[Recorded by Electronic Apparatus]
Tuesday, November 7, 1995
.0910 
The Chairman: Good morning all. Now we have a quorum. I apologize for being a little late starting. We like to get these things going on time, especially when we have such a limited time.
We're going to do this for an hour or so with the people from the Department of Health. Committee, don't forget we've got our own in camera session, because we've got two or three decisions we want to make today. They need to be made today, because one of them may involve getting a House order, but we'll come back to that.
Now, Joe, are you the chief honcho down there this morning?
Dr. Joe Losos (Director General, Laboratory Centre for Disease Control, Health Canada): For today, yes.
Some hon. members: Oh, oh!
The Chairman: Welcome. Maybe you'd like to introduce your colleagues who will be helping you today.
I'm assuming that the people from Health who are witnesses today - and we're glad to have you - all have a sense of what we're up to, so I won't take up the committee's time or your time to spell out what our current assignment is. I believe the purpose was communicated to you quite well. So we'll get right to the issue at hand.
We would hope you will have a brief statement and then leave some opportunity for us to put some questions to you.
[Translation]
Dr. Losos: Good morning everyone. Mr. Chairman, today I would like to present to you general action programs in the area of child health protection and risk prevention.
I am here on behalf of the Assistant Deputy Minister, Mr. Kent Foster. With me are Mr. Roy Hickman, Director General of Health Canada's Environmental Health Directorate and a group of scientists responsible for programs.
[English]
Mr. Chairman, the health protection branch of Health Canada is a major player nationally in the prevention of risks to the health of children. Each PV, as we call it, carries out its activities in four core program areas: safe and effective drugs; safe and efficacious food; safe environment and safe effective medical devices; and national surveillance, disease prevention, and control. This health protection branch capacity is based on strong science in-house and taps into and coordinates external expertise nationally and internationally when we apply these core functions and this expertise to deliver on the role of risk management through the identification of hazards in a wide variety of areas through systematic risk assessment in these areas and subsequent risk management strategies ranging anywhere from dissemination of information to full-blown regulation.
Health protection programs are built through collaborative arrangements with a wide variety of partners: provincial ministries of health, professional associations, non-governmental organizations, the academic sector heavily, and the private sector. Throughout all of these, international linkage is prominent.
Programs within the branch are planned, prioritized, designed, executed, and evaluated with heavy stakeholder participation. We use criteria for ranking and choosing projects and programs, and we carry out constant program reviews and evaluations in cyclic external peer reviews.
Of the programs under the child development initiative, the health protection branch carries out seven of the ten prevention programs. That is about 5% of the resources of CDI. It amounts to just a little under $25 million over five years.
.0915
Through those resources, we are able to have leverage to impact a fair amount of provincial and private infrastructure. The infrastructure of the health protection branch is applied to identification of those hazards, carrying out those risk assessments, and orchestrating risk management through that infrastructure. Infrastructure that I'm describing has been relying on short-term or sunsetting funding, usually limited to several years in duration. Continuation of these activities are dependent on continuation of the resources for that infrastructure. The programs are varied and form components of that risk management framework of hazard identification, assessment, and risk management.
At this point I think I'll open the book to any questions you might have and answer whatever you would like, or we'll ask the scientists to give you specific details.
The Chairman: Thank you. Harold will start.
Mr. Culbert (Carleton - Charlotte): I'm looking at your book and the presentation you've just made, and I take this opportunity to welcome you here this morning, as our chair did.
One of the things I'm convinced of in addressing health for our future generations, especially when we think of children who obviously later become adults and our future generations and populations, is that in addition to nutrition and good healthy environment, there is the nurturing component. I'm wondering, as I hear you speak and look briefly at your book and presentation this morning, whether there has been in-depth consideration of its effects later in life as well as through childhood, both health-wise and in terms of other social behaviours. If so, I'm wondering what your research has found in that area and what you feel is the best approach to addressing that whole situation.
I'm sure you're well aware of the studies that have been done statistically over many years in Canada, the United States, and Europe in this area. I'm wondering whether you have addressed this situation and how you feel we might address it in the future to get the message out to the population as to the importance of nurturing along with proper nutrition and all the other components that we know create a healthy environment.
Dr. Losos: Yes, sir, we are aware of that. The branch, in large part with its capacity to identify hazards and do the risk assessment, could be compared to the hurricane watch of some of the risks that occur in children. From measuring those risks, we can telescope back into broad determinants such as social and cultural determinants, economic and otherwise. Although traditionally or historically that hasn't always been a perfect program component in any sector - and ours would be included - over the last several years we have built into our programs steering mechanisms to ensure that the promotion side and the social side are actually part of the design of the actual hazard identification and risk assessment programs we have.
I'll hand the baton to Dr. Catherine McCourt. She runs the perinatal, reproductive, and child health component and will give you an idea of how we've tried to broaden that area to include exactly the dimensions to which you're referring.
Dr. Catherine McCourt (Acting Director, Bureau of Reproductive and Child Health, Health Protection Branch, Health Canada): Thank you for the question.
We know in the health protection branch from our knowledge of the research done in Canada and other countries and from what the many child health advocacy groups and child welfare groups tell us that development of a future adult with self-esteem and skills to contribute in society is affected very much by what happens in childhood, as you've said, and particularly in early childhood ages - zero to three, for example. We think even that is affected by the experiences around the perinatal period and pregnancy and the experience of the whole family to the pregnancy and the birth of the child.
