public drug plan managers in Canada. These people are competent and accountable managers of this important sector of the health care system. But they’ve never really been given an honest opportunity to do so on behalf of the population as a whole. Currently, the government of New Brunswick pays for $208-million of the $746-million in prescription drugs that New Brunswickers use outside of hospitals every year. The government’s 28 percent share of the market gives them very little power to influences prices, prescribing patterns, and the use of cost-saving generic drugs. But if the government of New Brunswick became a single-payer for pharmaceuticals by financing all medically necessary prescription drugs through a universal drug plan, it could use its bulk purchasing power to lower costs quite dramatically. Experience in other comparable countries suggests it could lower drug costs by 25 percent to 40 percent. This means that a well-run government program could cover the entire province at costs to taxpayers that are far lower than the premiums under the Conservative’s drug plan. Moreover, employers would no longer be on the hook for the cost of coverage to their employees. There are always opponents to policy reforms that save money – after all, someone is currently making the money that would be saved in a better run, single-payer system. But to argue that New Brunswick needs a multi-payer system for prescription drugs is simply to argue that taxpayers should foot the bill of an unnecessarily costly system because somebody is making a profit from that system. The private sector can do many things exceptionally well. Managing prescription drug benefits in the context of Canada’s otherwise public health care system is not one of them. New Brunswickers deserve better. With government acting as the single payer and system manager, taxpayers and companies would save hundreds of millions of dollars every year while New Brunswick patients would be assured access to the medicines they need. Steve Morgan is an expert advisor with EvidenceNetwork.ca and professor and Director of the Centre for Health Services and Policy Research at the University of British Columbia.
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L’assurance obligatoire ne favorise pas un accès abordable aux médicaments d’ordonnance En instaurant un régime à payeur unique, le NouveauBrunswick aurait l’occasion de faire baisser leurs coûts de manière substantielle Par Steve Morgan Il semble que le gouvernement du Nouveau-Brunswick soit sur le point de renoncer à instaurer l’assurance-médicaments obligatoire, à deux doigts de l’entrée en vigueur de celle-ci. C’est une bonne décision. Les conservateurs provinciaux avaient vanté leur projet en prétendant qu’il s’agissait d’une formule préférable à celle d’un régime public qui ne subventionnerait que les médicaments « onéreux » dont le coût dépasse un pourcentage donné du revenu d’un ménage. Dans un rapport publié ce mois-ci par l’Institut de recherche en politiques publiques, mes collègues et moi-même expliquons pourquoi les régimes d’assurance-médicaments qui offrent une couverture en fonction du revenu ne sont bons ni pour les personnes âgées, ni pour l’économie. Le régime préconisé par les conservateurs reposait sur une fausse prémisse, à savoir que le secteur privé est mieux placé que l’État pour gérer les choses. Cela est peut-être vrai dans de nombreux domaines, mais pas dans celui de la santé. Et certainement pas en ce qui touche l’approvisionnement en médicaments d’ordonnance sur le marché mondial. Les conservateurs avaient conçu leur régime de façon à ce que le nombre de Néo-Brunswickois couverts par un assureur privé soit le plus élevé possible. Pour arriver à leurs fins, ils avaient exigé que les employeurs offrent ce genre de couverture à leurs employés, en menaçant d’imposer des pénalités à ceux qui omettraient de le faire. De plus, ils avaient fixé pour le régime public d’assurance-médicaments des primes exorbitantes, espérant peut-être ainsi écarter l’attrait que pourrait susciter un programme gouvernemental des plus efficaces. Pour adhérer à ce dernier, une majorité de ménages néo-brunswickois se seraient vus obligés d’acquitter une prime mensuelle équivalant à près de 3 % de leur revenu ou davantage. Cette prime se serait ajoutée aux impôts qu’ils auraient continué à verser afin de subventionner le coût des médicaments pour les familles à faible revenu – sans parler du financement du régime privé d’assurance-médicaments des employés du secteur public. À titre d’exemple, les couples qui gagnent un revenu brut de 50 000 $ auraient déboursé 2800 $ par an en vertu de ce programme obligatoire. Cela représente plus de 5 % de leur revenu! Et ils auraient quand même eu à débourser jusqu’à 30 $ par ordonnance; cet
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obstacle aurait continué à faire hésiter un grand nombre à se procurer les médicaments qu’on leur prescrit. Le problème ne réside pas dans l’idée de demander aux gens de contribuer en proportion de leur revenu à un programme destiné à répondre aux besoins en matière de médicaments d’ordonnance dans la province. Il concerne plutôt le fait qu’il est possible d’offrir aux Néo-Brunswickois, à un coût beaucoup moins élevé, un régime à payeur unique efficace, administré par le gouvernement. Dans notre rapport à l’IRPP, nous argumentons que les régimes d’assurancemédicaments à payeurs multiples, quels qu’ils soient, font grimper inutilement les coûts administratifs et réduisent le pouvoir d’achat des régimes publics. Ce genre de régime nous coûte collectivement plus cher que nécessaire. Le Nouveau-Brunswick compte certains des gestionnaires les plus expérimentés et dévoués au Canada dans le domaine de l’assurance-médicaments. Ce sont des personnes compétentes et responsables, un atout dans ce secteur important du système de santé. Or elles n’ont jamais vraiment eu la chance d’être mises à contribution pour le bien de la population dans son ensemble. Aujourd’hui, la province débourse 208 millions de dollars sur les 746 millions dépensés annuellement à l’extérieur des hôpitaux pour l’achat de médicaments d’ordonnance. Cette part de marché, qui équivaut à 28 %, ne lui accorde pas un pouvoir suffisant pour exercer une réelle influence sur les prix, les habitudes de prescription et le recours aux médicaments génériques abordables. Par contre, s’il instaurait un régime universel à payeur unique chargé de l’achat auprès des fabricants de tous les médicaments d’ordonnance médicalement nécessaires, le gouvernement disposerait d’un pouvoir suffisant pour faire baisser leur coût de façon assez substantielle. L’expérience de pays comparables indique en effet que leur prix pourrait diminuer de 25 % à 40 %. Cela signifie qu’un programme gouvernemental bien géré permettrait d’offrir une couverture à l’échelle provinciale à un coût largement inférieur, pour les contribuables, que les primes prévues en vertu du régime d’assurance-médicaments envisagé par les conservateurs. Qui plus est, les employeurs ne seraient plus tenus d’assumer les coûts du régime de leurs employés. On trouve toujours des opposants aux réformes qui permettraient de faire des économies. Après tout, il y a bien quelqu’un quelque part qui profite en ce moment même de l’argent qui pourrait être épargné grâce à un système à payeur unique bien administré. Prétendre que le Nouveau-Brunswick a besoin d’un régime à payeurs multiples revient à dire que les contribuables devraient acquitter la facture d’un système inutilement coûteux dans le seul but de laisser certaines personnes réaliser des profits.
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Il y a des choses que le secteur privé accomplit à merveille. La gestion des régimes d’assurance-médicaments n’en fait pas partie, étant donné le caractère éminemment public du système de santé au Canada. Les Néo-Brunswickois méritent mieux que cela. Si le gouvernement devenait l’unique payeur et administrateur du régime d’assurance-médicaments, les contribuables et les entreprises économiseraient chaque année des centaines de millions de dollars. Les patients, pour leur part, bénéficieraient d’un accès garanti aux médicaments dont ils ont besoin. Steve Morgan est expert-conseil auprès du site EvidenceNetwork.ca, professeur et directeur du Centre for Health Services and Policy Research à l’Université de la Colombie-Britannique.
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Pharmacare is for kids too By Avram Denburg and Steve Morgan You are the parent of a sick child. You have a limited budget and you must decide to buy the medicine the doctor prescribed for your child or provide food and shelter for your family instead. What do you do? Sadly this dilemma is one too many Canadians are facing. We have an incomplete health system where doctors and hospital care are paid for publicly but the drugs often necessary to treat health conditions are not. Prescription drugs can be costly – and not just for those living in poverty, but for middle income Canadians too. Several studies have found that about one in 10 Canadians cannot afford medicines prescribed by their doctors. This affects approximately one in four Canadian households, including many young families. In most provinces, access to medicines for children is tethered to socioeconomic status, and therefore highly inequitable. The very poor sometimes have access to public assistance – a good thing. And the relatively wealthy have access to work-related private drug coverage. But too many of those in the vast middle ground fall through the cracks. This creates painful and unjust dilemmas for parents who have to choose between the costs of prescription drugs and other life necessities for themselves and their children. Canada is the only universal health care system in the developed world that does not include universal coverage of prescription drugs. Canada is also an outlier for not having a universal program for prescription drugs for children in particular. Two of the four federal political parties in this election have committed to a universal pharmacare program – the NDP and the Green Party – while the Liberals have committed to costsaving measures for prescription drugs. The Conservatives have been silent on the issue. Most of the discussion has been centred on seniors’ access to prescription drugs. But pharmacare is for kids too. We need to press all the political parties to make prescription drugs accessible to Canadian children. The glaring gaps in drug coverage for Canadian children are made stranger by the economic dimensions of the issue. Children’s health care represents a drop in the ocean of health care budgets; extending universal drug coverage to children would constitute a small fraction of total pharmaceutical spending. In fact, universal prescription drug coverage for children would save money both now and in the future. How so? The long term benefits of universal drug coverage for children are compelling. Canada stands to benefit considerably from the developmental gains reaped by healthy children. Reliable access to medicines is crucial to the control of childhood diseases such as 267
asthma, diabetes, cancer and immunologic disorders. Optimal disease management both improves survival and minimizes late effects. With time, this lays the foundations for a healthier and more productive society. The UK, New Zealand, and the Netherlands have national approaches to optimizing pediatric prescribing practices. These countries have something else in common: they provide universal drug coverage for children. This provides an ongoing public rationale for prioritizing safety and efficacy in pediatric drug prescribing. Most of the drugs for common pediatric conditions are available in relatively low-cost generic formulations which the government could prioritize over equivalent more expensive brand-name products. The price of such medicines would fall further if provinces and the federal government bought them in bulk under a universal pharmacare plan. Fluticasone, a commonly prescribed asthma inhaler, costs over $45 in Canada and under $15 in New Zealand, where government purchases medicines on behalf of the entire population. Ondansetron, a medicine used to treat nausea among pediatric cancer patients, costs Canadian governments over $3.00 per 4mg tablet and the US government less than $0.20 under its health program for all veterans. Amoxicillin and many other front-line antibiotics are likewise a fraction of the cost in countries committed to bulk purchasing for public provision of medicines. Novel therapies also have an important role in pediatrics. Frequently costing thousands of dollars per year, specialized medicines for rare and often life-threatening pediatric diseases impose a financial burden that no family should be left to bear on its own. Such costs are far more easily managed and more fairly distributed at a population level – and in fact represent a very small proportion of overall drug use and expenditure. It is rare in matters of policy that the economic, medical and moral dimensions of an issue all point to the same conclusion. Universal drug coverage for Canadian children is this rare exception. With public discourse on universal pharmacare at a political tipping point, we are faced with a window of opportunity to do the right thing. As the federal election nears, Canadians should ask themselves whether our current patchwork of policies on pediatric drug funding – and the resultant gaps in drug access for children – is in line with our values and vision for Canadian society. Dr. Avram Denburg is a paediatric oncologist at Sick Kids and a 2015 Trudeau Scholar. He sits on the Board of Canadian Doctors for Medicare. Dr. Steve Morgan is an expert advisor with EvidenceNetwork.ca and professor of health policy at the University of British Columbia.
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Getting a grip on the risks of vaccination By Brian W. Rotenberg Every day when I see patients in my surgical clinic, some are offered a procedure to help them feel better. Whether it is a minor surgery like a tonsillectomy, or something larger scale such as tumor resection, I have a full discussion with the patient regarding the benefits and risks of doing “something.” Each time I go over the common minor risks of an intervention and the exceedingly rare, but potentially very serious risks that can occur. I also review with them the risks of doing “nothing” – of what may happen if they don’t have surgery. Vaccination is no different. Vaccination involves an injection in order to provoke the body’s immune response to protect against an outside infection. Like all medical therapies, vaccination has both its benefits and its relative risks, and an informed patient or parent needs to balance the two. In the case of the Measles Mumps Rubella vaccination (also known as MMR), its overwhelming success in eradicating deadly diseases of childhood speaks clearly to the benefits. However, it has become fashionable in society recently to hold vaccination to a different standard than most other medical risks individuals generally accept when they receive health care. Understanding the nature of relative risk can help to frame the issue into a clearer perspective. Not all risks are the same either in terms of likelihood or severity, and sometimes the risk of doing nothing can be potentially more harmful than the risk of doing something. In the case of MMR vaccination, the risks of doing something – of receiving a vaccine – include relatively common but minor issues such as fever or a sore arm, and an exceedingly rare severe allergic reaction called anaphylaxis. The risk of doing nothing – of not receiving a vaccine – at first glance seems very simple, that being a higher likelihood of getting the disease the vaccine is designed to prevent. In the case of measles for example, the risk of getting the disease if an unvaccinated person is exposed to someone carrying the virus is very high, close to 100 percent. People who have measles then subsequently have the further risk of developing a host of devastating medical problems including brain damage, deafness or blindness. However, there is a more serious but hidden risk of doing nothing — not getting the MMR vaccine — that being the risk of causing serious harm to someone else who hasn’t received the vaccine. Not all people can be vaccinated even if they wanted to be (e.g., very young children and people having chemotherapy) and because of this, they are at higher risk for catching a contagious disease. Measles is one of the most contagious diseases known.
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In order to have a low likelihood of transmitting measles to those who are unable to be immunized, it is estimated that approximately 95 percent of the population has to be vaccinated. According to the Public Health Agency of Canada, the overall country-wide MMR vaccination rate just barely meets that mark (based on the most recently available 2011 data). If the vaccination rate begins to fall in different provinces, our population will lose its overall immunity. The media are reporting daily new outbreaks of measles in children in Canada and the United States, a scourge society once thought defeated. There appears to be a strong cause-and-effect relationship between the emerging trend not to get vaccinated and the growing number of new sick children. The overwhelming majority of cases of measles are in children who did not get vaccinated. This fact should not be seen as surprising. For those children, the parents’ decision to do nothing is what allowed the virus to grow within them; in their case, the decision to do nothing clearly outweighed the risk of doing something, with potentially life-altering consequences. Even these small dips in vaccination rate have had major consequences – just imagine if the trend continues? Patients who are considering not getting an MMR vaccination for themselves or their children need to compare the relative risks of doing something versus nothing. In the case of the MMR vaccine, doing nothing is the more dangerous choice — and it is putting children, and society at large, at risk. Dr. Brian Rotenberg is an expert advisor with EvidenceNetwork.ca and an Associate Professor in the Department of Otolaryngology – Head & Neck Surgery at Western University, London, Ontario. See also our Podcast on the issue: Measles outbreaks: When celebrities get in the way of science
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Bien saisir les risques de la vaccination Par Brian W. Rotenberg Lorsque je reçois des patients à ma clinique de chirurgie, pas une journée ne passe sans que je ne propose à quelqu’un une intervention pour l’aider à améliorer son état. Qu’il s’agisse d’une chirurgie mineure comme une amygdalectomie ou d’une intervention plus sérieuse comme une résection de tumeur, je discute longuement avec la personne des avantages et des risques rattachés au fait de « tenter quelque chose ». Chaque fois, j’explique quels sont les risques mineurs les plus courants, ainsi que le risque de survenue d’incident très grave. Enfin, je passe en revue les implications de « l’inaction », c’est-àdire ce qui pourrait se produire si l’on n’opère pas. La vaccination consiste en une injection qui vise à provoquer une réponse immunitaire de l'organisme afin de le protéger contre les infections. Comme tous les traitements, elle a ses avantages et ses risques relatifs; une fois bien renseigné, le patient ou le parent doit les soupeser. L’intervention ne diffère en rien d’autres actes médicaux à cet égard. Le fait que le vaccin contre la rougeole, les oreillons et la rubéole (le « vaccin ROR ») ait permis d’éradiquer aussi efficacement les maladies mortelles de l’enfance démontre incontestablement ses bienfaits. Or il est devenu à la mode, dans notre société, de juger la vaccination selon des critères différents de ceux sur lesquels on se fonde pour évaluer la plupart des autres risques médicaux qu’acceptent généralement de prendre les patients qui reçoivent des soins. La notion de risque relatif pourrait nous aider à jeter un nouvel éclairage sur cette question. En effet, tous les risques ne sont pas égaux sur le plan de la probabilité ou de la gravité; parfois, l’inaction peut comporter un risque de conséquences plus graves que le fait d’intervenir. Pour revenir au vaccin ROR, les risques associés à l’action – soit se faire vacciner – peuvent se traduire par des effets relativement courants, mais mineurs, comme une fièvre ou un bras endolori, ou par une réaction allergique grave, mais extrêmement rare, appelée anaphylaxie. L’inaction – c’est-à-dire ne pas recevoir le vaccin – comporte un risque évident, soit une plus forte probabilité de contracter la maladie que le vaccin est censé prévenir. Dans le cas de la rougeole, par exemple, le risque pour une personne non immunisée de tomber malade si elle est exposée à un porteur du virus est très élevé : près de 100 pour cent. De plus, les personnes infectées risquent de subir par la suite une foule de répercussions dévastatrices, dont des lésions cérébrales, la surdité et la cécité. Il existe un risque encore plus sérieux associé au fait de ne pas se faire vacciner : celui de causer des torts considérables à une personne à qui on ne peut pas administrer le vaccin pour différentes raisons. En effet, il n’est pas toujours possible de se faire vacciner, même lorsqu’on y consent; c’est le cas des très jeunes enfants et des patients traités par 271
chimiothérapie. Ces personnes courent ainsi un risque plus élevé de contracter une maladie contagieuse. Parmi les maladies connues, la rougeole l’est au plus haut point. Pour réduire les chances de transmettre la rougeole aux personnes qu’il n’est pas possible de vacciner, on estime qu’il faut immuniser 95 pour cent de la population. Selon l’Agence de la santé publique du Canada, le taux de vaccination ROR à l’échelle du pays atteint cette proportion de justesse (sur la base des données les plus récentes, qui datent de 2011). Si le taux de vaccination se met à fléchir dans différentes provinces, la population de notre pays perdra son immunité globale. Ces derniers temps, les médias rapportent quotidiennement de nouvelles éclosions de rougeole au Canada et aux États-Unis, un fléau qu’on croyait pourtant avoir vaincu. Il semble y avoir une forte relation de cause à effet entre la tendance actuelle à ne pas se faire vacciner et le nombre grandissant d’enfants qui contractent cette maladie. La grande majorité des cas de rougeole touchent des enfants qui n’ont pas été vaccinés. On ne devrait pas s’en étonner. C’est la décision des parents de s’abstenir qui a permis au virus de s’implanter; de toute évidence, ils auront jugé que cette voie comportait des risques moindres que le fait d’agir, malgré le fait que les répercussions pourraient bouleverser leur existence. Même une légère diminution des taux de vaccination a engendré des répercussions majeures. Imaginez ce qui se produira s’ils continuent de fléchir. Les personnes qui envisagent de ne pas recevoir le vaccin ROR ou de ne pas le faire administrer à leurs enfants devraient d’abord s’attarder à comparer les risques relatifs entre l’action et l’inaction. Dans ce cas précis, l’abstention est le choix le plus risqué; elle met les enfants en danger, ainsi que la société dans son ensemble. Le Dr Brian Rotenberg est expert-conseil auprès du site EvidenceNetwork.ca et professeur associé au département d’oto-rhino-laryngologie (chirurgie de la tête et du cou) à l’Université Western, London, Ontario.