.0920
So we haven't done research ourselves on the issue of nurturing and subsequent outcome in terms of a child's or an adult's well-being, but, as Joe mentioned, we're starting a national perinatal surveillance system. Its objective is to monitor the determinants of healthy birth outcome, what happens around pregnancy and the perinatal period, and hopefully, ultimately, as we grow, to follow children and the family into the first year of life.
We see our objective mainly as building on what is already known about the relationship between the perinatal period and healthy child development, and to provide that information to the many groups that will be able to use it in proper programming. That's the main program that addresses the topic you've talked about.
Second - this is also related - we want to establish a program of national surveillance of child abuse and neglect. This is the negative side or the absence of nurturing. In a small way, we hope that will again increase the body of knowledge and our understanding of the factors that cause children to be mistreated in this way. Therefore, we might work toward preventing it.
Mr. Culbert: Just to go a little bit further, I noticed that in your response you indicated that in the area of three-year-olds you're working with, some of the information that has come forward to this committee has suggested - this is a concept that I used to have as well - that three- to five-year-old children are capable of not only developing good health habits, but of developing good social habits and the whole component of building the child. Now we're informed that it even goes back to a much younger age. It goes almost back to birth or the first six months of age.
I'm wondering again how we get the message forward to the Canadian public that we want them to be assured this is important, as well as the proper nutrition. As we've heard before, a low social standing perhaps is relevant in some cases. We know of many large, poor families that have developed children in an excellent fashion in a very caring and nurturing attitude, not only from the parental perspective but also from that of brothers and sisters and other family relationships. This appears, from some of the early statistics we've seen, to be extremely important for the child all the way through his life as a preventative measure in providing good health, as well as for good social and economic follow-ups.
Have you looked at that type of thing? If so, how have you suggested it could be addressed?
Dr. McCourt: I agree with everything you've said. We are aware of the effect of the very early life experience on the subsequent development of a healthy, well-adjusted person.
I'm not passing the buck, but I think I will retreat a bit. At least in the Bureau of Reproductive and Child Health and LCDC, this is an issue that we alone cannot address. As for the contribution of our program, we want it to be good national information that is grounded, as Joe said, in good science. It should have the input of the expertise we will get from our colleagues in universities, such as social scientists, as well as epidemiologists, pediatricians, and obstetricians. This should provide information that will give a direction to many of the groups at the national level that should respond to this issue. That includes informing the public.
.0925
I think a lot of people know about the adverse effects of early bad situation on children's well-being, particularly problems with child care and with parents not being able to feed their children properly. It's a challenge that's greater than LCDC's capacity alone.
What we must bring to the job is good information with especially the health and also the social science contexts that lead us to solutions. We'll have to work with Human Resources Canada in health promotion. We are concerned about the health of immigrants, pregnant women, and their children. We'll have to work with the Department of Employment and Immigration and of course with NGOs that are concerned about child health.
It's not really an answer, but I agree with what you're saying.
Dr. Losos: I think Mr. Hickman can add another perspective to it.
Mr. Roy Hickman (Director General, Environmental Health Directorate, Health Protection Branch, Health Canada): Just to build on a couple of examples, we have recognized the situation you're referring to. For example, the health protection branch worked with New Mother magazine to produce a special supplement on ``Your Baby and the Environment'', and another one on ``Your Baby and Protection from the Sun''. These go into those packages that every mother carries home from the hospital that have examples of commercial products like powders and so on.
We're trying to encapsulate the knowledge base among our scientists and put it into a form the mother can use to encourage her to nurture the child in an acceptable way.
Take the sun example. If the children are protected from the sun, the adults will protect themselves from the sun. That's just an example of the way in which we're trying to tackle the kind of problem you're bringing to us.
Mr. Culbert: I'll refer to something Dr. McCourt had indicated. Is the department working with other departments? You're absolutely right that this takes in more than just your particular Department of Health; it takes in the Departments of Justice, Human Resources Development, and, as you indicated, Immigration. A number of departments have to be interested in this from the statistical information early on to provide that assistance later on in life.
Dr. Losos: Yes, sir. I think it's fair to say that we do work with the other departments on these broad determinants. We work with other departments, such as Agriculture, Environment, Justice, etc.
I would also like to make the comment that I think you'll see that increasing even more over the coming months and years as the realization of broader determinants becomes more ingrained. These programs will build these bridges more automatically than in the past.
The Chairman: Sharon.
Mrs. Hayes (Port Moody - Coquitlam): Thank you for coming this morning. I have a couple of questions. The first one is to quickly follow up on my colleague's question.
Certainly it appears there's a lot of work being done on looking at problems in families, including the abuse of children, fetal alcohol syndrome, and poverty factors. Have you done any work at all or seen any good national research on things such as the effect of the presence of one or two constant persons within the formative crucial years of zero to three of a child? I recently read something on that and the importance of it in future social development.
Also, what about the absence or presence of a mother or father figure within a parenting relationship and the effect on children over the long term? Is there any research on that?
Dr. McCourt: I'm sure there is good Canadian research. I am not aware of it. I'll retreat to my own discipline, which is public health. For example, we want to build a new program of surveillance of child abuse and neglect. We will be hiring people with social work expertise and building an advisory committee that will consist of people who know that research very well.
.0930
I couldn't answer professionally. It would be almost a layperson's answer. There might be others here who would know more than I.
Mrs. Hayes: I like to think we should be pursuing a positive model rather than avoiding a negative one. There is a part for both, of course, but certainly we want to know where we're going to not just where we're coming from. I would like to think the majority of families think of themselves as positive and so should be supported in that role.
The other question I have is more general. I guess again it's very different and it has to do with some information you've given us in our book about the programs that are being supported in your work.
There is one section - appendix G - showing some of your program work on page three. It's interesting. There's one called ``Strengthening Families''. I guess it was funded in 1992-93, with $0.7 million going down to zero. I gather that means it either has been or will be terminated.
As well, on the next page there are two things of interest to me: promotion of Canada's national action plan for children and the promotion of the UN Convention on the Rights of the Child. The first one goes from $1 million to $1.5 million. That includes reporting on Canada's implementation on the Convention on the Rights of the Child. For the second one the promotion is $750,000 per year ongoing.
I know there's been a challenge, for instance, on our section 43 from this study. I believe it's within the Department of Health. Could you perhaps explain to us first the apparent importance of these programs and how section 43 applies or what part of this program activity relates to, for instance, the UN challenge to Canada that section 43 should probably be removed from our law?
Dr. Losos: The section to which you were referring were components of the health promotion and programs branch. The section for the health protection branch is on pages one and two of that appendix G. The preventive component is all this branch is involved in. The other programs were the testimony of Kay Stanley and her group. I believe it was last week.
Mrs. Hayes: All right.
Dr. Losos: We're not involved in those programs.
Mrs. Hayes: All right, I'll make a mental note. Thank you.
The Chairman: Bernard.
[Translation]
Mr. Patry (Pierrefonds - Dollard): Good morning.
In your brief statement, you noted that the department evaluates the different programs. In your opinion, have these evaluations of prevention strategies proven satisfactory and above all, have they led to an improvement in the initiatives taken?
In short, did you attain your objectives and if so, to what extent? Also, would it be possible to get a copy of the objectives sought and of the conclusions of the different program evaluations?
[English]
Dr. Losos: Yes, sir, I can give you an idea of the types of reviews. There are departmental reviews of the lab centre for disease control, for example, done by the audit unit. There is also the health protection review carried out under Treasury Board supervision in 1992-93 and of course the Messier review of last year. Also, every program area undergoes annual program reviews and in many of our programs we have cyclic peer reviews. Every two or three years academic and private sector teams will come in to follow a set format of program review, to look not only at impact but also program quality and ongoing program utility. They will advise us on program redesign. We in the lab centre for disease control, for example, have just started a major redesign of our field epidemiology investigation service, based on program reviews and peer reviews.
.0935
These various mechanisms are at play constantly to evaluate quality, make sure the outcome is being delivered, and rechannel lower priority programs into higher priority programs. That happens constantly at the departmental level and also with stakeholders.
That is basically how all the directorates work. We'd be happy to give you copies of all or any examples of these peer reviews.
[Translation]
Mr. Patry: Following up on my colleague's question, in your opinion, are the current prevention strategies geared to children well coordinated? Does the left hand know what the right hand is doing?
[English]
Dr. Losos: I think it's fair to say we're well coordinated with stakeholders across the country. The leverage I commented on earlier is very established and happens constantly.
Within the department, the steering groups, mechanisms for ensuring that promotion's working with health protection programs, are strengthened. They are certainly in place now. A good example I could call upon again is Dr. McCourt's perinatal area. I think the tobacco area is another area that perhaps Mr. Hickman might want to comment on as far as ensuring that horizontal functioning.
Mr. Hickman: As part of the management of the tobacco sales to young persons act, for example, we have very close links with a management committee whose members are the ADMs of each of the program branches of the department. Then there are links to other departments such as Revenue Canada and Agriculture Canada in order to ensure, for example, the taxation implications are considered in terms of the strategy. I believe there is good coordination.
Mr. Szabo (Mississauga South): I feel like I'm in the review of the public account of health right now. There's this formality and maybe a little bit of apprehension about saying the right things.
I hope you feel very comfortable here, because we're here to try to educate ourselves. I know there are departmental lines and you don't want to sort of encroach on somebody else's bailiwick, but it is important to focus ourselves. We need your help to focus.
Dr. Susan Bradley is a psychiatrist at the Hospital for Sick Children. She talks to me quite a bit about the formative years and parenting during that period. According to her, the most important thing for good mental health of children is that parents have good stress and time management because of the lifestyles parents live. The window of opportunity for child care is squandered by chores, etc.
Dr. Mark Genuis, who's the executive director of the National Foundation for Family Research and Education, has an organization that is talking extensively about bonding and secure relationships, attachments.
Dr. Fraser Mustard came before this committee and said that one dollar of investment in the right spot could translate into seven dollars in savings over the life of a child.
Today we received this book called The Health of Canada's Children by the Canadian Institute of Child Health. It says that from birth to 17 months of age, 276,600 children require child care because of parental employment. From ages 18 months to 35 months, 276,500 require child care. So it goes down by 100. But from three to five years of age it doubled to 585,000. That tells me those first three years are critical, and parents know it. They respond by providing direct parental care.