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Are we finally in a health election campaign? Why national pharmacare should be an all-party priority in this federal election By Ryan Meili It's become almost a matter of faith: health and health care are perennially among the top priorities for Canadians, but are nearly invisible in election platforms and debates. This observation has led health care providers, health care advocates and labour leaders to call for greater attention to this key issue, and others to try to explain why it is an issue of which politicians may be well-advised to steer clear. Something changed this week, when Tom Mulcair announced that an NDP government would implement a national pharmacare program. With this he joined Elizabeth May and the Green Party in advocating for a program that, if implemented, would be the biggest step forward for Canadian health care since the introduction of medicare. Are we finally in a health election campaign? Will the Liberal and Conservative parties also come forward to act on an issue of critical importance to the health of Canadians? Public opinion polls in favour of introducing pharmacare suggest they’d be wise to do so. National drug coverage has long been a priority for the over one in five Canadian households that can’t afford to buy needed prescription medicines. But in spite of decades of calls for a new program by expert panels and commissions, the idea seemed not ready for prime time. The cost of national pharmacare was seen to be too great in a time of low political appetite for new universal benefits. But it turns out that pharmacare isn’t a money sucker – it’s a money saver. A new look at the numbers has people realizing that the cost of not having national drug coverage is far greater than that of implementing it. A groundbreaking economic analysis in the spring of 2015 by Steve Morgan and Danielle Martin demonstrated that universal drug coverage would save over $7 billion dollars in private and public spending, with little or no increase to government budgets. Where do these savings come from? Canada is the only OECD country with universal health care that doesn't include drug coverage, and as a result we miss out on opportunities to get value for money when we buy drugs. The popular anti-cholesterol drug Lipitor, for example, costs $800 per year for a Canadian patient. In New Zealand, where bulk-buying and aggressive price negotiations are part of a national drug plan, the same medication costs only $15 year. That’s not a typo. This means that Canadians are either paying far more out of pocket for medications, or they're simply not taking them at all. A recent Angus Reid poll showed that 23 percent of households surveyed had not been able to properly take prescribed medications due to cost. This is obviously bad for the health of those individuals; and it also contributes to greater costs in other parts of the health system when patients suffer preventable 273
consequences. In my practice, as in medical practices across the country, I see patients with chronic illnesses like diabetes, high blood pressure, HIV and lung disease who are too often forced to choose between the medications that are essential to keep them well and necessities of life, such as rent and nutritious food. This is not just an issue for very low income Canadians – it spans across income lines as drugs become more expensive and employer benefits less common. Doctors are so concerned about the issue that the Canadian Medical Association’s General Council voted 92 percent in favour of a resolution in support of pharmacare last month. The general public agrees: recent polls show 91 percent of Canadians are also in support of universal drug coverage. Federal elections should be a time to concentrate on what matters most to Canadians. This includes health care when we’re sick, as well as action on the upstream factors that determine whether we get ill or well, such as housing, income, child care and the environment. What else are our elections about, if not the quality of our lives, our health and wellbeing? Health and health care may be dangerous territory for politicians, fraught with ideology and emotion, but the argument for pharmacare is so compelling that all parties should be moved to take action. It's extremely encouraging to see the Greens and the NDP join the Canadian public in their support of this important step forward. Hopefully the Liberals and Conservatives will join them shortly as we move to a national consensus on this sensible and timely approach to controlling costs and improving health outcomes. The voting public deserves to know where all parties stand on this issue. Ryan Meili is an expert advisor with EvidenceNetwork.ca, a practicing family physician in Saskatoon and founder of Upstream: Institute for A Healthy Society and Chair of Canadian Doctors for Medicare.
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Catastrophic pharmacare is a catastrophe Why the provinces don’t need $3 billion in federal tax dollars for flawed prescription drug policies By Steve Morgan Last week, the CD Howe Institute called on Ottawa to give provinces nearly $3-billion to establish national standards for catastrophic drug coverage and to mandate a system of transparent price negotiations with pharmaceutical drug manufacturers. Acting on those recommendations would represent a major step backward for Canada, one that would cost Canadians billions of dollars per year. The CD Howe Institute claims it is not feasible for Canada to implement what their own evidence suggests is the best pharmacare model – national standards for universal, comprehensive coverage of medicines of proven value-for-money. They instead argue the feasible policy option is to have all provinces pay for drug costs that exceed three percent of household incomes. This is surely “feasible” because as good or better drug coverage already exists for most people in most provinces without billions of new tax dollars provided by the federal government. The “feasible” model of catastrophic drug benefits is also already a proven failure for patients, businesses and taxpayers. How so? Catastrophic drug coverage fails to ensure universal access to necessary medicines. Numerous studies that have shown that deductibles under catastrophic drug plans act as barriers to filling necessary prescriptions. Residents of British Columbia – the only province with exactly the kind of pharmacare program recommended by the CD Howe Institute – are more likely to skip prescriptions because of cost than residents of provinces with more comprehensive drug coverage. If Ontario adopted the same type of coverage, as many as 68,000 elderly Ontarians would find their prescriptions too costly to fill. Financial barriers to filling necessary prescriptions result in worse health for patients. They also result in increased use of taxpayer-finance hospital and medical care. In other words, they don’t save anybody money in the long run. The catastrophic model of pharmacare also imposes considerable direct costs on families and on the businesses who sponsor extended health benefits for workers and retirees. In 2003, when British Columbia adopted the model recommended by the CD Howe Institute, the private sector had to pick up an additional $134-million per year in drug costs. Today, in Ontario alone, a similar policy shift would likely increase employers’ and families’ drug costs by over $500-million. This brings up another key failing of catastrophic drug coverage: it does the opposite of controlling costs because it unnecessarily increases administrative costs and dramatically 275
reduces purchasing power. Both of these outcomes result from involving private insurers in the financing of medically necessary prescription drugs. Private sector analysts estimate that up to $5 billion spent by Canadian employers on private drug benefits is wasted because private drug plans are not well positioned to manage drug pricing or the prescribing and dispensing decisions of health professionals. To remedy that problem, the CD Howe Institute recommends that provincial governments work to lower prices paid by private insurance companies through a transparent system of drug pricing in Canada. Sounds great in theory, but it won’t work in practice. Why? The era of transparent pharmaceutical pricing is over. So many nations – including Canada – have historically regulated drug prices based on what manufacturers charge in other countries that firms now artificially inflate their list prices for medicines worldwide. Then, instead of giving every country price reductions offered to those with effective negotiating power, pharmaceutical manufactures now simply do price deals in secret. In effect, pharmaceuticals are now priced like new cars: there’s a manufacturers "list" price, and then there is the confidential price that each customer actually negotiates. Recommending that Canada have a transparent system for drug pricing is equivalent to saying that our governments cannot negotiate deals. This would not lower prices for the private insurers incapable of negotiating on their own. And it would eliminate the opportunity for governments to save hundreds of millions of dollars per year on behalf of taxpayers. To act on the recommendations of the CD Howe Institute is a "feasible" way to squander billions of dollars of federal transfers on a model of pharmacare that will cost Canadian patients, businesses and taxpayers billions every year. Better, more equitable and sustainable options are viable for Canada, especially if $3-billion in new federal money is on the table. Steve Morgan is an expert advisor with EvidenceNetwork.ca and professor of health policy in UBC’s School of Population and Public Health. Follow him on twitter at @SteveUBC
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Canada’s chance to catch up on drug safety for children Studying medicines in children is always possible and in their best interests By Terry P. Klassen and Martin Offringa Almost a year has passed since an important report was released on ways Canada needs to improve medicines for children. The report was commissioned by Health Canada and undertaken by the Council of Canadian Academies after many alarms were sounded by experts in the community. “How can we continue to prescribe or deny medications to children without knowing the possible consequences first?” many asked. The truth is one that is rarely declared publicly: Canadian children are often treated with drugs in the absence of evidence. What the report, Improving Medicines for Children in Canada confirmed was what pediatricians in the field already know — that much of the medications given to children in Canada have never been adequately studied or even formally approved for the conditions they are commonly prescribed to treat. The report also noted that children respond to medications differently from adults, which means that medicines must be both studied in children and formulated for children. The good news is that there are precedents. In the United States and the European Union, pediatric medicines research is encouraged, required and monitored in ways that offer lessons for Canada. What such precedents teach us is that studying medicines in children is always possible and is in their best interests. The report rightly emphasizes that pediatric medicines research is a Canadian strength, but it requires reinforcement and sustained capacity and infrastructure to realize its full potential. So what’s been done since this landmark report on children’s health? Not much. Although the report flags that Canada is uniquely positioned to engage in collaborative disease-specific networks that have already been established internationally, this first critical step still needs to be taken. To do this, we need our federal government to help us set this in motion now by working with Health Canada, provincial counterparts, universities and children’s hospitals to implement a proposed national network for the study of medicines in children. What would this mean for Canadian kids? A Canadian network working in collaboration with global partners could support rapid delivery of studies on new children’s medicines that we cannot deliver alone and bring medicines for children to market more quickly. It would also allow critical Canadian participation in global health, economic and other international studies so that pharmaceutical pricing can reflect the needs in our country. 277
The wheels are already in motion: the Canadian government is now studying a comprehensive proposal for a child health drug research network prepared by the joint children’s hospitals in our country – a unique Canadian development in which child health leaders choose to collaborate rather than to compete. At the same time, international pharmaceutical companies are actively promoting a plan to develop a Global Pediatric Clinical Trials Network involving national networks of the best children’s hospitals in over 20 countries in the world. Instead of a single children’s hospital building up a local or provincial infrastructure to answer one drug research question at a time, then breaking it down, Canada would benefit immensely from a sustainable network, taking on multiple questions, working with multiple partners, led by Canada’s reputable clinicians and scientists. Of course, whichever way we move forward, the child and family should be put first for all decisions made. This will guarantee that only ethical, relevant research proposals are adopted by the network. Can we really afford not to be part of this global development and miss having our national infrastructure organized? It’s time Health Canada made progress on the recommendations of a report they, themselves, commissioned — and for the federal government to set the course. As the report stipulates, only a small investment is needed to align existing resources and send a strong international signal. If we don’t, Canada will lose its competitive advantage to engage pharmaceutical companies. Worse, Canadian families will be at further risk of failing to benefit from emerging scientific breakthroughs. Terry P. Klassen is an advisor with EvidenceNetwork.ca, a pediatric emergency physician and clinical epidemiologist who is currently the CEO and Scientific Director of the Children’s Hospital Research Institute of Manitoba and Head of Pediatrics, University of Manitoba. Martin Offringa is a Professor of Paediatrics at the University of Toronto, a practicing neonatologist and a Senior Scientist in Child Health Evaluative Sciences at The Hospital for Sick Children. Both authors served, with many others, as experts on the Council of Canadian Academies committee that looked into Therapeutic Products in Children.
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Antibiotics – overprescribed and under-effective Why antibiotic resistance can be deadly By Brian W. Rotenberg I am privileged to help patients deal with a variety of common disorders such as ear infections, pharyngitis and sinus inflammation. People suffer a great deal from these problems, especially when they are in the acute phase. I offer pain medication, ear or nasal rinses, gargles or decongestants, all of which work reasonably well. The overwhelming majority of these incredibly common infections are caused by viruses – that is, they will not respond to antibiotics — so I don’t routinely offer antibiotic treatments. When patients hear they won’t be getting an antibiotic many become surprised and often upset. I then spend time counseling them about why antibiotics are, in most cases, the wrong treatment choice. Let us use sinusitis as an example to frame the discussion. In 2013, according to Health Canada, almost five percent of the Canadian population was diagnosed with an acute sinus infection. This represents almost two million Canadians. Of these people, the same study reported that approximately 85 percent received an antibiotic prescription. However, the disturbing part is that according to the modern Canadian Sinusitis Guidelines published in 2011, 98-99.5 percent of people with sinusitis actually have a viral infection without bacteria. Therefore, the vast majority of people receiving the antibiotic not only didn’t need the therapy, but were actually treated incorrectly. Antibiotics are a precious resource that, if used appropriately, can be life-saving and curative. However, the overuse (or “misuse” as some might say) of antibiotics in humans has led to the development of many types of antibiotic-resistant bacteria that fail to respond to these agents – and that can be deadly. Antibiotic resistance is now a major global public health problem with serious societal costs. Since antibiotic resistance genes are shared between bacteria in our ecosystem, inappropriate use of antibiotics — even in a single individual — could potentially affect every living creature on earth. In Canada we live in a blessed country where most acute infectious illnesses of the past have become rare enough to have faded from memory. Most of our current health care dollars now go towards treating chronic conditions, many of which involve surgical treatments, such as hip and knee replacement to treat arthritis. These surgeries simply could not happen if they carried a major infectious risk. Having an implant get infected is devastating to a patient. Imagine if your grandmother couldn’t have her hip replacement surgery because the risk of developing an antibiotic resistant infection was too high. I don’t believe I’m exaggerating when I say this risk is a real possibility in our lifetime.
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Modern society eschews disease, and nobody feels they have time anymore to be sick. A reasonable level of tolerance for mild viral illness has largely been replaced by selfmaximization of symptoms and requests for aggressive therapy, most commonly antibiotics. It is a rare patient who is satisfied with time honored and effective conservative measures – drink plenty of fluids, take some pain medication and wait a few days for it to get better. More problematically, it is also becoming a rare doctor who will take the time to educate patients that in all likelihood their infection is viral, and won’t respond to antibiotics anyway. Sometimes it is easier to just write a prescription. Add to this the fact that pharmaceutical makers have been lackluster in developing newer antibiotics as the costs associated with drug development make such ventures very risky. You are more likely to see instead lifestyle medications such as cholesterol pills or blood pressure medications, which are far more lucrative for pharmaceutical firms. And here’s a strange fact of history: did you know that most of the current types of antibiotics were discovered by scientific accident, and that the targeted research fostered by modern society has been notably unsuccessful in replicating the happy serendipity of our historical scientists? When was the last time you heard of a new type of antibiotic being released for use by physicians? It would be wonderful to see a willing wealthy philanthropist, or a strong government leader, partner with big pharma to set a financial motivator for antibiotic development. Absent that though, society in general needs a reset for how antibiotics are regarded and used, and physicians in particular need to stop overprescribing them. It really is ok to just be sick for a little while with a virus. Dr. Brian Rotenberg is an expert advisor with EvidenceNetwork.ca and an Associate Professor in the Department of Otolaryngology – Head & Neck Surgery at Western University, London, Ontario.
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The other drug problem in Canada’s cities How Canada’s piecemeal pharmaceutical drug insurance coverage costs Canadian cities – and taxpayers — plenty By Steve Morgan Canada's cities face a number of problems: traffic, housing, crime, infrastructure – the list goes on. Prescription drugs are one of these problems – one that is costing local governments as much as $500-million every year. How so? Municipalities, like most employers, realize the value of a healthy workforce. Recognizing that access to necessary medicines is critical for health and wellbeing, many cities offer their employees private insurance coverage for prescription drug costs. For example, the cities of Toronto and Calgary spend approximately $43-million and $20million, respectively, on private drug insurance plans for their employees. The coverage they offer is relatively comprehensive, resulting in costs per employee that are equal to private sector averages. Vancouver and Halifax offer less comprehensive drug coverage for their employees but still at considerable cost – about $3-million each. The numbers add up. According to Statistics Canada, there are over 600,000 local government employees across the country, about two thirds of whom receive private health insurance from the cities, towns and districts they work for. Based on the cost of such coverage for the four cities above, these local governments are spending about $500-million a year on private drug insurance for their employees. Cities have to spend this money – taken from local taxpayers – because Canada’s medicare system is the only universal, public health care system among developed countries that does not include universal coverage of prescription drugs. It is not wrong for cities to care for their employees. But leaving these costs to the cities makes about as much sense as requiring every homeowner to maintain the roads and infrastructure surrounding their property. Here’s why. Just as would happen if infrastructure was left to individual homeowners, the system that leaves drug coverage to individual patients and employers – including cities – creates an uncoordinated patchwork. Most cities provide coverage, but some can’t afford to. Some workers qualify for coverage, but some don’t. The same pattern plays out in cities, hospitals, schools, and businesses across the country. As a result, millions of Canadians are without drug coverage and one in 10 Canadians cannot afford to fill their prescriptions. This patchwork is not just inequitable, it is profoundly inefficient because it fails to place responsibility for drug coverage and costs with the right level of government.
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Provinces and the federal government are responsible for Canada’s health care system. They are best suited to manage access to medicines as an integral part of health care for all Canadians. They are also best positioned to reduce waste and overspending on pharmaceuticals. Having multiple drug plans operating in every province – including multiple private plans for public sector employees – needlessly duplicates administrative costs. Worse yet, this fragmentation diminishes Canadians’ purchasing power on the global market for pharmaceuticals. Provincial governments wield about $10-billion in purchasing power when negotiating rebates for prescription drugs. This reduces public drug plan costs by millions of dollars. But it does not lower costs for cities and other organizations who insure their workers through the private drug plans that are miniscule in comparison. No matter how hard they try, cities would have about as much chance of negotiating competitive drug prices as homeowners would have of securing the best prices for infrastructure planning, engineering and construction. Some things are best done through well-planned, population-level procurement processes. A recent study in the Canadian Medical Association Journal shows how a universal public drug plan run by provinces could provide all Canadians coverage for prescription drugs while saving taxpayers $7-billion per year. Such a program would end the downloading of $500-million worth of prescription drug costs to local governments and thereby allow cities to better address problems like traffic, housing, crime, etc. For these reasons, the federal and provincial governments should take responsibility for our prescription drug problem by implementing universal pharmacare for all Canadians. Doing so would support the health and wellbeing of public and private sector workers alike at far lower cost than Canadians are paying for our disorganized, patchwork system today. Steve Morgan is an expert advisor with EvidenceNetwork.ca and professor and Professor of Health Policy at the University of British Columbia School of Population and Public Health.
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Pharmacare is good for business By Steve Morgan and Danielle Martin Repeatedly over the past 50 years, national commissions and inquiries have recommended that Canadian medicare include universal, public coverage of prescription drugs. So far, no government has acted on this, creating profound inequities and inefficiencies in our health care system. But more than that: the lack of universal pharmacare is bad for Canadian businesses, large and small. In this election year, it is time for Canada’s business leaders to call for universal, public pharmacare. Here’s why. Businesses care about the health and wellbeing of the Canadian workforce. Employees that can afford the medicines as and when prescribed will be healthier, happier, and more productive. But VPs of Human Resources will tell you that, with growing use and cost of prescription drugs, managing drug benefits has become much more complex and difficult to sustain. Regrettably, private drug coverage decisions are made as part of contract negotiations that put employers and unions in the impossible position of deciding who gets access to what treatments. And as the costs of private plans grow, businesses of all sizes are forced to make difficult trade-offs. Small businesses – a cornerstone of our economy – are the least likely to offer drug coverage. Simply put, they can’t afford it for the same reason that individuals find it difficult or impossible to get insurance if they have chronic disease: private insurance companies are not charities. Private insurers must charge groups and individuals premiums that reflect their actuarial risk. The problem is that about one in ten adults has costly, chronic needs for prescriptions – to treat conditions like asthma, diabetes, hypertension, heartburn or arthritis. Smaller firms have difficulty shouldering the risk of employing a worker with such needs, or one with a spouse or child with such needs. The situation is worse for entrepreneurs who want to work for themselves but have chronic health needs in their families. All this leads to a labour market wherein people with chronic medical needs in their families must choose jobs based on insurance. Matters will only get worse as more specialized medicines – which can cost $50,000 or even $500,000 per patient per year – come to market. Currently, speciality medicines account for 1.3 percent of private drug plan claims, but their costs add up to a staggering 24.2 percent of total drug plan spending. These extraordinary costs should not be borne by a single business.