.0940
I think this is the area that's fascinating us the most. We are sort of reaching out at this point to try to figure out what factors occur during the formative years of life that may have, in all probability, an influence on future positive outcomes.
There are a lot of signals here, and I'm not sure whether we can wait for a Michigan study or another detailed Perry preschool study or whatever to show that enriched care helps. We know it does. If you give that focused attention it helps. But how do we emulate that in the formative years, given the family structures or whatever?
I appreciate that this encroaches, unfortunately, on social policy. Let's not be afraid of that, because good health policy makes good social policy too. How do we get at this determination of help Dr. Robert Evans wrote about in his book? It was complex to me, but there were areas in there that actually made a great deal of sense. This is where that one dollar may have to be invested.
The other programs you have listed are extremely important. There are no simple solutions to all of this. It's a complex problem we have to deal with, and it needs an army of solutions in a number of ways. It's almost an intangible area where things like bonding and consistent relationships are cheap to acquire because you can do them at will. But the impact in real terms of good health and dollar savings is immense.
How do we get at this? Where are we going to find it? I find there is reluctance to deal with those factors among many of the health care professionals I have talked to because there is a political correctness concern, possibly about the role of women, etc. You know what I am talking about. We need help to educate ourselves and focus ourselves, but are we looking in the right area?
Dr. Losos: I would like to make a comment, and any of our folks can jump in.
Certainly the realization of these factors and broad determinants is clear. I think I can honestly say that the key factors or group of factors for changing the well-being remain murky, regardless of the literature.
I think I can say the department is very committed to making it work this time from a hazard identification and risk perspective with the health protection branch. We are committed to including in our measures the socio-economic, cultural, and family dynamics that would allow Dr. McCourt, for example, to flag what is coming into emergency departments with respect to injury, abuse, whatever, and then get a handle on what those broad determinants or dynamics may have been.
It has been the department's intention over the last several years to see itself as a trustee or an advocate with respect to this health dimension in other jurisdictions. It could be other departments such as revenue, other social departments, provinces or whatever. I think you will find that as we, with our promotional colleagues and social science colleagues, are able to define these factors better, they will steadily get into actual programming, federally and provincially, to try to make a difference.
Some of these are very long-term determinants of course. Our ability to define which broad determinants are immediately doable and will have an impact still remains shaky at this point.
Mr. Szabo: I have one last question about fetal alcohol syndrome. I would like to get some factual indicators of importance.
.0945
Dr. McCourt: Yes, okay. I can start anyway.
Fetal alcohol syndrome is a condition that is a complex diagnosis. We don't have good incidence in Canada, so we can only estimate. Because it's a complex diagnosis and for reasons it hasn't been paid much attention to in the past, we don't have good figures for occurrence in Canada. We have to extrapolate from American extrapolations from international estimates.
If we do that, the estimate is about 140 or 200 babies born with FAS each year in Canada. If you put that in perspective, with neural tube defects there are about 400. With SIDS deaths there are about 250 or 300 a year in Canada.
Fetal alcohol syndrome is preventable. That's the tragedy of it. It's 100% preventable. It's something we should focus on because something can be done about it. It's not easy, mind you, because what are the factors that lead women to drink during pregnancy?
The second thing, as I'm sure a lot of you know, is that with fetal alcohol syndrome itself, with the difficult diagnosis in terms of facial dismorphology, etc., which I talked about, there's also something that's a little less well defined, generally called fetal alcohol effect. It is not quite the full diagnosis and it could be three, four, five or ten times more common than fetal alcohol syndrome. People who work in the field, especially people in B.C. who have done a lot of work in it, say that fetal alcohol effects are.... The population in many of our prisons are people who are dysfunctional, drop out of school and get in trouble with the law. We should be looking at alcohol exposure in utero as a possible cause.
That's a high priority for the department. It very much was a few years ago and still is now in terms of our birth defects surveillance work. That's something we have to improve and get some help from our colleagues on.
Mr. Szabo: Just to complete this, I attended a seminar on the weekend and I think somebody from Health Canada was there. The figures I have are that 5% of birth defects are attributable to FAS or FAE. About one in 500 children, or live births, are FAS, compared to I think one in 600 for Down's syndrome. So their figures showed that it was more prevalent than even Down's syndrome or spina bifida, which was one in 700.
It is an area - and I think you've hit on it - that's 100% preventable. It's the kind of thing, hopefully, that we'll be able to include in a report.
The Chairman: Thank you, Paul.
We have a number of interveners on five-minute rounds. Pauline.
[Translation]
Mrs. Picard (Drummond): Good day and welcome to the committee.
You stated earlier that the strategies are evaluated every two or three years. When was the last evaluation conducted and do you feel that it is relevant for the committee to examine prevention strategies geared to children at the present time? If so, how should the committee go about doing this?
[English]
Dr. Losos: The last evaluation would have been the program review done in 1994. The last specific evauation of the whole health protection branch program would have been 1992-93.
Each program area within the health protection branch is reviewed annually and that would be available to you. The peer review is done externally, cyclically, at the Laboratory Centre for Disease Control. Then other programs are done - several programs every year - so there's a cyclic review of programs every year. You are welcome to see any or all of those.