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Drug prices in Canada are among the highest in the world, mostly because our myriad of private drug plans dilutes Canada’s potential purchasing power on the world market for pharmaceuticals. Take the common hypertension drug, amlodipine, which happens to be sold by a Canadian company in both Canada and New Zealand. A year’s supply of this drug would cost $88 here but only $7 in New Zealand, where government purchases medicines on behalf of all patients. Canadians spent $286-million on amlodipine prescriptions in fiscal 2012/13. Businesses picked up much of the inflated tab. We recently published a study in the Canadian Medical Association Journal that quantified just how much Canada stands to gain from a universal, public drug plan. Under conservative assumptions, we found that such a program would save Canada’s private sector over $8-billion annually while covering all Canadians for virtually all drugs – including all expensive biologic drugs. Contrary to what some pundits have claimed, our estimates included the cost of increased use of medicines that will result from increased access for Canadians who are currently under- or uninsured. What we did not include was the additional savings that research also shows Canadians can expect by way of improved patient health and reduced demand on our hospitals. The proof that this would work for Canada is found in every other developed country with universal coverage of prescription drugs: they all promote more equitable access to medicines at substantially lower cost than we pay in Canada. Of particular interest to Canadian businesses is the fact that, if a national pharmacare program on par with average comparator countries were instituted today, private sector employers and unions would save over $5.5-billion, net of the $2 to $10 co-payments that would be charged under such a program. It is important to note that such savings would not come at the expense of the taxpayer. Indeed, the power of a universal public program as a negotiator of drug prices and promoter of appropriate prescribing is such that the incremental public cost to government of a universal program – including the cost of increased use of medicines resulting from expanded public coverage – would be only $1-billion, shared across all 13 provinces and territories and the federal government. Every comparable country with a universal health care system provides universal coverage of prescription drugs. Even the most expensive of such systems would cost Canada $4-billion less than our fragmented private/public system costs us today. Universal pharmacare would not only help the working poor, the uninsured, and the sick. It would also enable Canadian businesses to remain competitive in the global marketplace
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by securing the health of their workforce at far lower cost to business and society as a whole. It is time for business leaders to champion the cause. Steve Morgan is an expert advisor with EvidenceNetwork.ca and professor and Director of the Centre for Health Services and Policy Research at the University of British Columbia. Danielle Martin is a physician and Vice President at Women’s College Hospital in Toronto.
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Why we should think twice before we institutionalize national pharmacare By Alan Cassels Amalgamation always seems like a good idea. Greater Victoria has 13 municipalities, 13 councils, oodles of separate fire and police departments and multiple separate teams of garbage-persons, road fixers, parks maintainers and others that you need to keep our cities humming. Which makes everyone ask: Wouldn’t it be easier (and cheaper) if we just had one of each? That’s right, “Let’s amalgamate.” I don’t know much about municipalities amalgamating, but joining forces, preventing duplication and saving money has been suggested with something I do know about — pharmacare programs. Canada has at least 16 separate drug public plans – each of the provinces, plus ones for the RCMP, veterans, aboriginals and others, as well as hundreds of private drug plans. Wouldn’t it also be easier – and cheaper — if we just had one national drug plan? Earlier this summer, at least eight provinces got together to discuss a national drug plan. Cost-efficiencies, a better ability to negotiate drug prices and other economies of scale make it a compelling idea. I agree. Yet, I also agree that if done poorly, a national drug plan could be an utter disaster, characterized by waste, political coverage decisions and even more irrational and unsafe pharmaceutical use than we’ve got now. Bigger does not always equal better; sometimes bigger means dumber. Let’s take a major new drug to see how we might fare with a national drug plan. The diabetes drug Januvia (generic name: sitagliptin) globally earns about $6 billion per year for its manufacturer, Merck. It costs about $3.50 per pill in BC and lowers blood sugar on par with older, cheaper diabetes drugs. Proponents of a national drug plan would assert that with the buying power of one big agency, we’d negotiate much better prices for Januvia. Instead of paying $3.50 per pill maybe we could get it for $2 a pill which is about what Australia pays, seeing as they have national buying power. Sound good? It would be good only if Januvia had advantages over older, cheaper diabetes drugs. Sadly, independent experts say that drugs like Januvia are less effective than older diabetes medications. So are they more dangerous? A trial published in early June tested the drug in 14,000 people over three years and found it wasn’t any more harmful than “usual care” plus placebo. This “non-inferiority” trial suggested that over three years Januvia won’t increase your risk of heart failure, heart attacks, death or cancer compared to placebo. Hmm. Hardly a slam dunk. Taxpayers in Ontario and in Quebec pay tens of millions a year for this drug. And 286
Canada’s private plans? It’s a good chance if you get drug benefits through your employment, then you’re paying for Januvia as well. For my tastes, the first priority of a national drug plan wouldn’t be price, but evidence. If the best available evidence suggests that a new, more expensive drug like Januvia is in the “not better or worse than comparator drugs” category, you’d have strict rules to make sure the drug was only covered for the subset of people who can’t tolerate other diabetes drugs. You’d use the money you saved to expand coverage for drugs that are costeffective so that more Canadians can be covered for high drug costs. These are the types of hard decisions you have to make when you’re facing the political power of one of the world’s biggest drug companies. The BC government, just recently, made a hard decision when it decided BC Pharmacare won't pay for Januvia. Why? Maybe given little evidence the drug could extend the quality or the length of a diabetic's life and the fact that Merck refused to lower the price to bring it on par with the other DPP-4 inhibitors, the government made the decision not to kowtow to the lobbying pressure. That’s the kind of spine that would be essential in a national drug plan. Yet if you look at other federal health-related organizations (Health Canada, CIHR and CADTH) you find very poor models of national spine. We have a watchdog that doesn’t bite, a national health research funder that encourages Canadian researchers to “partner” with drug companies and a technology evaluator that takes money from drug companies in the form of ‘fees,’ thus making them beholden to the very industry they are supposed to assess. Any national pharmacare program would need an absolute firewall to protect it from the inevitable politics of drug coverage, otherwise you’d be left with even more irrational and expensive drug coverage decisions. Amalgamation in Victoria and a national pharmacare program both sound great in theory. But in practice? Hmm, I am usually optimistic about doing things collaboratively and working for efficiencies but I’d hate to see Victoria lose its character or Canada to accidently create a national form of institutionalized drug coverage that can’t make hard, politics-free and evidence-based decisions. Alan Cassels is a pharmaceutical policy researcher, author and expert advisor with EvidenceNetwork.ca. He lives in Victoria, BC.
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Provincial Health Ministers right to push for national pharmacare program – but what kind? Quebec’s outdated drug coverage policies should not be model for rest of Canada By Marc-André Gagnon In spite of very high expenditures for drug coverage, one in 10 Canadians cannot afford to fill their prescriptions. The current patchwork of public and private plans across the country means that Canadians are covered for their prescription drugs based on where they live or work, rather than on their medical needs. Eight provincial health ministers organized a roundtable with health care professionals and academic experts on June 8 to discuss how we should transform drug coverage in Canada and several are now calling for a national pharmacare program. The question now is, what kind? The suggested reforms discussed were based on international best practices, which overwhelmingly emphasize a single payer universal public drug coverage system equipped with the institutional capacity to ensure value for money. The evidence consistently shows that such a system would provide better access while substantially reducing costs. Nevertheless, private insurers, the drug industry and some think tanks are advocating for the implementation of Quebec-style hybrid private-public drug coverage for the rest of Canada. Here’s why this won’t work for Canada – because it no longer works for Quebec. In 1997, Quebec created a drug coverage system where it is mandatory for workers to enroll in private plans when they are available. Those for whom no private plan is available end up on the mandatory public plan. Thus, all Quebecers are covered by some form of drug insurance. Premiums can be very expensive, and patients still have to pay out-of-pocket a maximum copayment of 32.5 percent when purchasing prescriptions, which can add up to more than $1,000/year. What has been the result of Quebec’s hybrid model? Access to medications improved when the plan was implemented, but by keeping a fragmented system based on multiple public and private plans, Quebec has not developed the needed institutional capacity to contain costs. Canada has the world’s second-highest per capita costs for prescription drugs (only after the United States), and Quebec has the highest costs per capita among all provinces. Twenty years ago, Quebec’s system was a great step forward, but it is certainly not a model for the 21st Century. While it did provide better access to prescription drugs, the
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system remains inequitable, inefficient and unsustainable, according to a recent official report by Commissaire à la santé et au bien-être. Inequity persists in the Quebec system because the prices of drugs vary between the public and private plans. The public plan tends to balance its budget by shifting costs onto the shoulders of private plans rather than containing its costs. Since insurance companies are paid as a proportion of spending, they rarely complain. So who pays? Employers and employees end up paying steep premiums. This increases labour costs and reduces the competitiveness of Quebec’s businesses. Mandatory private coverage is also not related to income, so the costs can be substantial for some — especially the working poor. I was shocked when a student working part time told me that she had to pay $190 of her $514 net monthly income on drug premiums. There’s also the systemic issue of institutional ‘skimming’ between “good” and “bad” risks. Seniors, people on social assistance, or unemployed end up on the public plan while those with a “good job” (the wealthier and healthier population) enrol in private plans. Then there’s the inefficiency. For decades, private plans remained fixed on the idea that a “good drug plan” covered all new drugs at any cost, even when a lower cost alternative was available. Considering that the majority of new drugs do not provide therapeutic benefits over existing therapies, drug plans without the capacity to evaluate costeffectiveness become a major source of waste. A good drug plan also requires the capacity to negotiate with drug companies to obtain better prices. Can you really negotiate prices if from the start your position is to pay for any product whatever the price? When you look at the numbers, it really is surprising that all public employees in Quebec are required to enrol in costly private coverage given that administration costs account for 1.7 percent for Quebec’s public plan, yet 18 percent for private insurers. In fact, more than 30 percent of all people enrolled on private plans are public employees. This is a massive indirect subsidy to insurance companies, in addition to tax subsidies offered by the Federal Government, which represent 13 percent of expenditures by private drug plans. In a presentation last November, former health minister Jean Rochon, who implemented Quebec’s drug regime 20 years ago, said that, at the time, such a hybrid model was the right thing to do, but added that the system is now outdated and we needed to move on to tackle the new challenges relating to drug coverage. The question, he said, is not “if,” but “how” we should implement universal public drug coverage for everyone. Corporate lobbies and doubt manufacturers are working very hard, however, to tout Quebec as a model for the rest of Canada – against the best evidence.
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Marc-André Gagnon is an expert advisor with EvidenceNetwork.ca and assistant professor with the school of public policy and administration, Carleton University.
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Why employers in Canada waste $5 billion a year on inefficient drug coverage By Alan Cassels, Sean O’Brady and Marc-Andre Gagnon There is certainly a lot of waste in health systems, but one area that seems to have escaped close scrutiny is the waste in private drug plans in Canada. To put it simply, that waste is gut-churning. Estimated at over $5 billion a year, this represents over half of the annual prescription drug bill paid by private insurers in Canada and is money that could be better spent on increasing salaries and improving other benefits such as dental care. The biggest part of an employee’s benefits package is their drug plan. And unlike public drug plans in Canada, private plans are notoriously inefficient, often covering higher priced drugs that do not deliver better health outcomes for users or using sub-optimal renewal intervals. But why are private plans so inefficient in Canada? We can learn a lot about why companies squander tons of money on prescription drugs by looking at how they negotiate drug plans with their employees and other players in the insurance universe. Our new study in Health Policy analyzes how drug plans are negotiated in the private sector. By carrying out interviews with experts from private sector companies, unions, insurers and plan advisors, the study was able to drill down into the experience of the interviewees to understand the basics of “how things work” in negotiating drug benefits in unionized settings. Basically, our findings show that everyone keeps each other in the dark about the drug plans they negotiate (if we can even call it ‘negotiating’ at this point). Employers who understand the technical details of their drug plans withhold data on drug spending from employees, thus awarding them an advantage in the negotiating process. Union experts may understand how inefficient their current drug plan is but they often lack sufficient detail of drug spending in order to convince employees about the need to introduce costcontainment measures. Employers want their drug plans to be as competitive as those offered by other employers. So what happens when the norm is to cover all new drugs at any cost, even if the drugs do not provide additional therapeutic value? Well, the end result is that everyone buys “generous” plans instead of increasing employee compensation. Everyone we spoke with agrees about the need to educate employees and employers alike. And in fact, everyone agrees (even insurers) that exorbitant drug costs are a big issue for Canadians. Insurers could raise awareness to change this irrational norm of covering everything, since covered drugs often do not provide additional therapeutic value for money. One 291
solution would be to proactively implement managed drug formularies. However, insurers’ financial incentives are not aligned with those of their clients because inefficient drug plans are unfortunately very profitable for insurers. Insurers are paid as a percentage of the drug bill. So the bigger the bill, the more they make – a principle that absolutely counters the drive to root out and eliminate waste in the compensation package. Take the arthritis drug celecoxib (Celebrex) for example. It is automatically paid for by most private drug plans in Canada, but not by BC Pharmacare covering those BC citizens without private insurance. And why is that? It’s because this drug costs more and is considered less safe (it carries a black box warning for increased risk of heart attacks or strokes) than alternative drugs for arthritis. A public drug plan like BC Pharmacare restricts automatic coverage for drugs like celecoxib for the key reason that they don’t represent value for money. But these are precisely the types of drugs that drive up the drug bill for private companies and increase insurers’ profits in the process. Sometimes drug companies explicitly target private drug plans for their products because such plans do not implement any restriction to get value for money. During our study we also learned that unless unions and employers demand drug plans that deliver only drugs that are safe and cost-effective, they will remain incapable of cutting out wasteful spending on drugs. And because of the lack of trust and of information-sharing between unions and employers, it is unlikely to happen any time soon. Our study shows that employers, unions, insurers and consultants all agree that the current system is unsustainable and will not change by itself. Everyone is calling for some type of state intervention. Most of the interviewees agreed that a universal pharmacare program in Canada makes sense and we need to move in that direction. It is time to seriously consider what can be done to reform drug coverage and eliminate wasteful spending on prescription drugs. The system will not change by itself. Tackling the wastefulness of private drug plans would not only increase the disposable income of all Canadians, it would also reduce labour costs and increase the competitiveness of Canadian enterprises. It is time to start thinking outside the inefficient box. Sean O’Brady is a PhD student at École de relations industrielles, Université de Montréal, Montreal. Marc-Andre Gagnon is an expert advisor with EvidenceNetwork.ca, Assistant Professor with the School of Public Policy and Administration, Carleton University. Alan Cassels is a researcher with the Faculty of Human and Social Development, University of Victoria.
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See also our Podcast on the issue: Why Canadian employers waste $5 billion a year on inefficient drug coverage
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L’inefficacité de l’assurance-médicaments privée coûte 5 milliards chaque année aux entreprises Par Alan Cassels et Sean O'Brady Il existe beaucoup de gaspillage au sein des systèmes de santé, mais un aspect qui semble avoir échappé à cette analyse est le gaspillage dans les assurances-médicaments privées au Canada. Estimés à plus de 5 milliards par année, cela représente la moitié des dépenses annuelles des prescriptions payées par les assureurs privés canadiens. Ces montants versés par les employeurs pourraient être mieux investis dans l’augmentation salariale et dans l’amélioration d’autres avantages sociaux, comme les couvertures dentaires. La plus grande partie des avantages sociaux d’un employé est l’assurance-médicaments. Contrairement aux régimes publics, les régimes privés sont notoirement inefficaces. Par exemple, ils couvrent souvent des médicaments plus chers qui ne donnent pas de meilleurs résultats pour la santé des assurés ou ils utilisent des intervalles de renouvellement sous-optimaux. Pourquoi les régimes privés sont si inefficaces? Il est possible d’apprendre beaucoup de la façon dont les entreprises gaspillent des montants faramineux sur les prescriptions de médicaments en analysant comment ils négocient ces régimes avec leurs employés et avec d’autres acteurs du monde de l’assurance. Notre nouvelle étude publiée dans le périodique Health Policy analyse comment les régimes d’assurances-médicaments sont négociés dans le secteur privé. En recourant à des entretiens avec des experts provenant des entreprises privées, des syndicats, des assureurs et des consultants en rémunération, notre étude nous a permis de comprendre l’expérience des interviewés et les bases de la négociation d’assurancesmédicaments dans le contexte d’entreprises syndiquées. Nos résultats démontrent que chaque acteur garde les autres dans l’ignorance quant aux régimes qu’ils négocient. Les employeurs qui connaissent les détails de leurs régimes d’assurances cachent des données sur les dépenses en médicaments de leurs employés pour ainsi conserver un avantage dans le processus de négociation. Les experts syndicaux savent que les régimes sont inefficaces, mais ils manquent souvent d’informations suffisantes sur les dépenses en médicaments pour convaincre les employés de la nécessité d’introduire des mesures de réduction de coûts. Les employeurs veulent que leur régime soit aussi compétitif que ceux offerts par les autres employeurs. Puisque la norme est de couvrir tout nouveau médicament à n’importe quel prix même si ceux-ci n’offrent aucune valeur thérapeutique additionnelle. Au final, il ressort que ces employeurs achètent des régimes « généreux » au lieu d’augmenter les avantages sociaux de leurs employés.
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L’entièreté des personnes interviewées s’accorde sur le besoin d’éduquer les employés et les employeurs. En effet, les intervenants interrogés (même les assureurs) s’entendent sur le fait que le coût exorbitant des médicaments est un défi de taille qui met en jeu la pérennité des régimes. Par exemple, les assureurs pourraient davantage sensibiliser leurs clients que la norme de couvrir « tout à tout prix » n’apporte souvent peu de valeur thérapeutique additionnelle. Une solution possible serait d’implanter de manière proactive des formulaires de gestion des médicaments plus contraignants. Cependant, les intérêts financiers des assureurs ne sont pas en phase avec ceux de leurs clients puisque des régimes d’assurancemédicaments inefficaces sont, malheureusement, très profitables pour les assureurs. Le problème central est que les assureurs sont rémunérés en fonction d’un pourcentage des dépenses totales en médicaments. Ainsi, plus la facture est élevée, plus ils sont payés — il s’agit donc d’un principe qui contrecarre les efforts pour identifier et éliminer le gaspillage dans les régimes. Parfois même, les compagnies pharmaceutiques ciblent la vente de certains produits uniquement pour les régimes privés d’assurance-médicaments parce que ceux-ci n’implantent aucune restriction. Selon les propos recueillis, puisqu’il existe peu de confiance et d’échanges d’informations entre les syndicats et les employeurs, ceux-ci resteront incapables de s’unir afin de demander des régimes efficaces qui permettraient d’assurer une bonne couverture en médicaments tout en jugulant le gaspillage. La majorité des intervenants interviewés seraient d’accord avec l’introduction d’un régime public universel d’assurance-médicaments et croient que nous devons aller dans cette direction. Il est actuellement temps de s’interroger sur les possibilités de reformer les régimes d’assurance-médicaments et d’éliminer le gaspillage dans les dépenses en médicaments. Il est peu plausible que le système change par lui-même. Identifier et éliminer le gaspillage dans les régimes privés permettrait d’augmenter les revenus disponibles des travailleurs tout en réduisant le coût de la main-d’œuvre, ce qui permettrait d’accroître significativement la compétitivité de nos entreprises. Sean O’Brady est étudiant au doctorat à l’École de relations industrielles de l’Université de Montréal. Alan Cassels est expert-conseiller chez EvidenceNetwork.ca et chercheur à la Faculty of Human and Social Development de l’Université de Victoria. Marc-André Gagnon est expert-conseil à EvidenceNetwork.ca et professeur adjoint à la School of Public Policy and Administration de l’Université Carleton.