.0950
The evaluation framework of the health protection program was built on a scientific assessment or model developed in the branch and peer reviewed externally. We threw in a number of factors with respect to the severity of the condition that the program area represents and the efficacy of interventions, and we have a rating set of criteria that we apply to programs for their evaluation. This evaluation framework is now being built upon to add another dimension with more quantifiable criteria as this evaluation system evolves.
So the summary answer would be that the evaluations are ongoing annually in every program area. Peer review is cyclic, every two to three years depending on the program area. The last intensive overall program review of the branch was at the end of 1993.
[Translation]
Mrs. Picard: Earlier on, you mentioned that agreements were reached before programs were implemented. I seem to remember that you spoke of agreements with the provinces to determine whether these programs met their needs.
How is it that in Quebec, the Department of Health views the prenatal nutrition program as interference in its affairs? Prior to the federal department setting up this program, there was already a prenatal program in place for mothers giving birth to low-weight babies.
[English]
Dr. Losos: I believe the program to which you refer, Madame, is in the health promotion branch. Perhaps Dr. Cheney could address that.
Dr. Margaret Cheney (Chief, Nutrition Evaluation Division, Food Directorate, Health Protection Branch, Health Canada): The program to which you refer is being run under the CAPC program of the health promotion and programs branch, and the health protection branch is not involved in it.
Dr. Losos: I'd like to add one more example or comment. All of our programs within the branch, with no exceptions I can think of, are largely steered by federal-provincial groups. They could be expert groups such as the National Advisory Committee on Immunization, for example, which represents every province and territory and a number of specialty societies such as the Canadian Medical Association, the Pediatric Society, and the like.
These groups will dictate the priority areas and the content and design of those programs to prevent duplication, to make it cost-effective, and also to give all areas of the country access to the best information possible.
One of the flagships in the Lab Centre for Disease Control's world has always been the National Advisory Committee on Immunization. It has existed for decades as that mechanism. Each province is then at liberty to use the information we publish constantly for their own policies or their own immunization programs.
However, collectively, quarterbacked or chaired by Dr. Philippe Duclos, we have over the last several years come up with immunization goals and targets for the country. Expert groups have gotten together, examined the field, and come up with suggestions that the provinces can use or don't need to use, depending on what their policy needs are with respect to how immunization practice is carried out.
These are mechanisms for quality production of tools and coordination that have been tested and tried for decades and work quite well in our area. If you're interested in more details about this example with respect to immunization policy and the types of problems it can overcome, perhaps Dr. Duclos could add some words.
[Translation]
Mrs. Picard: Thank you.
[English]
Mrs. Hayes: I have two quick questions. I was just looking at this book from the Canadian Institute of Child Health, and in it I see several graphs that are very disturbing. I'd like to draw two of them to your attention and then maybe ask you a quick question on them.
.0955
There's a youth suicide rate that shows the shocking number of suicides of male youth 15 to 19 years old and the difference between 1960 and 1991 has gone up fourfold. Those are on page 97. And then on page 98 we find violent crime of youth charged for violation of Criminal Code and federal statutes, 12 to 17 years old. Violent crime has gone up from 9,275 in 1986 to 20,000 in 1992. This is only a five-year window, during which violent crimes more than doubled. Again, typically, I think, a majority of that would be the young men of our society.
Do you look at preventative strategies in terms of the sex of the children, and can you give us any explanation for this malaise we're seeing in our young men in Canada?
Dr. Losos: Could I ask Dr. Rick Mathias to comment on that, please?
Dr. Rick Mathias (Acting Director, Bureau of Surveillance and Field Epidemiology, Health Canada): Thank you very much for that question.
In the Bureau of Surveillance we are now undertaking an in-depth review of reported suicide, particularly the aspect that at least some of the increase you're seeing is due to differences in reporting and how the deaths are being classified. We're trying to sort out how much of this is a change in the reporting structure and how much is in fact a change in the incidence of suicide.
There is no question, from the work as it's progressing in our bureau, that there is in fact an increase in suicide. It is not quite as dramatic as it has been shown.
You're also correct that what we're seeing is that there are a number of age shifts occurring. Suicide used to be more frequent in middle-age to late-age males - and I use the term less easily than I used to perhaps, in the age group I'm in. We're now very definitely seeing this shift to the younger age group. But we're also seeing it in girls, which is also very disturbing, particularly in the younger age group.
One of our difficulties is in sorting out the issue of how much of this occurs with our aboriginal peoples and how much with other people, because, for reasons that are not entirely clear, much of that information is not available. The records have been stripped of that kind of information, and we're going back and trying to re-create that information so we can target programs much more specifically than they have been targeted in the past.
But your observation is entirely correct. We do have a major issue there, and it is increasing. We hope the surveillance information can now be translated into programs to try to address this issue.
Mrs. Hayes: All the more reason to maybe suggest that since, I presume, preventive strategies have been in place for some time, maybe some of those, with your evaluation.... What is it we have been doing? Have some of these things not worked, or can they be changed and re-evaluated to go in a different direction?
Perhaps I could also ask - and this is purely a numbers question - of the total health expenditures, how much does Canada currently spend on prevention, and how much of this is towards children? Specifically to Health Canada, what are the answers to those two questions, if you know them?