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Is it finally time for a national drug plan? By Livio Di Matteo A new study in the Canadian Medical Association Journal with health economist Steve Morgan as lead author argues a national universal care drug program would not result in substantial tax increases. Indeed, such a plan reduces public and private spending on prescription drugs by $7.3 billion annually – or by 32 percent. According to Morgan et al., the private sector would save $8.2 billion (worst-case scenario $6.6 billion, best-case scenario $9.6 billion), whereas costs to government would increase by about $1.0 billion (worst-case scenario $5.4 billion net increase, best-case scenario $2.9 billion net savings). The authors suggest that any perceived barriers to implementation of a national universal care drug plan appear to be unjustified. Given that a national drug program is the forgotten child of Canadian public health care and was also advanced in the 2002 Romanow Report, the time may finally be ripe for such a plan. With the federal government close to balancing its budget and future surpluses possible under the current federal tax structure, new resources may come available without the need for tax increases. Also, aside from the fact that it is going to be a federal election year, another reason why now might be the appropriate time to consider implementing a national drug care program is that the costs of public drug spending have actually been declining making it even more attractive to introduce such a plan. According to expenditure numbers from the Canadian Institute for Health Information (CIHI), it is estimated that in 2014, provincial-territorial governments spent $10.4 billion on drugs. Despite past concerns of escalating public drug plan costs, the growth rate of this spending has declined remarkably. Pharmaceuticals used to be one of the fastest growing parts of health care spending in Canada. Between 2000 and 2005, the average annual nominal growth rate of provincialterritorial government drug expenditure was 11.7 percent. This dropped to an average 6.3 percent annually for the 2005 to 2010 period while the average since 2010 is approximately one percent annually. Indeed, the estimated growth rate for this spending in 2014 is actually negative. As a result, the share of drug expenditures in provincial-territorial health spending has been on a decline since peaking in 2006 at just over 8.4 percent and now stands at 7.4 percent. Per capita nominal drug spending by provincial and territorial governments has also been on the decline peaking in 2011 at approximately $300 per capita and estimated at $292 in 2014 – a 2.6 percent decline. The prospect of federal surpluses removing the need for any tax increases given the modest outlay projected by the Morgan et al., base case scenario, combined with the 296
demonstrated declining cost of drug spending suggests that this may indeed be an ideal time for a national drug plan. The caveats? First, basing decisions on best-case scenarios may be an overly optimistic way in which to implement public policy changes. It would be more fiscally prudent if any planning for a national drug plan made use of the worst case cost scenarios. Cumulative federal surpluses over the next five years have been estimated by TD Economics at as much as 56 billion dollars – an average surplus of 11.2 billion dollars annually. Even if we consider the impact of the recent slowdown on federal revenues, the worst-case scenario of 5.4 billion dollars in annual spending still appears quite affordable. Second, the recent decline in drug spending may be transitory. The savings have resulted from government regulation of drug prices, increased use of less-expensive generic drugs as well as slowdown in innovation of new pharmaceutical products. However, there are likely fewer savings from generics on the horizon that to date have led to spending declines in some medicines to treat common conditions such as cholesterol lowering drugs and anti-hypertensives. As well, while there are fewer new drugs coming onto the market, the average cost of these new drugs in specialty areas like cancer and rheumatoid arthritis is actually quite high. Despite these caveats, it seems the time is ripe to finally complete our universal system of public health care coverage by adding a national public drug plan. If anything, the aforementioned cautions should serve as guideposts to make sure a new national drug plan is not only effective but also designed in a fiscally sustainable manner. Livio Di Matteo is Professor of Economics at Lakehead University and an expert advisor with EvidenceNetwork.ca.
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Four things needed to make pharmacare work for Canadians By Steve Morgan A growing number of health professionals, patients, community groups and even politicians are calling for national pharmacare. But many Canadians likely wonder what pharmacare is and whether Canada is ready for it. Let’s start at the beginning. Affordable access to safe and properly prescribed prescription medicines is so critical to patient health that the World Health Organization has declared governments are obligated to ensure such access for all of their citizens. Unfortunately, Canada is the only developed country with a universal health care system that does not include universal coverage of prescription drugs. The negative consequences for our health and economic wellbeing are significant. Without universal coverage of prescription drugs, one in 10 Canadians cannot afford to fill the prescriptions their doctors prescribe. When patients don’t fill prescriptions they need, it hurts them and our economy because they end up needing more health care in the long run. But pharmacare is about more than just drug coverage. Insurance companies can do that. What national pharmacare must do is to ensure sustainable, equitable and affordable access to medicines that are safe and appropriately prescribed. In the Canadian context, this is a public responsibility. And, to be clear in this election year, it will require federal engagement – and not just in the form of cutting cheques for provincial pharmacare programs, but real leadership. More so than other aspects of health policy in Canada, the federal government has responsibility for matters that affect the safety, availability, use and cost of prescription drugs. Here are four things the federal government could do to make national pharmacare work for Canadians: 1. Commit to a clear and comprehensive pharmacare plan. Not a patchwork of private and public insurance and not income-based or “catastrophic” drug coverage. Research has consistently shown those systems don’t work well and are unnecessarily costly. Canada needs a universal, public, and comprehensive pharmacare system that will meaningfully integrate medicines into medicare in ways that lead to safer, more affordable use of medicines for all Canadians. We’ve known this since the 1960s. Time for a government to commit to make it their legacy for Canada. 2. Get on with the task of improving prescribing in Canada. About one in three seniors receives prescriptions known to pose health risks for older adults. The preventable 298
problems of overuse, underuse and misuse of medicines cause one in five hospitalizations in Canada. Cutting these problems in half would save Canadians billions. The federal government should fund the development and implementation of a national strategy to improve prescribing. Done in partnership with patients, professionals, and the provinces, this national strategy should aim to establish a culture of safety and appropriateness, to put an end to questionable drug marketing practices, and to put credible and usable information in the hands of patients, prescribers and policy makers. 3. Quit applying antiquated drug price regulations. We live in a world where most comparable health systems have abandoned the blunt instrument of price regulation in favour of more sophisticated tools of price and supply contract negotiation. When done well, negotiations with suppliers lead to more competitive prices and more assurances of a secure supply of the medicines the country needs. The federal government should take the $11-million spent enforcing antiquated price regulations and invest it in joint capacity for negotiating, monitoring and enforcing contracts on behalf of public drug plans and hospitals from coast to coast. This would not only level the playing field within Canada, it would also make Canada much stronger on the world market. 4. Sustainability of any system to encourage access to medicines depends to a great extent on timely and vigorous generic competition. Yet Canadian regulations create unnecessary barriers to generic drugs entering our market. The federal government should create a clearer, faster and fairer path to generic entry following required periods of market exclusivity for patented drugs. This would save Canadians millions – and wouldn’t cost the federal government a dime. If done right, a pharmacare plan would effectively integrate medicines into Canadian medicare and ensure that the Canadian principles of universal access to high quality, affordable health care do not end when doctors give patients prescriptions to fill. It is within reach with the right plan — and leadership. Steve Morgan is a Professor in the UBC School of Population and Public Health and an expert advisor with EvidenceNetwork.ca. See also our Podcast on the issue: Why Canada needs a national pharmacare program
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Are we medicalizing healthy people? Why the over-treatment of risk factors for heart attacks and strokes may do more harm than good By John Frank Modern medical practice is engaged in a battle, not for hearts and minds, but for the conversion of perfectly healthy people into patients, labelled “at high risk” of various diseases in the name of prevention. However, a substantial majority of persons so labelled will not benefit despite the significant costs of preventive interventions; some may be harmed. This “medicalization” of healthy persons, especially after mid-life, arises largely from ever lower cut-offs for treatment of risk factors for cardiovascular diseases (CVD) — heart attacks and strokes. Modest elevations of blood pressure and blood cholesterol, for example, typically cause no symptoms until they have been present for decades. Overtreatment of these risk factors can do more harm than good. Controversy on both sides of the Atlantic surrounds new thresholds for cholesterol treatment in the U.S. (2013) and the UK (2014), which recommend the statin family of drugs, indefinitely and daily, for one quarter to one-third of the healthy older-adult population. Canadian doctors often look to U.S. and UK guidelines for guidance. The specific concern is this: millions of additional persons with no symptoms will now be prescribed statins. But for many, their absolute risk of cardiovascular disease is quite low, and their first heart attack or stroke is many years to decades away. The new guidelines are not simple to communicate to patients – the UK evidence fills more than 500 pages. But here’s the bottom line: there is now a significantly lowered risk-threshold for starting statins (from 20 percent to 10 percent – the likelihood that a given healthy patient will have a heart attack or stroke in the next 10 years. In the U.S., that cut-off is even lower – at 7.5 percent). Let’s measure this another way: as the number of person-years of treatment required for each patient who clearly benefits — i.e., their heart disease or stroke is prevented. Persons just above the new risk-thresholds must undergo 300 (UK) to 400 (U.S.) personyears of treatment to prevent each heart disease or stroke. This compares with less than 200 person-years at the previous treatment threshold (itself hardly a small number). Statins do have impressive benefits compared to risks for people who have significantly higher CVD risk levels, and in persons who have had symptoms of heart attack or stroke. But this is not the case for everyone. What is driving these guideline changes? 300
The continuing fall in the price of powerful generic statins has converted statins prescribed for these lower risk thresholds into a competitive health economic investment. In other words, the new guidelines meet NICE (National Institute of Health and Care Excellence) criteria in the UK for “quality-adjusted years of life gained, per pound sterling spent.” The societal cost implications of the new guidelines are, however, breath-taking: £285 million cost annually to the NHS; much more in the USA. Guideline advocates claim the guidelines will reduce the rate of heart attacks and strokes in those treated by a third or more. Critics, however, point out that many patients, citing side-effects such as muscle discomfort, simply won’t continue taking statins long-term. Also, next to nothing is known about the long-term safety of the newer, high-potency statins. Large groups of patients on statins have only been followed-up for 10-15 years, and many of them were on older, less potent statins. Worrisomely, even this limited follow-up has recently found one new case of Type 2 diabetes per 700 person-years of statin treatment. But if it has taken epidemiologists more than two decades to discover the statin/Type 2 diabetes link, what other subtle and delayed side-effects of statin use are we not yet aware of? Discovery of just one additional side-effect of similar seriousness and frequency would virtually wipe out the net benefits at the new thresholds for statins. Some physicians and researchers are asking: “Is this really how we want to spend our scarce health care resources?” In terms of preventing cardiovascular disease specifically, why not work harder on promoting non-smoking, healthy diet and physical activity instead? These lifestyle risk-factors are reversible without drugs, and still constitute the fundamental “upstream” causes of heart disease. Lifestyle changes population-wide would also yield spin-off benefits in preventing certain cancers and other chronic diseases not affected by statins. This is where the controversy currently sits. Many physicians are reluctant to follow the new guidance. In the interim, the increased complexity of such closely balanced risks and benefits will require clinicians to more skilfully engage patients’ personal values and preferences before starting statins. John Frank is an expert advisor with EvidenceNetwork.ca and Chair, Public Health Research and Policy, Medicine and Veterinary Medicine at the University of Edinburgh. His book, Prevention: A (Very) Critical View, will be published by Oxford University Press in late 2015.
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Why I decided to get the flu vaccine for myself and my children New flu vaccine options for children and those afraid of needles By S. Michelle Driedger It’s time again for the familiar “Get the shot, not the flu” campaign. It comes every October and we are reminded into the spring that it still isn’t too late to get the flu vaccine for those who haven’t taken advantage of the free campaign. I regularly get the flu shot and I vaccinate my children too. But every so often, I question these decisions, particularly when I come across words that are new to me, like “live attenuated vaccine” or a new vaccine delivery type, such as nasal mist instead of the usual needle. This happened to me this week while deciding whether to get the annual flu shot or not. Vaccination decisions are a touchy subject for many people. In Canada, our seasonal influenza vaccine is typically delivered in an inactivated, or dead, trivalent form, which includes the three flu strains that scientists believe will be in highest circulation this flu season. It is known as the inactivated seasonal influenza vaccine and is most commonly administered by needle. But what most people may be less familiar with is that Canada also offers a nasal mist vaccine that contains a live attenuated set of the strains of viruses believed to be circulating this flu season. “Live attenuated” viruses are a weakened form of a live virus. However, even though the virus is live, it doesn’t give you the flu because of its weakened state. So what kind of vaccine is best? Well, that depends. There are important differences to note. First, a nasal mist vaccine involves inhaling the vaccine through the nose instead of receiving a needle injection in the muscles of your upper arm. For people who are afraid of needles (including many children), this might be a preferred option. Secondly, this “new” vaccine option is actually not so new after all. The nasal vaccine has only been available in Canada since 2010, but it has been available in the United States for over 10 years, which means that the data detailing its safety and effectiveness is based on a longer timeframe and at a population level. In fact, groups of scientific experts in Canada and the United States argue that there is growing evidence that the nasal mist live attenuated vaccine might be even more protective in children than the traditional needle. The National Advisory Committee on Immunizations, which advises the Public Health Agency of Canada, has recommended the live attenuated influenza vaccine since 2011 302
for healthy children between two and 17 years of age. In the United States, the Centers for Disease Control recommend that healthy children aged two to eight years get the nasal spray flu vaccine. Healthy is defined as children who do not have underlying medical conditions that would put them at higher risk from influenza complications. Evidence suggests that the live attenuated vaccine is better for kids and the inactivated vaccine is better for adults. But public health professionals recommend that either vaccine is good for both kids and adults if the choice is not available to you. What about associated harms and risks? With a needle injection, the common list of side effects include a sore arm, mild fever and achiness – common, harmless reactions. With a nasal mist, the common list of side effects is longer: a runny nose, headache, sore throat and cough (in both adults and children), with wheezing, and occasionally vomiting, fever and muscle aches (reported in children only). Nonetheless, the bottom line: the benefits of seasonal flu immunization outweigh the harms. But no vaccine decision is completely risk-free. A live attenuated vaccine isn’t recommended for everyone, for example. Your provincial health department website as well as any flu clinic will have detailed information about who should not receive the live attenuated vaccine which typically includes people with wheezing or asthma episodes (within last 12 months), those on aspirin therapy, people with egg allergies, pregnant women, people with compromised immune systems, those who’ve had allergic reaction to allergies in the past, and those who fall outside the age range. In the end, the decision to get a vaccine is up to the individual. An adult needs to decide if getting the vaccine is worth the effort relative to the risk of time off work due to getting the flu or – and perhaps most importantly – the risk of making someone else very sick by passing the flu on to them. For some of our youngest children (particularly under two years of age) and our oldest adults, getting the flu can be deadly. So, after worrying, searching information, comparing different websites, talking to smarter people than me who study this stuff and then combining all that together — both my kids and I were immunized against seasonal flu. It was the informed thing to do. S. Michelle Driedger is an expert advisor with EvidenceNetwork.ca and Professor and Canada Research Chair in Environment and Health Risk Communication in the Department of Community Health Sciences, in the College of Medicine at the Faculty of Health Sciences, University of Manitoba.
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Qu’est-ce qui m’a incitée à nous faire vacciner, moi et mes enfants, contre la grippe De nouvelles options pour les enfants et les gens qui craignent les aiguilles Par S. Michelle Driedger La campagne de vaccination contre la grippe est de retour. Elle débute chaque mois d’octobre et on nous rappelle jusqu’au printemps qu’il est toujours temps de se faire vacciner, même après la période de vaccination sans frais. La plupart du temps, je me fais vacciner, ainsi que mes enfants. Mais parfois, je m’interroge, surtout lorsque je vois des appellations avec lesquelles je ne suis pas familière, comme « vaccin vivant atténué », ou lorsque je prends connaissance de nouvelles méthodes de vaccination, comme la vaporisation intranasale au lieu de l’injection traditionnelle. C’est ce que j’ai vécu la semaine dernière, alors que je me demandais si je me ferait vacciner cette année. Pour plusieurs personnes, la vaccination est un sujet épineux. Au Canada, notre vaccin saisonnier contre la grippe est généralement administré sous une forme trivalente inactivée, avec agents infectieux morts. Ce type de vaccin comporte trois souches de grippe qui, selon l’avis des scientifiques, seront prédominantes au cours de la saison grippale qui s’amorce. Le vaccin est connu sous l’appellation de « vaccin inactivé contre la grippe saisonnière » et est généralement administré par injection. Cependant, la plupart des gens ne savent pas qu’au Canada, on offre aussi un vaccin par vaporisation intranasale. Il contient un ensemble de souches vivantes atténuées des virus qui, selon les prévisions, circuleront au cours de la saison grippale. Les virus « vivants atténués » sont certes vivants mais dans un état atténué, et parce qu’ils sont atténués, ils n’entraînent pas de grippe. Alors, quel type de vaccin convient le mieux? Cela dépend de plusieurs facteurs. Il existe des différences notables. Premièrement, la vaccination par vaporisation intranasale se fait par inhalation nasale au lieu d’une injection intramusculaire administrée dans la partie supérieure du bras. Pour ceux qui craignent les aiguilles (dont plusieurs enfants), cela peut s’avérer une option intéressante. Deuxièmement, cette « nouvelle » option de vaccination n’est pas vraiment nouvelle. Le vaccin intranasal n’est offert au Canada que depuis 2010, mais il est administré aux ÉtatsUnis depuis plus de 10 ans. Les données sur l’innocuité et l’efficacité du vaccin sont donc fondées sur une période plus longue et sur une population plus grande. En fait, des groupes d’experts scientifiques au Canada et aux États-Unis estiment qu’il existe de plus en plus de preuves à l’effet que le vaccin vivant atténué administré par voie
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intranasale offre chez les enfants une plus grande protection, comparativement à l’injection traditionnelle. Le Comité consultatif national de l’immunisation, qui conseille l’Agence de la santé publique du Canada, a recommandé l’utilisation du vaccin vivant atténué contre l’influenza depuis 2011 chez les enfants en bonne santé et âgés de deux à 17 ans. Aux États-Unis, le Centers for Disease Control [Centre de contrôle des maladies] recommande que les enfants en bonne santé et âgés de deux à huit ans soient vaccinés contre la grippe par vaporisation intranasale. Le terme « enfants en bonne santé » est défini comme étant des enfants n’ayant pas d’antécédents médicaux qui augmenteraient le risque de développer des complications liés à l’influenza. Certaines données probantes suggèrent que le vaccin vivant atténué convient mieux aux enfants et que le vaccin inactivé convient mieux aux adultes. Or si vous n’avez pas le choix, les responsables de la santé publique affirment que l’un ou l’autre vaccin convient aux deux populations. Quels sont les risques associés? Dans le cas d’une vaccination par injection, les effets secondaires sont, entre autres : une douleur au bras, une légère fièvre et des douleurs musculaires. Ce sont des réactions courantes et bénignes. Pour ce qui est de la vaccination par vaporisation intranasale, les effets secondaires courants sont plus nombreux : écoulement nasal, mal de tête, mal de gorge et toux (chez les adultes et chez les enfants), respiration sifflante, et parfois, vomissement, fièvre et douleurs musculaires (observés chez les enfants seulement). Malgré ces effets, le bilan est positif, puisque les bienfaits de la vaccination contre la grippe saisonnière dépassent les méfaits. Cependant, toute forme de vaccination comporte certains risques. Par exemple, le vaccin vivant atténué ne convient pas à tous. Le site Web du ministère de la Santé et les cliniques de vaccination contre la grippe donne des consignes détaillées précisant quelles sont les personnes chez qui le vaccin vivant atténué est contre-indiqué. Ceci inclut les personnes qui ont eu des épisodes de respiration sifflante et d’asthme (au cours des 12 derniers mois), les personnes traitées avec de l’aspirine, les personnes allergiques aux œufs, les femmes enceintes, les personnes avec un système immunitaire affaibli, les personnes qui ont déjà eu des réactions allergiques et les personnes hors de la catégorie d’âge recommandée. Pour conclure, la décision de se faire vacciner ou non revient à l’individu. Un adulte doit décider si il veut se faire vacciner ou risquer de devoir prendre un congé de maladie parce qu’il a contracté la grippe et, ainsi éviter de contaminer les personnes de son entourage. La grippe peut s’avérer mortelle même chez les très jeunes enfants (notamment ceux de moins de deux ans) et les aînés. Donc, après avoir fait des recherches et comparé divers sites Web, après avoir parlé avec des gens qui en savent bien plus que moi sur le sujet et combiné toutes ces données, je me 305
suis fait vacciner et j’ai fait vacciner mes enfants, sans inquiétude. Ce fut une décision mûrement réfléchie. S. Michelle Driedger agit comme conseillère experte auprès d’EvidenceNetwork.ca. Elle est professeure agrégée et titulaire de la Chaire de recherche du Canada sur la communication des risques environnementaux et des risques pour la santé, au Département des sciences de la santé communautaire du Collège de médecine, Faculté des sciences de la santé, à l’Université du Manitoba.
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Saskatchewan has the highest rates of HIV in the country Can we create an HIV-free generation? By Julio Montaner and Ryan Meili Canadians are rightly proud of the universal coverage provided by our national health care system. Sadly, there are gaps in access with very grave consequences. In regions across the country, care and treatment is failing to reach those living with HIV. Saskatchewan is among a number of regions in Canada, such as Manitoba and even our nation’s capital, currently experiencing alarming spikes in the spread of HIV. In 2009, the province saw rates of new HIV cases comparable to those in Nigeria. Numbers have declined since this peak, partly due to Saskatchewan’s four-year HIV strategy (concluded in 2014) that increased testing, treatment and support for people living with HIV and AIDS. Unfortunately, rates of HIV in Saskatchewan continue to be the highest in the country. Incidence rates in 2012 were at 17 cases per 100,000. By comparison, the 2012 rates of HIV-positive test reports for BC, Ontario, and Quebec were 5.1, 6.2, and 5.6, respectively. Saskatchewan also continues to have high levels of HIV-related illness and death. The province is looking for solutions. SHARE, the Saskatchewan HIV/AIDS Research Endeavour, is working to establish a research agenda and learn from successes in other provinces. They are turning to the trailblazing work of the BC Centre for Excellence in HIV/AIDS for answers. BC has an impressive track record for slowing the spread of HIV/AIDs in the province. Indeed, between 1994 and 2013, the number of AIDS cases in BC went from 696 to 84, or an 88 percent decrease. AIDS-related deaths went from 261 to 44, or an 83 percent decrease. And deaths attributed to an AIDS-defining illness decreased from 89 percent to 20 percent, a 77 percent decrease. Over the same period, mother-to-child transmission of HIV has been virtually eliminated, and overall HIV transmission has decreased by two thirds. How did they achieve this? The BC Centre created a Treatment as Prevention strategy which provides widespread access to HIV testing, care, support and treatment. Keys to the strategy’s success have been political commitment, programmatic focus, ongoing innovation coupled with monitoring and evaluation, appropriate resourcing and free services (including fully free antiretroviral therapy (ART)). And now the Treatment as Prevention strategy, prioritizing full universal access to free HIV treatment and care, is gaining traction globally. Indeed, as the 2015 Millennium Development Goals come to fruition, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has formally proposed a new and ambitious 90-90-90 target for 2020. The new target calls for 90 percent of people living with HIV worldwide to be diagnosed, 90 percent
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of people diagnosed with HIV to be on ART, and 90 percent of people receiving ART to have sustained viral suppression by 2020. Meeting the 90-90-90 target would maximize the effectiveness of existing tools in order to virtually eliminate progression to AIDS, premature death and HIV transmission by 2020, and thereby transform the HIV/AIDS pandemic into a low level sporadic endemic by 2030. The 90-90-90 target has already been formally endorsed by China, parts of the U.S., Brazil, South Africa, Argentina, Panama, France and Switzerland among a growing number of countries. Canada, unfortunately, has yet to embrace the target, which means we’re missing an important opportunity for the control of HIV and AIDS across the country, particularly in hard-hit regions like Saskatchewan. Addressing the social determinants of health – such as housing, employment, poverty, and access to health care – is essential to HIV prevention and care. National Chief Perry Bellegarde of the Assembly of First Nations has specifically called for addressing poverty and other upstream factors among Indigenous people in Saskatchewan. These groups are among those hardest hit by the province’s HIV epidemic and their input is essential to charting an effective course of response. In BC, a concerted effort to reach the especially high-risk and vulnerable population of injection drug users – coupled with harm reduction programs – led to the virtual elimination of the spread of HIV among this group. This extraordinary outcome could be replicated in Saskatchewan, and elsewhere, with the necessary infrastructure and support. A Treatment as Prevention strategy also makes good economic sense. It has been estimated that acute care costs from HIV in Saskatchewan alone are $40 million per year. Adopting a targeted strategy would alleviate these costs. By 2017, Treatment as Prevention in BC will result in lower drug costs for treating people with HIV and AIDS, with savings of up to $48 million by 2035. The sooner provinces make the necessary investments to reach the 90-90-90 target, the sooner they will save money, and lives. Now is the time for Saskatchewan to make the investments in HIV care that will pay dividends in reduced health care costs, and healthier people. An AIDS and HIV-free generation is possible, but only if we secure the political will now to take full advantage of Canadian leadership. Julio Montaner is Director, British Columbia Centre for Excellence in HIV/AIDS (BCCfE). Ryan Meili is an expert advisor with EvidenceNetwork.ca, a practicing medical doctor and founder of Upstream: Institute for A Healthy Society. See also our Podcast on the issue: Saskatchewan has the highest rates of HIV in Canada. Can we create an AIDS-free generation?
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We have built a sickness care system rather than a health system We have designed that system for the convenience of practitioners, not patients Convocation speech delivered to graduating MDs at the University of Manitoba on the receipt of an honorary doctorate. By André Picard Mr. Chancellor, Mr. President, distinguished guests, soon-to-be MDs and their deeply indebted family members. I’m touched and humbled to receive an honorary degree from the University of Manitoba. Thank you for letting me share this special moment with you. I’m not a doctor. I never will be. I’m a lowly journalist. I tell stories. For almost 30 years I’ve tried to help Canadians understand their health system and their medical care. In that time, I’ve seen tremendous advances in medicine and I’ve met, quite literally, thousands of health professionals, from students to Nobel Prize winners — and patients, from those with rare genetic mutations to those with everyday ailments, from those cured miraculously to those who died needlessly. Today, I’d like to take few minutes to share some of what I’ve learned from telling their stories. One of the greatest privileges in our society is to have the letters M.D. after your name. Those two letters confer great power. And with that power comes great responsibility, to quote Voltaire — or Spiderman, depending on your literary predilections. Shortly, you will be taking the Hippocratic oath. You’ve probably all heard that it says: “First do no harm.” It doesn’t actually – that’s just bad media reporting. But it does say a lot of important things. I think the line that matters most in the oath is this: “Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient.” Sadly, too many physicians fail to honor that part of the pledge. We have built a sickness care system rather than a health system. We have designed that system for the convenience of practitioners, not patients. Modern medicine has become so specialized that many physicians treat specific syndromes and body parts, and the patient herself gets lost in the process. We have filled 309
our temples of medicine with such bedazzling hi-tech tools that we’ve forgotten that we should treat people where they live. In our desire to cure, we over-treat. We fail too often to say the three most important words in medicine: “I don’t know.” We see death as a failure, instead of aspiring to make patients’ comfortable and at peace at end-of-life. In our unrelenting quest for efficiency and measurement, we too often lose sight of what really matters. The patient. What does your patient want? What are his or her goals? Those are the questions that must guide your practice. For some of your patients, the goal is to repair their acute woes, to help them live long. But most of your patients will be older, and have a number of chronic conditions and be nearing the end-of-life. Their goals are different. They’re not going to be cured. You have to focus on their quality of life. They want to be at home. They don’t want to fall. They don’t want to be in pain. They don’t want to be a burden. They don’t want to be alone. They don’t expect miracles – but they would like respect. They don’t fear dying. They fear losing their autonomy and their dignity. They don’t care about your metrics, or your age-adjusted mortality rates, or your fancy new genomic test. They want to be listened to, and heard. We hear a lot these days about personalized medicine, about drugs and treatments that can be tailored to specific genomic and epigenetic markers. But you know what people really long for: personal medicine, not personalized medicine. They crave a human connection. Not just care, but caring. The very best medicine you can offer your patients is a listening ear. The very best treatment you can offer them is a compassionate heart. Now you may be sitting there thinking, this is all feel-good nonsense. It’s not. The more sophisticated and complex medicine becomes, the more the basics matter. What did you learn in medical school? Anatomy, biochemistry, genomics, countless mnemonics to help you remember bits of knowledge; you know how to deliver babies and treat cancer and diabetes and depression and asthma, take out people’s appendix and do MRIs and PCIs, and countless other things.
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What you’re going to learn now, in the real world, is that physical woes are the least of patients’ worries. Their health problems aren’t strictly caused by mutating cells, opportunistic pathogens and poor genes, but by poverty, lack of education, poor housing, stress and social isolation. You’re going to, sooner or later, learn humility. And, the earlier you do, the better the doctor you’re going to be. In this, the Internet age, we are drowning in information, but starving for wisdom. I urge you, as you forge long, successful and prosperous careers, to not just be smart, but be wise. In every interaction you have, embrace the ancient wisdom of Hippocrates: “Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient.” A version of this speech was delivered May 14, 2015 to the graduating class at the University of Manitoba. André Picard is a health reporter and columnist at The Globe and Mail, where he has been a staff writer since 1987. He is also the author of three bestselling books. See also a video of André Picard’s speech
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Un système de santé orienté vers la maladie plutôt que la santé et conçu en fonction des médecins et non des patients Discours prononcé devant les nouveaux diplômés de la Faculté de médecine de l’Université du Manitoba à l’occasion de la réception d’un doctorat honorifique. Par André Picard Monsieur le chancelier, Monsieur le président, distingués invités, chers finissants sur le point d’embrasser la carrière de médecin, et chers parents qui êtes désormais fortement endettés. Je suis touché de l’honneur que me fait aujourd’hui l’Université du Manitoba en me décernant ce doctorat honorifique. Merci de m’avoir invité à partager ce moment exceptionnel avec vous. Je ne suis pas médecin. Ni ne le serai jamais. Je ne suis qu’un humble journaliste. Mon métier consiste à raconter des histoires. Depuis près de 30 ans, je me suis efforcé de susciter chez mes concitoyens une réflexion sur leur système de santé et de prestation des soins. Durant cette période, j’ai été témoin de progrès fulgurants en médecine. J’ai rencontré, littéralement, des milliers de professionnels de la santé, parmi lesquels des étudiants et des récipiendaires du prix Nobel, ainsi qu’une multitude de patients : des malades atteints de rares mutations génétiques; des malades souffrant de maladies courantes; des malades qui ont connu une guérison miraculeuse; et des malades qui sont décédés inutilement. Aujourd’hui, j’aimerais prendre quelques minutes pour vous transmettre une part de ce que j’ai appris en racontant leurs histoires. Parmi les plus grands privilèges accordés par notre société, il y a celui qui autorise quelqu’un à inscrire les initiales « M.D. » après son nom. Ces deux petites lettres confèrent un grand pouvoir. Et ce pouvoir s’accompagne d’une grande responsabilité, pour citer Voltaire – ou bien Spiderman, selon vos prédilections en matière de littérature. Bientôt, vous allez prêter le serment d’Hippocrate. Vous avez probablement tous entendu dire qu’il renferme la phrase : « Je m’abstiendrai de tout mal et de toute injustice ». Mais ce n’est pas le cas – ce n’est qu’une fausse information relayée par les médias. Ce serment renferme néanmoins un grand nombre de principes essentiels. À mon avis, le plus important de tous est celui-ci : « Dans quelque maison que je rentre, j’y entrerai pour l’utilité des malades. » Malheureusement, trop de médecins ne respectent pas cet engagement. Nous avons bâti un système de soins orienté vers la maladie plutôt que la santé. Nous l’avons conçu en fonction des médecins et non des patients. 312
La médecine moderne est devenue si spécialisée que bon nombre de médecins sont appelés à traiter des parties du corps et des syndromes bien précis, tant et si bien que les patientes et patients ne s’y retrouvent plus. Nous avons rempli nos temples de la médecine d’appareils de haute technologie si éblouissants que nous avons oublié qu’il faudrait soigner les gens là où ils vivent. Dans notre désir de guérir les malades, nous recourons au surtraitement. Trop souvent, nous oublions que les trois mots les plus importants en médecine sont : « Je ne sais pas. » Nous considérons la mort comme un échec, au lieu d’aspirer à ce que les patients en fin de vie soient confortables et en paix. Dans notre quête inlassable d’efficacité et de mesures, nous perdons trop souvent de vue l’essentiel : les patientes et les patients. Quels sont leurs désirs? Quels sont leurs buts? Ce sont là les questions qui doivent guider l’exercice de votre métier. Dans certains cas, il s’agira de guérir les maux qu’ils endurent, de les aider à passer à autre chose. Mais la plupart seront des aînés souffrant de maladies chroniques, dont la fin de vie approche. Leurs objectifs sont différents. Ils ne vont pas guérir. C’est à leur qualité de vie qu’il faudra plutôt accorder la priorité. Les personnes âgées veulent rester chez elles. Elles craignent de tomber. Elles ne veulent pas souffrir. Ni être un fardeau. Elles craignent la solitude. Elles ne s’attendent pas à des miracles – mais elles aimeraient bien qu’on les respecte. Elles n’ont pas peur de la mort. Elles craignent de perdre leur autonomie et leur dignité. Elles se moquent bien de votre collecte de données, des taux de mortalité ajustés selon l’âge ou de vos tests de génomique sophistiqués. Tout ce qu’elles veulent, c’est qu’on les écoute et qu’on entende ce qu’elles ont à dire. Ces jours-ci, on entend beaucoup parler de médecine personnalisée, de médicaments et de traitements taillés sur mesure, en fonction de marqueurs génomiques et épigénétiques précis. Mais vous savez de quoi rêvent les patients? D’une médecine proche des gens, pas d’une médecine personnalisée de ce type. Les patients ont soif de rapport humain. Pas seulement de soins, mais aussi de bienveillance. Le meilleur remède que vous puissiez leur offrir, c’est une écoute attentive. Le meilleur traitement que vous puissiez leur donner, c’est un cœur compatissant.
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Vous dites peut-être en écoutant mes propos : ce sont que des paroles et de nobles sentiments. Vous vous trompez. Plus la médecine se spécialise et se complexifie, plus il faut revenir à l’essentiel. Que vous a-t-on enseigné à l’école de médecine? Des notions d’anatomie, de biochimie, de génomique; une foule de trucs mnémoniques pour mémoriser des parcelles d’information. Vous avez appris à faciliter des accouchements, à traiter le cancer, le diabète, la dépression et l’asthme, à enlever des appendices, à pratiquer des IRM et des SMT et quantité d’autres interventions. À compter d’aujourd’hui, vous allez vous rendre compte que les maux dont ils souffrent sont le dernier des soucis des patients. Que leurs problèmes de santé ne sont pas simplement attribuables à des cellules en mutation, à des pathogènes opportunistes ou à de mauvais gènes, mais aussi à la pauvreté, au manque d’éducation, à des logements inadéquats, au stress et à l’isolement social. Tôt ou tard, vous allez apprendre à faire preuve d’humilité. Plus vite vous le ferez, et plus vous serez de bons médecins. À l’ère d’Internet, nous croulons sous l’information, mais nous avons faim de sagesse. Je vous invite donc, tout au long de la carrière longue et prospère qui vous attend, à ne pas user seulement d’intelligence, mais aussi de jugement. Dans chacune de vos interactions, incarnez ce précepte ancien du serment d’Hippocrate : « Dans quelque maison que je rentre, j’y entrerai pour l’utilité des malades. » Une version de ce discours a été livrée le 14 mai 2015 devant les finissants de la Faculté de médecine de l’Université du Manitoba. André Picard est journaliste et chroniqueur sur les enjeux de santé au quotidien The Globe and Mail depuis 1987. Il a également publié quatres ouvrages à succès.
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Chapter 5: Mental Health
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Older adults living with mental illness need specialized housing and supports to avoid homelessness New Calgary report warns more homeless seniors a real possibility By Pat Cashion and Lee Tunstall Older adults living with mental illness often face a double stigma in our society – both from aging and from mental illness. They are some of the most invisible and most vulnerable individuals in our communities, and we need to find better ways to support them. “Sarah” was well-known to many of the senior-serving non-profit organizations in Calgary. Her behaviour became erratic due to a psychotic or schizophrenic episode, and she was evicted from her apartment. From here, her options were limited: find alternate housing (difficult in a low vacancy environment); stay in a motel (expensive); or go to an emergency shelter (often over capacity). With no safe, supportive housing available, her options were extremely limited and homelessness became a real possibility. Last week, the Older Adult Service Providers of Calgary released a report warning that more older adults could be at risk of homelessness if affordable seniors’ housing providers and mental health service providers don’t work together to tackle the growing problem of older adults living with mental illness. The report shows a considerable knowledge gap between these two types of providers and the lack of a coordinated effort. As with the general population, 20 percent of older adults live with a mental health issue. In Calgary alone, that equates to over 21,000 older adults, with between 1,000 and 2,000 living with severe and persistent psychotic disorders, including schizophrenia and delusional disorder. These figures do not take into account individuals between 45 and 65 who have lived a higher-risk lifestyle and been intermittently homeless. Such individuals age more quickly than the general population, and often present as “functionally geriatric” well before the age of 65. One of the most surprising findings in the report is the lack of appropriate housing for older adults living with mental illness in Calgary, in contrast to Edmonton where such specific supports are available. There are currently no housing communities in Calgary that are solely dedicated to seniors living with mental illnesses, notable after the closure of the 38-suite Sunnyhill Wellness Centre in 2011 which was dedicated to older adults, primarily with mental health diagnoses. There are some communities in the city that provide limited services to this population, such as Peter Coyle Place and Bridgeland Manor which provide housing for hard-to house and formerly homeless seniors.