Dr. Losos: I don't know that directly, but I can certainly find the information for you.
Mrs. Hayes: It would give us an idea of priority and what you're looking at.
Dr. McCourt: My understanding is that of total national health expenditures, about 5% is spent on traditional public health - public health nurses in public health agencies across the country, and broader public health programs. But public health is not the only area where preventive measures are undertaken. They're also done in clinical practice, in hospitals, etc. I don't think we have a very good number, but it's not enough from my perspective. But we can try to get those figures, yes.
Mrs. Hayes: Okay. Thank you.
.1000
Mr. Jackson (Bruce - Grey): I'd like to ask our guests one small question.
Since I came to Ottawa, one of the problems we're having as a nation is the fact that people want to reinvent a lot of things you're doing. I'm not sure if we're like the engineer who went in to drain the swamp. After being in there a little while, we forget that we're supposed to drain the swamp because we're fighting alligators. When people ask questions bureaucrats seem to get a kind of bunker mentality.
Obviously you're very intelligent people and have a lot of programs and evaluate a lot of programs and you have an infusion of new ideas and new drugs and things that could help the Canadian population. To me, one of the biggest problems - and it's with all departments, I'm not saying just with your department alone - is how to get this information out. We have a lot of brain power on the Hill. We have a lot of stuff going on and over time we have evaluated it. You said you've had evaluation programs. You said you've got a mission statement. Obviously you're going to try to improve your circumstances.
To me, the key question is how does this thing filter down to the general population so that they know what you're doing? And how do you use all of that feedback of the statistics of fetal alcohol syndrome, disease prevention, and all of the other things? How do you get it back into the department and the criminal justice system and all the other departments that are affected by that? Is there a method of doing that? Do you do it by public opinion polls? How do you get this feedback so that you can make these changes on a regular basis?
A witness: In my personal opinion, it is probably one of the most vital areas. We're redesigning it as we speak. This program and many other programs in many other jurisdictions have had historical ways of distributing information, such as newsletters, publications for new mothers, such as Mr. Hickman referred to, etc., etc.
However, I think it's very fair to say that in the information age - and this is my personal opinion - the way we do the information business has to and is changing drastically. In the investments the department has made in the public health programs over the last year or two, the investment into dissemination systems has been quite large, not only to get onto worldwide web sites and get into the electronic medium but to hire the types of communications professionals it takes to translate public health data into information and then into messages and the delivery of those messages. Those last two factors we realize are in a very special and specialized area. This is something the department and our various components of the health protection branch have invested in heavily over this last number of months.
We're not perfect in it. Historically and traditionally, we have a lot of information out where our evaluations show that the impact of this information isn't always as we would like it. So we have to redesign how we get information out and how we deal with our various professional sectors, public sectors, non-governmental organizations, or whatever. That's at the drawing board stage and it's probably one of our most vital components because our science has been fairly steadily good.
Mr. Jackson: I have one last comment. As a department, my advice to you would be to get out to town halls, and so on, notwithstanding the fact that they're going to have a lot of local issues. I think you have to be down on the ground; you can't just write things and report. We have great meetings in Ottawa, but people usually don't understand and don't know and actually it's more of a problem than a solution.
Dr. Andy Gilman (Chief, Great Lakes Health Effects, Health Protection Branch, Health Canada): Just by way of explanation, some of the recent research from the stewardship survey indicates that children learn primarily through television and teachers. Better than 90% of the information children get on social issues, environmental issues, and nutrition issues comes from teachers and television. So with that in mind, one of the things the branch has taken on is to work much more with the electronic media, not just the computer networks but with television programming, such as TV Ontario, in the Great Lakes basin region in an integrated way to bring forward information on the influences of environmental contaminants, lifestyle choices that we have to make as individuals in terms of our responsibility for caring for the environment and caring for our health, family networking, and also to try to reach physicians, who have a huge degree of credibility with the public. Even though they only provide 3% of the information, in the surveys that have been conducted their credibility standard is close to 70% as the most credible source of information.
.1005
The branch has also been putting together a number of handbooks for physicians to bring them up to date on new and breaking issues, many in the environmental health area, emerging disease, problems that are occurring, and the links between various diseases and publicly discussed determinants such as environmental contaminants.
I think more and more the department is doing the sorts of things Dr. Losos has mentioned to you - restructuring, rechannelling how it gets information out to people who need to use that information, not just our departmental colleagues, who also need it. Sometimes that's an equal and different kind of challenge, getting information to people in other departments, such as Finance, Industry Canada, Environment Canada, who have to help us make policy decisions within government that will smooth the way for improved conditions for children.
Reaching the children through television video programs, such as Great Lakes Alive, which some of you may have seen, those kinds of things have been increasingly important, and if we don't do it we simply won't be able to reach children in the 1990s.
Ms Fry (Vancouver Centre): I want to touch on something Mr. Jackson just said, although it was just answered. I want to ask about how the department is using physicians as a source of information.
Not only do physicians have that 75% to 80% credibility with the public and influence in terms of changing behaviours, but they also manage to see about 90% of the population in any one year. So you have a cheap source of disseminating information, not only through sending the physician information for physician education but in terms of putting your brochures in a physician's office for patients to pick up. It's a very cheap way of disseminating information. But that's not really what I want to talk about. It's just that Ovid brought that to the table and I thought I'd mention it.