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In Edmonton, older adults living with mental illness have access to numerous dedicated communities, including the 150-bed Villa Caritas, which alone eclipses Calgary’s entire capacity. Another 178 dedicated beds are also available in Edmonton. This discrepancy between the two cities is troubling and needs to be addressed by the provincial government. Although a continuing care facility was recently announced for Calgary for those who need specialized care outside of a hospital setting, it is not senior-specific. More needs to be done – and soon. In addition to housing supports, the report also found that there are several effective practices that could be put in place to help this population. One of the most promising is known as the ‘behavioural supports framework’ which focuses on aggression, wandering, physical resistance, agitation and other behaviours of seniors with mental illness, dementia or addiction. The framework focuses on adapting the environment or care to satisfy the individual’s needs to prevent or minimize the behaviour, and also addresses how this behaviour affects family and caregivers As the population of older adults is set to double in Alberta over the next 25 years, cases of older adults living with severe mental illness will only increase. More housing and support services dedicated to this population are needed — in Calgary in particular — if we are to avoid an increased number of homeless seniors. Pat Cashion is the outgoing Chair of the Older Adult Service Providers of Calgary. Dr. Lee Tunstall is co-author of the report and an advisor with EvidenceNetwork.ca, and an adjunct assistant professor in the Faculty of Arts at the University of Calgary.
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Five ways we can reduce suicides in Canada Why a suicide prevention strategy needs to include injury prevention By Jitender Sareen and Cara Katz Despite recent headlines, Canadian rates of suicide and attempted suicide have remained largely unchanged over the last several decades (11 per 100,000). What has changed is that we’ve seen increasing rates of suicide in the Canadian military recently, after stable rates for decades. With over 40,000 Canadian soldiers deployed to the mission in Afghanistan, there has been an understandable concern about mental health problems and suicides among military personnel and veterans. Both the Minister of Defense and Minister of Veterans Affairs have rightly made suicide prevention a top priority. The problem of suicide is not limited to the military in Canada; indigenous populations, especially in northern remote communities, have high rates of suicide. We need a unified approach across provincial and federal sectors to reduce suicides in the military, among veterans and civilians. Here are five promising evidence-based strategies for suicide prevention. 1. Implement a National Deliberate Self-Harm Registry The single most important predictor of future suicide attempts is a history of previous self-harm behavior. It is important to develop a confidential, administrative national registry of people with self-harm behavior, similar to the national registry created in Ireland, in order to record accurate data and to target and measure our evidence-based approaches to reduce the risk of future attempts. 2. Invest in anti-suicidal psychological treatment For patients presenting with suicide attempts, current practices and programs focus on treating the underlying mental health problem and/or addiction. Recent work is challenging this practice by showing that there is also a need for psychological interventions that directly address suicidal behavior. Two such treatments have shown to reduce suicide attempts among people with a history of self-harm behavior – cognitive behavior therapy and dialectical behavior therapy. Both types of therapy focus on understanding the causes of suicidal thoughts, improving coping skills in managing distressing emotions and developing careful plans to reduce future attempts. Strong investments nationally are required to increase the availability of these therapies for people with a history of self-harm behavior. 3. Reducing access to lethal means
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This approach has the greatest evidence for suicide prevention worldwide. Suicide can often be an impulsive act. Access to firearms is a risk factor for suicide and is a factor in half of the completed suicides in the United States. In the Swiss military, when access to guns was reduced, almost 80 percent of people were deterred from suicide. Although firearm related deaths are less common in Canada, 20 percent of male suicides in Canada are related to firearms. In the UK, limiting pack sizes of Tylenol per bottle was also shown to reduce suicide. In Canada, prescription medications, especially opioids, anti-anxiety and anti-depressant medications are common causes of both intentional and unintentional deaths. Limiting access to large quantities of prescription and over-the-counter medications for people with a history of self-harm may reduce suicides and accidental deaths. 4. Accidental deaths and undetermined deaths need to be tracked with suicide deaths Accidental or undetermined deaths look like suicides. We know that suicide rates around the world are widely underestimated, perhaps by as much as 30 percent or more. This is because it is often difficult to determine the nature of the death, and specifically whether it is definitively a suicide or an accident. Often, the case can be unclear, and the coroner classifies the death as undetermined. There is evidence to indicate that some mechanisms of suicide are more likely to lead to the undetermined classification. In fact, in the UK, injury deaths of undetermined intent are routinely included in their suicide statistics for this reason. 5. Suicide prevention strategy should include injury prevention We have learned that individuals dying by either suicide or by accident share many similar risk factors including male sex, younger age, being unmarried, lower education and income, impulsivity, mental health problems and addictions. Generally speaking, prevention efforts for accidental injuries and suicide are distinct. But given the shared vulnerability of these populations along with the finding that many of the accidental or undetermined deaths may in fact be misclassified suicide deaths, a more broad approach to suicide prevention must include injury prevention. If we really want to change the rates of suicide in Canada, we need to look at areas of medicine that have been successful in reducing mortality. For example, HIV disease prevention and cancer prevention have created national registries and invested heavily in innovative prevention programs that specifically target these deadly diseases. We need a concerted national effort that uses evidence-based strategies to specifically target suicidal behavior. Jitender Sareen is an expert advisor with EvidenceNetwork.ca, professor of psychiatry at the University of Manitoba and team leader of the Manitoba Population Mental Health Research Group.
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Cara Katz is a junior researcher with the Manitoba Population Mental Health Research Group and a psychiatry resident at the University of Manitoba.
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Cinq propositions pour réduire le taux de suicide au Canada Toute stratégie devra tenir compte de la prévention des blessures Par Jitender Sareen et Cara Katz En dépit des grands titres récents sur le sujet, les taux de suicide et de tentative de suicide n’ont pas beaucoup bougé au Canada depuis plusieurs dizaines d’années (11 sur 100 000). Ce qui a changé, c’est le taux de suicide chez les militaires, qui connaît une augmentation après être resté stable durant des décennies. Quarante-mille soldats ont participé à la mission canadienne en Afghanistan. D’où l’inquiétude légitime que suscitent les problèmes de santé mentale et les suicides rapportés chez les forces armées et les vétérans. D’ailleurs, le ministre de la Défense que le ministre des Anciens Combattants a fait de la prévention du suicide une grande priorité, et avec raison. Le problème ne concerne pas que l’armée; les populations autochtones affichent elles aussi des taux de suicide élevés, en particulier celles des communautés nordiques éloignées. La réduction du taux de suicide chez les militaires, les anciens combattants et la population civile nécessitera l’action concertée de tous les secteurs, tant au niveau fédéral que provincial. Voici cinq stratégies prometteuses en matière de prévention du suicide qui sont fondées sur des données probantes. 1. Établir un registre national des personnes au comportement autodestructeur Les comportements autodestructeurs constituent le plus important prédicteur d’une éventuelle tentative de suicide. C’est pourquoi il est essentiel d’établir un registre national confidentiel des personnes qui les adoptent, semblable à celui que l’Irlande a mis en place. Ce registre aurait pour but de colliger des données précises et d’évaluer les méthodes probantes mises en œuvre pour réduire le risque de tentative future. 2. Investir dans les thérapies anti-suicide Actuellement, les méthodes et les programmes destinés aux personnes ayant des tendances suicidaires visent à traiter les problèmes sous-jacents relatifs à la santé mentale ou à la toxicomanie. Or des travaux récents ont remis cette idée en question et démontré la nécessité d’une intervention psychologique directement axée sur le comportement suicidaire. D’après les observations, deux approches – la thérapie cognitivocomportementale et la thérapie comportementale dialectale – ont permis de réduire les tentatives de suicide chez les personnes qui ont des antécédents de comportement autodestructeur. Ces deux types de thérapie visent à analyser la cause des pensées suicidaires, à améliorer les mécanismes d’adaptation face au sentiment de détresse et à mettre en œuvre des plans 321
soigneusement conçus pour réduire le risque de tentative éventuelle. Pour améliorer l’accès à ces thérapies, il faudra des investissements importants à l’échelle nationale. 3. Réduire l’accès aux moyens létaux C’est l’approche qui a donné les résultats les plus probants en matière de prévention du suicide à l’échelle mondiale. Le suicide est bien souvent un acte impulsif. L’accès aux armes à feu est un facteur de risque; il joue un rôle dans la moitié des suicides réussis aux États-Unis. Dans l’armée suisse, le fait d’avoir limité l’accès aux armes a découragé le passage à l’acte dans près de 80 % des cas. Même si les décès par arme à feu sont moins courants au Canada, 20 % des hommes qui se suicident recourent à ce moyen. Au Royaume-Uni, on a montré que le fait de réduire le nombre de comprimés dans les contenants de Tylenol diminuait le taux de suicide. Au Canada, les médicaments d’ordonnance, notamment les opioïdes, les anxiolytiques et les antidépresseurs sont des causes fréquentes de mort intentionnelle ou non intentionnelle. L’idée de limiter l’accès des personnes au comportement autodestructeur à des quantités importantes de médicaments d’ordonnance ou en vente libre peut donc aider à réduire le nombre de suicides et de morts accidentelles. 4. Les morts accidentelles ou de cause indéterminée doivent être recensées comme des suicides Les morts accidentelles ou de cause indéterminée s’apparentent à des suicides. Nous savons que les taux de suicide dans le monde sont largement sous-estimés dans une proportion de 30 % ou davantage. L’explication, c’est qu’il est souvent difficile de déterminer la nature du décès et, plus précisément, s’il s’agit bel et bien d’un accident ou d’un suicide. Il arrive souvent que la difficulté d’en décider amène le coroner à attribuer une cause indéterminée à un décès. Des éléments indiquent que certaines méthodes de suicide sont plus susceptibles de conduire à une classification indéterminée. De fait, au Royaume-Uni, les décès par blessure dont le motif demeure incertain sont systématiquement comptabilisés dans les statistiques sur le suicide. 5. Toute stratégie de prévention du suicide doit inclure la prévention des blessures Nous avons appris que les morts par suicide ou par accident concernent des individus qui partagent un grand nombre de facteurs de risque : appartenir au sexe masculin; être jeune; être célibataire; avoir un degré de scolarité peu élevé; avoir un faible revenu; avoir un caractère impulsif; avoir des problèmes de santé mentale et de dépendance. En règle générale, selon qu’il s’agit des blessures par accident ou du suicide, les efforts de prévention sont distincts. Compte tenu du degré de vulnérabilité commun aux 322
populations concernées et du fait qu’un nombre élevé de morts accidentelles ou de cause indéterminée sont peut-être des suicides, toute initiative de prévention du suicide devrait englober un volet prévention des blessures. Pour véritablement réduire les taux de suicide au Canada, nous devrions jeter un coup d’œil du côté des disciplines médicales qui sont parvenues à réduire la mortalité. À titre d’exemple, les responsables de la prévention en matière de VIH et de cancer ont établi des registres nationaux et investi abondamment dans la création de programmes innovateurs pour lutter contre ces maladies mortelles. Il nous faudra les imiter et déployer une action nationale concertée afin de mettre en œuvre des stratégies probantes visant en particulier les comportements suicidaires. Jitender Sareen est expert-conseil auprès du site EvidenceNetwork.ca, professeur de psychiatrie à l’Université du Manitoba et chef d’équipe du Manitoba Population Mental Health Research Group. Cara Katz est chercheuse débutante au sein du Manitoba Population Mental Health Research Group et résidente en psychiatrie à l’Université du Manitoba.
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Many patients with chronic health conditions also have mental health issues that go undiagnosed and untreated We need to better integrate physical and mental health services By Sanjeev Sockalingam and Paul Kurdyak Our health system often divides mental health from physical health into distinct silos of care and treatment, yet no such mind-body duality exists in actual patients. Many individuals with chronic health conditions simultaneously experience mental health issues — and the reverse — and such “concurrent” health challenges are far from uncommon. According to the World Health Organization, four of the six leading causes of disability are due to mental illness. Awareness campaigns have lately flagged the importance of mental health services as a critical part of the health care system. What’s less well understood is that individuals suffering from psychiatric illnesses also have high rates of physical health conditions, such as diabetes and cardiovascular disease, and as a result, live up to 20 fewer years than those without mental illness. And individuals with chronic medical conditions are at increased risk of mental illness, such as depression, in comparison to the general population. Yet it is far too difficult for individuals with both psychiatric and medical illnesses to get the care they need when and where they need it because of the way health services are currently delivered. In Canada, individuals with diagnosed medical illnesses often have their psychiatric illnesses go undetected and untreated. And individuals with diagnosed psychiatric illnesses are known to have poor access to medical care. The impact of ignoring the reality of concurrent physical and mental health. It costs the system and hurts patients. It doesn’t have to be this way. There are several well-studied models of integrated care where patients receive both physical and mental health treatment in family physician settings, such as IMPACT (Improving Mood – Promoting Access to Collaborative Treatment) and COMPASS (Care of Mental, Physical and Substance Use Syndromes) from the United States. Evidence from these studies shows that when nurses and consulting psychiatrists are available to patients when they visit their family physicians, they experience improved medical and mental health outcomes. Studies also show such integration of mental health care directly into primary care is also cost-effective. Unfortunately, these evidence-based, integrated models of care have not been widely adopted across Canada. The good news is that we are taking steps in the right direction. In 2014, the Medical Psychiatry Alliance (MPA) formed in a unique partnership between the Centre for Addiction and Mental Health, The Hospital for Sick Children, Trillium Health Partners 324
and the University of Toronto with a $60 million dollar investment from the Ontario government, an anonymous generous donor and the four partners. The first of its kind in Canada, the partnership aims to address gaps in concurrent physical and mental health care in Ontario through clinical, research and education initiatives. The goal of the MPA is long overdue, yet attainable: to create future integrated care practitioners in the province who are able advocate and care for patients with complex physical and mental health issues. The goal is for patients to get seamless, integrated care for mental and medical illnesses when and where they need it. To that end, a cadre of experts are gathering at the 2nd annual Medical Psychiatry Alliance Conference this week in Toronto to focus on transforming medical education across health care professions to train future health care teams in medical psychiatry integrated care. It’s a good start but much more needs to be done. Our health system needs to reflect the needs of patients and address fragmented care. Integrated care needs to become the norm rather than the exception. So how can we get there? For starters, it is the responsibility of all health profession educators to reform training to better reflect the common reality of co-occurring physical and mental illness and to align with emerging integrated physical and mental health care models. Imagine the medical student whose early clinical experiences allow him to better help a patient suffering from schizophrenia to engage in care for their untreated diabetes. Or the health care professional who is now able to identify and treat depression in patients with heart disease before it impacts their medical care. But we also need leadership from the government to reshape the health system, to break down silos and help practitioners establish team-based models of care. We need to do a much better job of integrating medical and psychiatric care so that it is patient-centred and timely – and gives Canadians a better return on our publicly funded health care dollars. It’s time to stop dividing the mind from the body and treat the whole patient. Dr. Paul Kurdyak is an expert advisor with EvidenceNetwork.ca, the MPA Director of Health Outcomes and the Director of Health Systems Research at CAMH. Dr. Sanjeev Sockalingam is an expert advisor with EvidenceNetwork.ca, the MPA Director of Curriculum Renewal and the Director of Continuing Practice and Professional Development at the University of Toronto. See also our Podcast on the issue: Why is it so hard to get help for mental illness in Canada See also our Podcast on the issue: Why is it so hard to get help for mental illness in Canada?
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Canada needs improved access to mental health care services By Paul Kurdyak and Sanjeev Sockalingam In any developed country, politicians and clinicians are struggling to improve quality of care while reducing costs of health care systems. To remedy this, groups of doctors across North America — including here in Canada — have banded together to create lists of medical procedures or tests that are likely to be of no benefit (at best) or can possibly do harm while adding unnecessary costs. The goal of this initiative, called Choosing Wisely, is to improve quality of care and to address rising health care costs. This campaign hopes to inspire a dialogue between clinicians and patients about making good, evidence-based, cost-effective choices about their health and health care. But the big dilemma for those working in the field of mental health is not about overuse or misuse, but how difficult it is to get any treatment at all. You can’t choose wisely if you can’t access care. There is overwhelming evidence that access to mental health care across Canada is poor. Only one in five people with depression get appropriate treatment. And shockingly, only one in three patients discharged from a psychiatric hospitalization sees a primary care physician or psychiatrist within a month in Ontario as reported by Health Quality Ontario. This poor post-discharge follow-up rate is far worse than the nearly 100 percent of patients who see a physician following a hospitalization for heart failure. So why do we do so poorly for people with mental illnesses? The answer to that question is complicated, but mental illness is one of the biggest predictors of inequitable access to care in this country. We know that having a mental illness means that you are far less likely to get the health care you need than someone without a mental illness and that mental illness is a bigger predictor of poor access to care than low income. This is truly bad for patients with psychiatric illnesses, but it’s also bad business and costly to taxpayers – the price of a physician visit following hospitalization is far less than the cost of ending up back in the hospital because you had no hope of continuing the treatment that helped you get better. The good news is that we often know what works for people with mental illnesses. There are many types of treatment, both drugs and psychological (talk) therapies, that are welltested and effective. But in the mental health realm we need to start ‘Working Wisely’ before we can ‘Choose Wisely.’ What would ‘Working Wisely’ look like? Cancer care is an example of a system of care that is largely efficient across Canada. It works because most people with cancer get a good diagnostic work-up to measure the 326
cancer severity, and based on those tests, get the cancer treatment they need. In most provinces, we know what the population burden of cancer is and can create systems of care accordingly. Outcomes are also constantly measured and processes of care are modified based on continuous quality feedback. We have nothing close to this in mental health across the country, which means we don’t have a good sense of population-based need. And if we don’t have a clear sense of need, we won’t be able to align existing resources with present demand. ‘Working Wisely’ for mental health care in Canada would mean investing in the capacity to screen and triage for mental illnesses, to create care pathways based on the burden of illness highlighted by the screen and triage process, and to measure meaningful patient outcomes to constantly improve the way care is delivered. The Mental Health Commission of Canada’s National Strategic Framework, and virtually every province with a mental health strategy, has called for better performance measurement in the past five years. This is a daunting task – nothing less than the creation of a system of care where none currently exists. One of the reasons we are hearing more about mental illness in the media these days is because there is less stigma thanks to courageous individuals who are willing to share their stories. People are no longer willing to suffer in silence and we literally can’t afford to ignore the burden of mental illness. But as people come forward seeking help for the first time, they need a system that is ready, responsive and able to meet their needs. Without that, we will simply continue to read the depressing headlines on a weekly basis. Paul Kurdyak is an expert advisor with EvidenceNetwork.ca, a psychiatrist and clinician scientist at the Centre for Addiction and Mental Health. Sanjeev Sockalingam is a psychiatrist and Deputy Psychiatrist-in-Chief at the University Health Network and Associate Professor at the University of Toronto.