There are two things I'm going to phrase very quickly so I can give you time to answer them. One of them has to do with the issue of evaluation, which was brought up very much around the table. I wonder if you could tell me whether or not the department is moving toward a more quantitative method of evaluation - that is, setting objectives that are clear, definable, and measurable so that you can actually tell if you're achieving your targets. That way you can change or move your strategies forward or be flexible with them.
On the second one, obviously Mr. Szabo talked about FAE-FAS, and Catherine mentioned the fact that with FAE there is concern that so many people in the justice system and in prisons are there because of FAE. There is also the issue of child development, given that we're not going to turn back the clock with regard to two parents in the home working and the need for child development as opposed to child care - child care concentrating on child development.
How are you collaborating with other departments? Is there a plan to do so - departments like Justice in the issue of FAE-FAS, DIAND in the case of FAS-FAE, or Justice and HRD in the case of child development? How is that collaboration occurring, and what are you doing to ensure that is done in a very orderly manner in which there is real input and not just chatting across the backyard fence?
Dr. Losos: I'll have to ask Mr. Roy Hickman to address your first question.
Mr. Hickman: First, in the health protection branch program there is a formal process that does require quantitative objectives to cover all aspects of our work. We measure progress against those. I think Dr. Li perhaps can best illustrate that with an example.
.1010
Ms Fry: I want to have very clear benchmarks, clear objectives.
Dr. Felix Li (Acting Director, Bureau of Cardio-respiratory and Lung Disease, Laboratory Centre for Disease Control, Health Canada): I just want to give you an example. I'm sure there are lots of examples in LCDC, and the health protection branch uses a similar methodology.
I'm in charge of the area of cardio-respiratory health and diabetes. Asthma is one of the programs that has been running for a couple of years. I would like the committee to know that we had a national task force built up about a year ago. We were in the process of creating national asthma prevention and control goals and objectives for the nation. Actually, tomorrow I'm going to a meeting in Quebec City to finalize those goals and objectives. In those we will find very clear-cut, quantitative measurements on what we want the asthma rate to go down to and in how many years. We will also address issues of morbidity, hospitalization, disability among children, and other indicators that will enable us to monitor our progress, whether we eventually get to that benchmark or not.
Another comment by Dr. Fry I would like to comment on is the use and persistence of this as a vehicle for educating the public on health issues and other issues. Indeed, this it is an important thing, which we have been thinking about. The health promotion and protection branch has published a book called Preventive Health Services. Some of you might have seen it. It's a very thick book. In the area of cardiovascular health, respiratory health, and diabetes, we're thinking of a process of how to translate it into very simple activities physicians could incorporate into their day-to-day work and also educational efforts, which in a very time-effective manner could easily be transmitted to the patient.
I'm just answering those questions through a few examples of what we're working on.
Dr. Losos: I would like to add to that. Each director in our program is required to produce and is accountable for a three-year strategic plan, which is created by that stakeholder consensus and design, and for creation of that network for its surveillance and for the public health risk management. Each strategic plan, or action plan as we're calling it, has a one-year operational component with specific milestones for which they're answerable every year. The structures for quantifying and managing our program area project by project are in place and there is an accountability for output.
On your second question, how we are collaborating, I'll ask Dr. McCourt to give you some thoughts.
Dr. McCourt: As to formal structures, our programs, be it perinatal health surveillance, on-farm health, reproductive health and exposure to pesticides, our child injury program, all have interdepartmental committees. For example, with farm health it's Agriculture Canada that is involved, with child injury - well, adult fitness is actually part of our department - it's mortgage and housing, and other departments. There's that program, and I would venture to say it's very much the case in environmental health in terms of their work with Environment Canada.
Overall, in terms of our child-related work in the federal government, the health programs and promotion branch, Kay Stanley and her colleagues are proposing a formal structure of interdepartmental committee work. It would involve ADMs across about 13 departments and then one at the program level. I think that's just being finalized this year, so the one-on-one communication official to official has to take place. That cements it. The formal structures at higher levels are being planned. I think it has to be done at all levels.
The Chairman: Okay. We're out of time.
Mrs. Hayes: I have one short question. The information development program has a survey attached to it, I gather. According to this information, a Canada-wide longitudinal survey of children will begin in 1994. Is that survey created? Can we get a copy of what questions you will be asking on that survey?
.1015
Dr. Losos: I believe that program is run by the Department of Human Resources.
Dr. McCourt: Yes, I believe the data is almost available. We're going to get a copy of the database. The questions have been set. It was before my time, but it's being done out of the Department of Human Resources. That project moved to the Department of Human Resources when the welfare part of our department split off. The first data collection has been done and I'm sure we could get it to the clerk or make sure we give you the name of the person in the Department of Human Resources who has all that information.
Mrs. Hayes: Thank you.
If I have a moment before we adjourn, I want to comment on my colleague's statement. Actually, I guess this is an editorial comment in that there was a statement made by Dr. Fry that we don't want to turn back the clock in terms of the two-parent family. I hope there aren't blinders on such that what has been must be.