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Le Canada néglige les personnes souffrant de maladie mentale L’accès aux services doit être amélioré Par Paul Kurdyak et Sanjeev Sockalingam Dans tous les pays développés, politiciens et cliniciens se démènent pour améliorer la qualité des soins tout en réduisant du même coup les dépenses en santé. En Amérique du Nord (y compris au Canada), des groupes de médecins se forment dans le but d’établir des listes d’interventions ou d’examens susceptibles de n’avoir aucun bienfait (au mieux) ou d’être nuisibles et d’entraîner des coûts supplémentaires inutiles. Baptisée Choisir avec soin, cette campagne vise à améliorer la qualité des services et à endiguer la hausse des coûts de la santé. On espère ainsi susciter un dialogue entre médecins et patients, dans l’espoir qu’il conduira à des décisions judicieuses et rentables, fondées sur des données probantes. Dans le domaine de la santé mentale, cependant, ce n’est pas le recours abusif ou injustifié à certains actes médicaux qui pose problème, mais bien la possibilité même de recevoir des soins. Quand on n’a accès à aucun service, difficile de faire un choix judicieux. Tout démontre que l’accessibilité des soins de santé mentale au Canada est médiocre. Parmi les personnes souffrant de dépression, une sur cinq bénéficie de soins adéquats. Selon Qualité des services de santé Ontario, seulement un patient ontarien sur trois réussit à consulter un médecin de première ligne ou un psychiatre dans les 30 jours qui suivent son congé de l’hôpital psychiatrique. Une situation proprement scandaleuse, quand on sait que près de 100 pour cent des patients hospitalisés pour insuffisance cardiaque voient un médecin dans le mois suivant leur congé. Pourquoi alors cette négligence à l’égard des personnes souffrant de maladie mentale? La réponse à cette question est complexe. La maladie mentale est l’un des principaux indicateurs de l’accès inéquitable aux soins de santé dans notre pays. Les personnes atteintes sont beaucoup moins susceptibles que les autres d’obtenir les soins dont elles ont besoin. La maladie mentale surpasse la faiblesse du revenu comme facteur susceptible de prédire la difficulté d’accéder aux soins de santé. Cette situation est néfaste pour les patients souffrant de maladie psychiatrique, mais elle l’est aussi du point de vue du rendement et de ce qu’il en coûte aux contribuables. En effet, une visite chez le médecin après un séjour à l’hôpital coûte beaucoup moins cher qu’une réhospitalisation causée par le fait que vous n’aviez aucun espoir de continuer le traitement qui vous faisait du bien. La bonne nouvelle, c’est que nous savons souvent ce qui fonctionne. Il existe de nombreux types de traitement, des médicaments et des psychothérapies (par la parole); ce sont des méthodes éprouvées et efficaces. Or dans le domaine de la maladie mentale,
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nous avons un « travail judicieux » à accomplir avant de pouvoir envisager de faire des « choix judicieux ». Qu’est-ce que cela veut dire plus exactement? Prenons l’exemple du cancer. En ce domaine, la prestation des soins est efficace pour l’essentiel à l’échelle du pays. Le système fonctionne parce que la plupart des patients bénéficient de bons services d’investigation diagnostique qui permettent d’évaluer la gravité du cancer et, sur la base de ces examens, d’intervenir adéquatement. Dans la majorité des provinces, nous savons quel est le fardeau du cancer dans la population et nous sommes en mesure de créer des structures en conséquence. Par ailleurs, les résultats des soins sont évalués sur une base constante et les protocoles ajustés en fonction des données sur leur qualité. Dans le domaine de la santé mentale, on ne trouve rien qui se rapprocherait un tant soit peu de cette structure. Cela signifie que nous n’avons pas une bonne idée des besoins offerts à la population. Sans cette information, impossible de concilier les ressources en place pour palier à la demande. Par « travail judicieux » en santé mentale, nous entendons un investissement dans la capacité de dépistage et de triage; les données qui en découleront permettront de mettre au point des protocoles de soins adaptés au fardeau de la maladie et d’évaluer convenablement les résultats dans un esprit d’amélioration constante des interventions. S’appuyant sur son Cadre pour une stratégie en matière de santé mentale, la Commission de la santé mentale du Canada prône depuis cinq ans une meilleure évaluation du rendement, tout comme la majorité des provinces qui se sont dotées d’une stratégie. La tâche est gigantesque : créer une structure digne de ce nom à partir de rien. Si nous entendons parler davantage de maladie mentale dans les médias ces jours-ci, c’est grâce aux témoignages de personnes courageuses qui acceptent de raconter leur parcours, et qui contribuent par le fait même à réduire la stigmatisation. Les gens n’acceptent plus de souffrir en silence; désormais, nous ne pouvons plus fermer les yeux sur le fardeau de la maladie mentale. Néanmoins, il faudrait que les personnes qui se résolvent à demander de l’aide pour la première fois puissent trouver des services capables de les accueillir adéquatement et de répondre à leurs besoins. Sans cette structure, nous continuerons de trouver à chaque semaine à la une des journaux des histoires déprimantes à propos de l’aide insuffisante aux personnes souffrant de maladie mentale. Paul Kurdyak est expert-conseil auprès du site EvidenceNetwork.ca, psychiatre et chercheur clinique ou Centre de toxicomanie et de santé mentale (CAMH). Sanjeev Sockalingam est psychiatre, professeur associé à l’Université de Toronto et psychiatre en chef suppléant au Réseau universitaire de santé.
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Chapter 6: Comparing Canadian and American Health Systems
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Why Canadian hospitals outperform U.S. hospitals If U.S. hospitals ran as efficiently as Canada’s, the average U.S. family of four would save $2,000 annually on health care By Steffie Woolhandler and David Himmelstein In many countries, bereaved families get condolence cards and flowers. In the U.S., the survivors are also deluged with hospital bills and insurance paperwork. That paperwork isn’t merely an insult. It costs U.S. society a fortune. Take hospitals, for instance. According to research we recently published in Health Affairs, U.S. hospitals spent $215 billion in 2011 on billing and administration, a striking 1.43 percent of GDP. Put another way, about $1 of every $4 of U.S. hospital spending goes to bureaucracy rather than patient care. Other countries manage modern, first-rate hospital systems for far less. While administration devoured $667 per capita annually in the U.S., we found that Canada spent only $158, Scotland $164, England $225 and the Netherlands $325. If U.S. hospitals ran as efficiently as Canada’s, the average U.S. family of four would save $2,000 annually on health care. Moreover, U.S. hospital paperwork costs have risen sharply since 2000, even after adjusting for inflation. In contrast, administration’s share of hospital budgets in Canada has actually fallen since 1999. A generation ago, it took just one or two managers to run a U.S. hospital. Now, the CEO has been joined by “chief officers” for operations, finance, compliance, information, quality management, and more. Each chief commands his/her own legions – hundreds of billing and registration clerks, referral managers, upcoding specialists (to translate doctors’ diagnoses into the most profitable billing codes), and massive IT departments whose first commandment is “get the bill right.” Why are U.S. hospitals so inefficient? Our multiple-payer insurance system forces every hospital to negotiate rates with dozens of insurance plans, each with its own coverage rules, billing procedures and documentation requirements. And each hospital must collect deductibles, co-payments and co-insurance from tens of thousands of patients. In contrast, Canada and Scotland – where bureaucratic costs are lowest – have singlepayer systems that reject this kind of red tape and the need to bill for every Band-Aid. They pay hospitals simple lump-sum budgets, the way we fund local fire stations. And like fire departments, their hospitals don’t need to collect from each victim of misfortune. 331
But the complexity of hospital billing isn’t the only thing driving bureaucracy. Hospitals have been forced to add layers of business expertise in order to survive in our marketdriven system. A hospital that doesn’t show an operating profit can’t fund essential new investments in new equipment and cutting-edge services, or modern buildings. That means administrators have to devote resources to financial gaming like marketing lucrative services (e.g. sports medicine); billing units to squeeze every penny from insurers and patients; and strategies to recruit profitable (well-insured) patients, and avoid unprofitable (e.g. uninsured) ones. The dismal record of for-profit hospitals illustrates the problem with running hospitals as businesses. The for-profits have higher death rates and employ fewer clinical personnel like nurses than their non-profit counterparts. But care at for-profits actually costs more, and they spend much more on the bureaucracy, a reflection of the high cost of implementing shrewd financial strategies. Canadian and Scottish hospital administrators don’t have to play financial games to assure their survival. Government grants – rather than operating profits – pay for new buildings and equipment. Even in France and Germany, where hospitals bill multiple payers, bureaucratic costs are modest because government directly funds most hospital investments. England and the Netherlands provide unfortunate counter-examples. Pro-market reforms initiated during the Thatcher era have driven English hospital administrative costs sharply higher. And only U.S. hospitals have higher administrative costs than those in the Netherlands, where radical market-oriented reforms now pressure hospitals to show a profit. Economics textbooks hold that subjecting medicine to market forces will stimulate efficiency and root out waste. But reality stubbornly refuses to obey. In health care, market-oriented policies encourage hospitals to shift resources to business strategies that boost the bottom line, but contribute nothing to care. Dr. Steffie Woolhandler is an advisor with EvidenceNetwork.ca and co-founder of Physicians for a National Health Program. She is professor of public health at the City University of New York and lecturer in medicine at Harvard Medical School. She is also an internist at the Montefiore Medical Center in New York. Dr. David Himmelstein is an advisor with EvidenceNetwork.ca and co-founder of Physicians for a National Health Program. He is professor of public health at the City University of New York and lecturer in medicine at Harvard Medical School. He is also an internist at the Montefiore Medical Center in New York.
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Why this U.S. doctor is moving to Canada By Emily S. Queenan I’m a U.S. family physician who has decided to relocate to Canada. The hassles of working in the dysfunctional health care “system” in the U.S. have simply become too intense. I’m not alone. According to a physician recruiter in Windsor, Ont., over the past decade more than 100 U.S. doctors have relocated to her city alone. More generally, the Canadian Institute for Health Information reports that Canada has been gaining more physicians from international migration than it’s been losing. Like many of my U.S. counterparts, I’m moving to Canada because I’m tired of doing daily battle with the same adversary that my patients face – the private health insurance industry, with its frequent errors in processing claims (the American Medical Association reports that one of every 14 claims submitted to commercial insurers are paid incorrectly); outright denials of payment (about one to five percent); and costly paperwork that consumes about 16 percent of physicians’ working time, according to a recent journal study. I’ve also witnessed the painful and continual shifting of medical costs onto my patients’ shoulders through rising co-payments, deductibles and other out-of-pocket expenses. According to a survey conducted by the Commonwealth Fund, 66 million – 36 percent of Americans — reported delaying or forgoing needed medical care in 2014 due to cost. My story is relatively brief. Six years ago, shortly after completing my residency in Rochester, New York, I opened a solo family medicine practice in what had become my adopted hometown. I had a vision of cultivating a practice where patients felt heard and cared for, and where I could provide full-spectrum family medicine care, including obstetrical care. My practice embraced the principles of patient-centered collaborative care. It employed the latest in 21st-century technology. I loved my work and my patients. But after five years of constant fighting with multiple private insurance companies in order to get paid, I ultimately made the heart-wrenching decision to close my practice down. The emotional stress was too great. My spirit was being crushed. It broke my heart to have to pressure my patients to pay the bills their insurance companies said they owed. Private insurance never covers the whole bill and doesn’t kick in until patients have first paid down the deductible. For some this means paying thousands of dollars out-of-pocket before insurance ever pays a penny. But because I had my own business to keep solvent, I was forced to pursue the balance owed.
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Doctors deal with this conundrum in different ways. A recent New York Times article described how an increasing number of physicians are turning away from independent practice to join large employer groups (often owned by hospital systems) in order to be shielded from this side of our system. About 60 percent of family physicians are now salaried employees rather than independent practitioners. That was a temptation for me, too. But too often I’ve seen in these large, corporate physician practices that the personal relationship between doctor and patient gets lost. Both are reduced to mere cogs in the machine of what the late Dr. Arnold Relman, former editor of The New England Journal of Medicine, called the medical-industrial complex in the U.S. So I looked for alternatives. I spoke with other physicians, both inside and outside my specialty. We invariably ended up talking about the tumultuous time that the U.S. health care system is in – and the challenges physicians face in trying to achieve the twin goals of improved medical outcomes and reduced cost. The rub, of course, is that we’re working in a fragmented, broken system where powerful, moneyed corporate interests thrive on this fragmentation, finding it easy to drive up costs and outmaneuver patients and doctors alike. And having multiple payers, each with their own rules, also drives up unnecessary administrative costs – about $375 billion in waste annually, according to another recent journal study. I knew that Canada had largely resolved the problem of delivering affordable, universal care by establishing a publicly financed single-payer system. I also knew that Canada’s system operates much more efficiently than the U.S. system, as outlined in a landmark paper in The New England Journal of Medicine. So I decided to look at Canadian health care more closely. I liked what I saw. I realized that I did not have to sacrifice my family medicine career because of the dysfunctional system on our side of the border. In conversations with my husband, we decided we’d be willing to relocate our family so I could pursue the career in medicine that I love. I’ll be starting and growing my own practice in Penetanguishene on the tip of Georgian Bay this autumn. I’m excited about resuming my practice, this time in a context that is not subject to the vagaries of backroom deals between moneyed, vested interests. I’m looking forward to being part of a larger system that values caring for the health of individuals, families and communities as a common good – where health care is valued as a human right. I hope the U.S. will get there some day. I believe it will. Perhaps our neighbor to the north will help us find our way.
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Emily S. Queenan, M.D., currently resides in Rochester, New York, where she had, for five years, a solo full-spectrum family medicine practice Queenan Family Medicine and Maternity Care. She is a graduate of the University of Pennsylvania School of Medicine, and completed her family medicine residency at the University of Rochester/Highland Hospital in Rochester, N.Y., where she also served as chief resident.
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The Canadian doctor who prescribes income to treat poverty By Trudy Lieberman Last fall when I visited Canada, I met a Toronto doctor named Gary Bloch who has developed a poverty tool for medical practitioners. The tool assesses what patients might need other than prescriptions for the newest drugs. Bloch's idea was to zoom in on the social determinants of health – food, housing, transportation – all poverty markers linked to bad health and poor health outcomes. The tool, a four-page brochure, notes that poverty accounts for 24 percent of a person's years of life lost in Canada and offers three steps for doctors to address poverty. The first step is to screen every patient by asking them, "Do you ever have difficulty making ends meet at the end of the month?" The next two steps urge clinicians to factor poverty into clinical decisions like other risk factors and to ask questions about income support by age/family status, such as whether seniors have applied for supplemental income benefits they may be entitled to. "We've created an advocacy or interventional initiative aimed at changing the conversation about poverty and how doctors think about poverty as a health issue," Bloch explained. "It's one of those cultural shift things." The first blog post I wrote about Bloch and his "diagnosing poverty" tool received more than 3,000 hits on the Prepared Patient blog. Clearly, his message resonated in the U.S. and Canada. I wanted to circle back to Bloch and see whether a cultural shift in Canada was really taking place. Indeed it is. I was wowed by the acceptance of an intervention that seems so simple and could maybe lead to better health. "It's been a wildfire effect," Bloch told me. Bloch ticked off a laundry list of provinces and organizations that were using or about to use the tool. He described a "pretty amazing" and broad coalition that came together to promote the tool, including public health leaders, pediatric and family doctors, community health centers and regional health authorities. A doctor in British Columbia has developed a version for his region. Manitoba is about to roll out its own adaptation. A public health officer in Nova Scotia is pushing for the tool in that province. The tool is getting attention is Saskatchewan, too. Physician groups have signed on, like the College of Family Physicians Canada and the Registered Nurses' Association of Ontario. The Canadian Medical Association (CMA) has developed a continuing education module based on these poverty interventions. On his website, CMA president Dr. Chris Simpson says, "Dr. Gary Bloch is one of those guys who walks the talk and speaks about 'prescribing money' as a way to help patients who are economically disadvantaged." Simpson told me that Bloch's approach is the first clinically relevant tool to address social determinants of health. To support Bloch's work, the CMA's conversations and 336
advocacy about the tool are heightening awareness among Canadian physicians that they need to address these risk factors. Simpson added that Bloch and his team also conduct trainings to help doctors learn how to use the tool. In a phone interview last week, Bloch observed that adding the steps in the tool to clinical practice is just a beginning. "It was never an end unto itself. It was a stepping stone to other interventions." Bloch described what his family health group in central Toronto is doing. They hired an income security health promoter who meets with patients about their financial situations and works with them on becoming more financially literate. She works with the rest of medical team to acquaint doctors with patients' needs. For example, a person with diabetes without adequate housing will have trouble storing healthy food and insulin supplies. Bloch and his team are beginning to study the tool's impact with a randomized trial and collecting data on the social determinants of health for people in central Toronto. "This will allow doctors, health planners and epidemiologists to draw out data and learn about who they are serving," he said. The American Academy of Pediatrics and the Academic Pediatric Association are considering adopting some aspects of Bloch's tool and are studying the development of a poverty curriculum for physicians. There are also a few programs like "Health Begins," which is a group of doctors working on treating social and economic causes of poor health. But the U.S. has a long way to go to match the progress of Canada. Differences in our two health insurance and payment systems may account for lack of interest or movement in the U.S. "We feel rooted in the communities we serve," says Bloch. "We're not worried about insurance for the patients we provide care to." In the U.S., even with the Affordable Care Act offering access to care to more people, doctors should pause to consider how high deductibles and other out-of-pocket costs affect low income patients. "Will patients be able to afford the care they need?" is still very much an open question. In the U.S., we don't like to talk about any aspect of the Canadian health system unless it's waiting lists. It would be great if next year I could report there was real progress in the U.S. towards embracing the poverty tool that Gary Bloch has moved his profession to adopt across Canada. Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She is an expert advisor at EvidenceNetwork.ca, and a longtime contributor to the Columbia Journalism Review where she blogs for its website, CJR.org, about media coverage of health care, Social Security and retirement. This first appeared in the Prepared Patient Blog: www.cfah.org 337
The Canadian baby boom years are different from the U.S. Defining the Canadian baby boom as being parallel to that in the United States is both wrong and dangerous By Robert L. Brown As a retired demographer, I do indeed tire of the endless articles in the Canadian press that either just quote U.S.-based stories about the baby boom or make the incorrect assumption that the Canadian baby boom mirrored that south of the border (see, for example, a recent news item in the Globe and Mail). Defining the Canadian baby boom as being parallel to that in the United States is both wrong and dangerous. While it is fairly accurate to define the U.S. baby boom as having taken place in the period between 1946 and 1964, that is definitely not true for Canada. When one graphs the number of live births in Canada, it is quite clear that the “boom” years went from 1952 to 1965 (inclusive). Those are also the only years in Canadian history when live births in Canada exceeded 400,000. Interestingly, the number of live births in Canada has not exceeded 400,000 since 1965 despite our rapidly growing base population. Our baby boom births peaked in 1959 versus 1957 for the U.S. The number of live births in Canada in 1946 was 343,504 — well below our 400,000 criterion. Why does this matter? I was born in Canada in 1949, which means I am not a member of the baby boom. I did not experience overcrowding when I went to school. Getting into university (in 1967) was pretty easy and getting a job in 1971 was not a problem at all. I bought my first house in 1975 just before prices sky rocketed and before mortgage rates exploded. And I started to receive my Old Age Security cheque when I turned 65, exactly as promised. But those born several years later (1952-65– Canada’s actual baby boom) did face a lot of problems because of their birth year. They went to school in shifts or in portables. The marks required to get into university rose rapidly. When they graduated from university, youth unemployment rates exceeded 25 percent. By the time they bought their first homes, prices were already up and mortgage rates were 18 percent or more. And, if you were born in 1958 or later, you will have to wait as much as two more years for your Old Age Security benefits. So assuming Canada’s baby boom years mirrored the U.S. in this important statistical demographic is wrong. But why is it dangerous?
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First, assuming that the baby boom is a post-war phenomenon means we jump to the wrong conclusion when guessing the cause. The baby boom was not the result of frisky soldiers returning to Canada. It was, instead, the result of the very good economic times in the period 1952 to 1965 allowing for at-home moms and large families. Second, it leads to other erroneous conclusions. If you use as a single age the birth cohort of 1946 to define the baby boom, you will picture this demographic as turning 69 in 2015. That is, ‘old.’ But if you correctly anchor the baby boom around its peak and midpoint in 1959, then the baby boom will, in fact, turn 56 in 2015. That means the bulk of the baby boom is still in the labour force and the explosion in our dependency ratio will not peak until 2024 — a decade from now. Further, the average age of exit from the labour force has been steadily increasing since 2001 and many Canadians now retire after age 65, which means this major shift in our labour market may actually happen post2024. So, the tidal wave is not upon us — yet. We still have time to plan for its impact on the economy in terms of both lower GDP growth and in terms of rapidly rising costs for health care and social security. And the ski hills can still look forward to a few more good years before heading downhill. Robert Brown is an expert advisor with EvidenceNetwork.ca, a Retired Professor of Actuarial Science, University of Waterloo and Immediate Past President of the International Actuarial Association.
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Il ne faut pas confondre le baby-boom canadien et celui des États-Unis Une association à la fois erronée et risquée Par Robert L. Brown En tant que démographe à la retraite, je suis fatigué de lire dans la presse canadienne d’innombrables articles sur le baby-boom qui ne citent que des sources américaines ou qui supposent à tort que le phénomène fut en tous points semblable des deux côtés de la frontière (voir cet article récent dans le Globe and Mail). Le fait d’assimiler le baby-boom canadien à celui des États-Unis est à la fois erroné et risqué. Même s’il est assez juste de situer le phénomène durant la période de 1946 à 1964 aux États-Unis, on ne peut pas du tout affirmer la même chose pour le Canada. Lorsqu’on trace la courbe du nombre de naissances vivantes chez nous, on constate sans trop de peine que le « boom » correspond plutôt aux années 1952 à 1965 (inclusivement). Il s’agit également de la seule période dans toute l’histoire canadienne où le nombre de naissances vivantes a dépassé les 400 000. Fait intéressant, ce chiffre n’a pas été surpassé depuis 1965 malgré la croissance rapide de la population de base. Au Canada, le boom des naissances a atteint un sommet en 1959, alors qu’aux États-Unis, il a culminé en 1957. En 1946, le nombre de naissances vivantes s’élevait à 343 504 dans notre pays – largement sous la barre des 400 000 qui nous servent de critère. Quelle importance cela a-t-il? Je suis né au Canada en 1949, ce qui signifie que je n’appartiens pas à la génération des baby-boomers. Je n’ai pas connu la surpopulation dans les classes à l’école. J’ai été admis à l’université sans trop de mal (en 1967) et je n’ai éprouvé aucune difficulté à trouver du travail à ma sortie en 1971. J’ai acheté ma première maison en 1975, tout juste avant que les prix n’atteignent des sommets vertigineux et que les taux hypothécaires explosent. J’ai reçu mon premier chèque de Sécurité de la vieillesse à l’âge de 65 ans, tel que promis. Par contre, les personnes nées plusieurs années après moi (entre 1952 et 1965, soit la période qu’on peut véritablement qualifier de baby-boom au Canada) ont connu toutes sortes de problèmes en raison de leur année de naissance. Elles ont vécu le fractionnement des horaires à l’école et les classes portatives. Rapidement, les notes requises pour être admis à l’université ont été rehaussées. À l’époque où les membres de cette génération ont obtenu leur diplôme, le taux de chômage dépassait les 25 pour cent chez les jeunes. Au moment ils ont acheté leur première maison, les prix avaient fortement augmenté et les taux hypothécaires se situaient autour de 18 pour cent. Enfin, si 340
vous êtes né en 1958 ou après, il vous faudra attendre jusqu’à deux ans de plus avant d’obtenir vos prestations de Sécurité de la vieillesse. Voilà les raisons pour lesquelles il est erroné de penser, d’un point de vue statistique, qu’on peut assimiler le boom des naissances au Canada à celui des États-Unis. Mais pourquoi est-il risqué de le faire? Tout d’abord, le fait de supposer que le baby-boom est un phénomène d’après-guerre nous fait sauter à une conclusion erronée lorsque nous tentons d’en établir la cause. Au Canada, il n’est pas attribuable au retour au pays de soldats avides d’affection. Il est plutôt le résultat d’une période de grande prospérité économique qui s’est étendue de 1952 à 1965 et qui a permis aux mères de rester à la maison et d’élever des familles nombreuses. Ensuite, ce raisonnement conduit à des conclusions erronées. Si vous prenez comme âge unique la cohorte des naissances de 1946 pour définir le baby-boom, vous figurerez que les membres de cette population atteindront l’âge de 69 ans en 2015. Autrement dit, l’âge où ils seront « vieux ». Mais si vous ancrez le baby-boom, comme il se doit, en tenant compte de son apogée et de sa mi-parcours, vous choisirez l’année 1959 et conclurez qu’en 2015, les baby-boomers auront 56 ans. Qu’est-ce que cela signifie? Que la majorité d’entre eux font toujours partie de la population active et que le rapport de dépendance ne culminera qu’en 2024 – soit dans une décennie. Par ailleurs, l’âge moyen de la retraite recule de façon constante depuis 2001; bon nombre de personnes au Canada la prennent après l’âge de 65 ans, si bien qu’il est fort possible que notre marché du travail subisse une grande transformation à partir de 2024. Ainsi, le tsunami n’est pas encore à notre porte – du moins pas pour le moment. Il nous reste du temps pour anticiper ses répercussions sur l’économie, tant en ce qui concerne le ralentissement de la croissance du PIB que l’augmentation rapide des coûts en matière de soins de santé et de sécurité sociale. Les baby-boomers peuvent donc espérer dévaler les pentes de ski pendant encore quelques belles années avant que les choses ne se mettent à dégringoler. Robert Brown est expert-conseil auprès du site EvidenceNetwork.ca, professeur d’actuariat à la retraite de l’Université de Waterloo et président sortant de l’Association actuarielle internationale.
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About the Editors Noralou Roos Noralou P. Roos received her PhD from the Massachusetts Institute of Technology in 1968. In 1972 she received the SearsRoebuck Foundation Federal Faculty Fellow, and moved to the University of Manitoba in 1973. She joined the Population Health Group at the Canadian Institute for Advanced Research in 1988. Noralou was a co-Founder of the Manitoba Centre for Health Policy. She headed the group which received Canadian Foundation for Innovation funding to create Canada’s first data laboratory, containing population based data on health, education and social services and held a Tier 1 Canada Research Chair. Citations to Dr. Roos’ work place her among the top 100 Canadian scientists according to The Institute of Scientific Information. She was a member of the Prime Minister’s National Forum on Health, the Interim Governing Council setting up the Canadian Institutes for Health Research (CIHR), received the Order of Canada in 2005, was elected a member of the Academy of Sciences of the Royal Society of Canada (2009), and most recently received a Fellowship in the Canadian Academy of Health Sciences. Noralou led the Canadian Drug Policy Development Coalition working with Health Canada and the provinces which resulted in the funding of the Drug Safety and Effectiveness Network (DSEN) at CIHR. She has also been working with community groups, business and government to bring research on ‘At-Risk’ kids to the policy table; she is a Member of the United Way of Winnipeg Board of Trustees, the Winnipeg Poverty Reduction Council (Strengthening the Core Working Group), and a Member of the Point Douglas/Lord Selkirk Park Project Advisory Board. She has received the Inaugural Population and Public Health Research Milestone Award, CIHR and CPHA, and in 2010, gave the Emmett Hall Memorial Lecture, one of Canada’s most prestigious lectureships, which commemorates the father of Canadian Medicare with an annual address at the Canadian Association for Health Services and Policy Research Conference. Kathleen O’Grady Kathleen O’Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University and the author and editor of numerous books and articles on health, women’s and cultural issues. She is also the Founding Director of QUOI Media Group, specializing in political, policy and media research and strategy consulting. She has written and edited speeches, Op-Eds, policy briefs and research papers for Senators, MPs, MPPs, Chiefs of Police, academics and CEOs. Her client list includes the Senate of Canada, a number of 342
Ottawa-based think tanks, universities, politicians, artists and authors, and a wide range of national non-profit organizations. In this capacity, she works as the Managing Editor of EvidenceNetwork.ca. On behalf of the research network she strategizes and edits the Op-Ed content from a wide-range of academic experts and works with editors at Canada’s leading newspapers to make these submissions ready for publication. She also oversees a small communications team that actively pushes these commentaries, and other related projects, such as videos, media backgrounders, podcasts, webinars and infographics, through popular social media channels to raise the level of evidence in popular discourse about Canadian health policy options. Kathleen is also a volunteer editor with Wikipedia on the Canada Project and is a past board member for the national non-profit organization, Girls Action Foundation/Fondation filles d’action. She currently sits on the Research Management Committee for NeuroDevNet – a pan-Canada Network of Centre of Excellence to study children’s brain development. She lives in Ottawa, Canada with her family, and is the mother of two young boys, one with autism. Eileen Boriskewich Eileen Boriskewich is both the webmaster and e-Newsletter editor for EvidenceNetwork.ca, in addition to providing administrative and executive support to the Director/Editor-in-Chief and the Director of Communications/Managing Editor. She manages the day-to-day operations of EvidenceNetwork.ca and participates in the strategic direction of the project through team meetings. She is currently enrolled in the Certificate Program in Management and Administration (CIM) at the University of Manitoba. Mélanie Meloche-Holubowski Mélanie Meloche-Holubowski was the 2014 journalist intern at EvidenceNetwork.ca and is now the Podcast and Social Media Editor. She is also a webmaster and journalist for Radio-Canada in Montreal. She has worked as a journalist for a local paper, for the French television station TVA/LCN and has helped Québec en forme set up a website about children’s healthy habits. She also freelances for a hyperlocal newspaper in Montreal.
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Nanci Armstrong Nanci Armstrong is a part time Research Support for EvidenceNetwork.ca. She provides support to the team through communications with our experts, reporting and tracking of data and administrating day-to-day operations of the EvidenceNetwork.ca website. She earned her Certificate in Human Resource Management (HRM) at the University of Manitoba in 2012 and in addition to her work with EN she stays busy raising her young daughter and working on her family business. Carolyn Shimmin Carolyn Shimmin is a Knowledge Translation Coordinator with EvidenceNetwork.ca and the George and Fay Yee Centre for Healthcare Innovation.
Kristy Wittmeier Kristy Wittmeier is a physiotherapist and Director of Knowledge Translation at the Manitoba Centre for Healthcare Innovation. She is an Assistant Professor at the University of Manitoba, and a researcher with the Children’s Hospital Research Institute of Manitoba. She has a special interest in physical activity as a tool to prevent and manage obesity-related conditions in youth.
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Appendix A Write a Snappy OpEd To Change Minds, and Maybe Even Behaviours Here’s how: OpEds offer an important means to share your message – be it new research, a viewpoint or an idea on a topic that’s recently been in the news – with a wide, general readership. OpEds (which stands for ‘opposite the editorial pages’) are often one of the most widely read and redistributed sections of any respected broadsheet, and routinely influence key decision makers, affect policy and shape public perceptions. OpEds, sometimes also called ‘commentaries,’ are generally provocative, sharp and precise. Following the basic rules of commentary writing is paramount for getting your submission published in the leading media outlets. It will also help sharpen your argument and develop the narrative that will leave a lasting impression with readers. The following key perimeters will help keep your submission stylistically within the requirements of most major Canadian papers:
The commentary must be no more than 650-750 words and must be timely (on something that’s recently been in the news, or should be);
It must focus on only a single or a few major points or arguments – keep it simple and compelling;
It must express a point-of-view or opinion on a specific topic on which you have expertise. This viewpoint should be expressed in the first couple of paragraphs up front (proofs for this opinion can follow);
Ideally, it will draw on more than just evidence, but use personal experience or a personal story as an example, or use a helpful metaphor to make your argument compelling as well as convincing (we want the readership to connect with the article). Research on its own rarely changes minds;
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Stay away from jargon and too many statistical numbers – particularly upfront; it should read like a well-spoken, compelling speech with an informed conversational tone;
Citations are absolutely prohibited. If you have to credit someone with an idea, it has to be written within the sentence itself and be part of the story you are telling;
Leave the reader at the end with a solution, or steps toward a solution or next steps (other than ‘more research’), highlight who the players are (individuals? levels of government?) and what specifically needs to be done next.
Keep in mind that editors give preference to commentaries that follow these rules precisely, and that provide their readers with evidence, examples and possible solutions as part of a provocatively stated opinion.
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Appendix B 2011 - 2015 published Op-Eds analyzed by media category, December 30, 2015 Months 2011 January February March April May June July August September October November December
Op-Eds* Published per Month 4 10 3 3 2 4 1 7 4 38
Media Category A 0 2 2 1 1 2 1 2 1 12
Media Category B 3 15 10 5 3 6 0 9 9 60
Media Category C 3 5 5 1 5 0 0 9 1 29
Media Category D 15 25 8 5 4 2 0 8 3 70
Total Media Mentions 21 47 25 12 13 13 1 28 14 171
*2 French Op-Eds were published in a major media (Le Devoir; Le Soleil; La Presse; Le Huffington Post Québec). These were included in the analysis. Ten “pending” Op-Eds were not included in the analysis. ** Huffington Post & Huffington Post Québec were included as Category B
Months 2012 January February March April May June July August September October November December
Op-Eds* Published per Month 6 16 6 3 9 7 13 6 12 6 6 9 99
Media Category A 1 3 3 0 2 3 6 2 3 0 3 3 29
Media Category B 5 26 6 6 14 9 25 11 18 8 16 10 154
Media Category C 0 3 4 4 10 5 10 15 3 7 9 16 86
Media Category D 5 23 7 6 14 11 22 20 8 12 12 11 151
Total Media Mentions 11 55 20 16 40 28 63 48 32 27 40 40 420 347
*18 French Op-Eds were published in a major media (Le Devoir; Le Soleil; La Presse; Le Huffington Post Québec). These were included in the analysis. ** Huffington Post & Huffington Post Québec were included as Category B
Months 2013 January February March April May June July August September October November December
Op-Eds* Published per Month 13 7 6 9 12 16 7 6 5 16 11 7 115
Media Category A 3 1 2 4 4 2 3 4 1 8 0 4 36
Media Media Category Category B C 22 18 12 14 13 7 19 13 19 14 12 22 13 6 14 18 4 9 20 23 17 15 4 11 169 170
Media Category D 28 21 9 19 14 25 11 7 15 28 25 10 212
Total Media Mentions 71 48 31 55 51 61 33 43 29 79 57 29 587
*23 French Op-Eds were published in a major media (Le Devoir; Le Soleil; La Presse; Le Huffington Post Québec). These were included in the analysis. ** Huffington Post & Huffington Post Québec were included as Category B
Huffington Post and Huffington Post Québec as Media Category B
Months 2014 January February March April May June July August September October November December
Op-Eds* Published per Month 8 5 10 11 14 14 10 12 15 15 18 10 142
Media Category A 1 2 3 6 4 10 2 4 4 2 1 2 41
Media Media Category Category B C 11 20 15 12 12 12 20 14 19 20 14 13 8 15 8 34 24 27 18 18 22 40 10 16 173 241
Media Category D 33 12 13 19 25 26 22 35 44 21 46 30 326
Total Media Mentions 65 41 40 59 68 55 47 81 99 59 109 58 781 348
Months 2015 January February March April May June July August September October November December
Op-Eds* Published per Month 20 13 6 11 6 19 11 7 7 11 5 11 100
Media Category A 2 4 2 8 2 7 2 7 1 0 1 5 41
Media Media Category Category B C 21 50 18 24 10 21 11 19 16 15 24 20 22 20 19 23 8 15 17 11 10 15 15 9 191 242
Media Category A
Globe and Mail La Presse Le Devoir National Post Toronto Star
Media Category B
Calgary Herald Calgary Sun Halifax Chronicle Herald Hill Times Huffington Post Huffington Post Quebec iPolitics Le Soleil Montreal Gazette Ottawa Citizen Ottawa Sun Toronto Sun Vancouver Province Vancouver Sun Winnipeg Free Press Winnipeg Sun
Media Category C
Media Category D 48 44 24 37 22 50 27 40 44 40 24 23 423
Total Media Mentions 121 90 57 75 55 101 71 89 68 68 50 52 897
Small city papers and equivalent (Sample):
Charlottetown Guardian Edmonton Journal 349
Guelph Mercury Hamilton Spectator Kingston Whig Standard Le Droit Leader-Times Medical Post New Brunswick Telegraph NB Times and Transcript Ottawa Life Saskatchewan Star Phoenix St. John’s Times and Telegraph Sudbury Star Victoria Times Colonist Waterloo Region Record Windsor Star Media Category D – Regional and niche media (Sample): Alaska Highway News, Battlefords News-Optimist, Belleville Intelligencer, Brandon Sun, Brooks Weekend Regional, Cambridge Times, Carstairs Courier, Chilliwack Times, Didsbury Review, Fox Creek Times, Kelowna Daily Courier, King’s County Record, Lethbridge Herald, New Glasgow News, Okanagan Sunday, Penticton Herald, Ponoka News, Prince Albert Daily Herald, Red Deer Express, Rimbey Review, Slave Lake Scope, Shoreline Week, Sundre Roundup, Surrey Times, Sylvan Lake News, Victoria Star (New Brunswick) Wabasca Fever, Woodstock Bugle-Observer, Yorkton News Review, and other regional media not found above.
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Appendix C Number of Op-Eds, by where published NUMBER OF OPEDS, BY WHERE PUBLISHED NATIONAL MEDIA REGIONAL MEDIA, MASS CIRCULATION REGIONALMEDIA, NICHE CIRCULATION ALL OTHER The Globe and Mail La Presse Le Devoir National Post Toronto Star
2011
(Sample) Montreal Gazette Vancouver Sun Hill Times Huffington Post Canada, Huffington Post Québec Le Soleil, etc.
60
29
70
(Sample) Charlottetown Guardian Edmonton Journal Medical Post New Brunswick Telegraph Journal Victoria Times Colonist, etc.
(Sample) Battlefords News Optimist Brandon Sun Kelowna Daily Courier King’s County Record Yorkton News Review
171
(Apr - Dec)
2012
2013
2014
2015
154
86
169
173
191
151
170
420
212
241
242
587
781
326
897
423
351