As parliamentarians, as a government, and as a department, we don't necessarily have to say things have progressed in a certain way so we will carry on with that. We can make recommendations to that. We can say that something is better than something else, even though the trends are going in certain directions.
I think we have to look at this study very openly and honestly. Actually, it disturbed me to think that someone would say that just because something is, it must be, or that a trend is there so it's a done deal.
The Chairman: I have a couple of quick ones.
First of all, when Kay Stanley was here last week she indicated they had reorganized that branch. Does the same apply to your branch? If so, do you have a new score card so we can keep track of the players? Is there an organizational chart?
Dr. Losos: Yes, we can certainly get you an organization chart. The major reorganization really occurred with the intensive health protection program review in 1992-93.
There has been restructuring. The most recent was several months ago. Because of the expansion and broadening of the programs of the Laboratory Centre for Disease Control, it had more depth and breadth added to its organization. It hadn't changed since the late 1960s.
We can certainly get you a new score card, as you called it.
The Chairman: Okay.
On the weekend I was down in my riding in a town called Burgeo and I was reminded of what we call a Newfie party. During the cocktail hour, when everybody is getting ready for the banquet, all the women go over and sit down on one side of the room and all the men sit on the other side of the room. Well, the Ottawa equivalent of the Newfie party, of course, is what always occurs here, because all the bureaucrats come in and sit around the wall and talk to each other and all the members come and sit at the table and talk to each other.
I'm rather delighted that so many have come from the department this week and last week, because it suits our purpose. We want to get to know the players, as I said just now, but we can't do that if you insist on talking only to yourselves. I'm talking both to bureaucrats and to members. So I would hope we will use these occasions to introduce ourselves to each other. It helps us as members if we can put a face on who we're calling.
We have what we believe is a very exciting assignment here, but while it's exciting, we don't know a lot about it yet. We're determined to learn, determined to find out more about it. When I say we, there are exceptions. There are professional health care people on the committee, but as I told my colleagues earlier, I'm the token ignoramus on the committee in terms of health matters. We're trying to get educated.
I would hope you'll leave your business cards for the members and otherwise buttonhole them so we can have some ongoing dialogue.
Joe, I thank you, and please thank Ken for me for making available so many people this morning.
.1020
I want to put a question to everybody, because a lot of you have not had an opportunity to participate orally this morning. I want to ask anybody or all the people from Health Canada if there's something specific you'd like to flag for us this morning in terms of our present assignment where we're looking at disease prevention, particularly as it relates to children. If there's something you think we might not give enough emphasis to, if there's something you think we ought to look fairly closely at, any comment or bit of advice any of you have, we would like to hear it. Would somebody want to venture a thought on that subject?
Dr. Losos: Boy, that's asking for it.
Mr. Richard Viau (Director, Product Safety Program, Health Canada): One area that people don't think about as being a health issue is accidents and injuries, and it is a very major problem. It's the number one cause of death for children between the ages of one and fifteen. Indeed, people think of disease and this sort of thing, but injury and injury prevention I think is a major issue.
The Canadian Institute of Child Health has done some studies that support these findings. We've done a lot of collaborative work with that organization in terms of trying to promote strategies for injury prevention. I flag that as an issue you may want to look into in some greater depth at some future time.
The Chairman: Thank you. Are there any others?
Dr. Li: This is not at all advice to the committee, but I have a comment on what Mr. Szabo earlier indicated, that the health of children is a very complex issue, which the health care people alone could not deal with. It's a whole range of social, employment, and economic issues.
We at Health Canada - as you heard from the other group last week and this week - have come together as a group to talk about the various social programs, the welfare programs, and the health programs in the child development initiative. We found that process really enlightening. We were able to share a lot about our experiences and together take a more comprehensive look at the health of children and try as bureaucrats to take care of the various areas as well as we could.
It would be a dream for bureaucrats at the policy level, at the government level, if that kind of interconnection could be made, because a lot of the health care depends on the country's social policy, employment policy, and economic policy. So one thing we would as health professionals really like to see happen is that there be a close branching between health and social and economic policies in various levels of government.
Dr. Losos: My last comment is that in my experience, nationally and internationally, I know of no jurisdiction that isn't undergoing massive redesign. We've had a very good public health system over decades and it has served Canada quite well. We're in the middle right now of redesigning how public health is going to occur in the next century - nationally in Canada, centres for disease control in Atlanta, the World Health Organization, etc. A lot of it has to do with the types of things we've been talking about today in terms of linking to socio-economic data the cultural variables and other effects on well-being that perhaps we have not paid enough attention to.
The branch itself, with its various measurement networks and tools, will in fact provide some of the benchmarks for the outcome measures that many of you have been asking about today. In the future, when we're evaluating what is important and how our programs are working, it's the measurements of the branch that will be called upon to be that outcome measure.
The Chairman: Do you have something?
Dr. Gilman: Yes, Mr. Chairman, I have three quick comments. One is on publicly negotiated objectives that are clear and available for people to read in terms of whether or not the department is meeting the responsibilities it's laid out. I think the branch has that message and is putting a lot more effort into consultation activities, not just with community groups, but also with professional groups, which I also call communities. Although they are not in one location, they are still communities in the sense that they require input as to what those objectives should be.
.1625
Three programs that have done that recently within the branch would be the Great Lakes 2000 program,
[Translation]
the St. Lawrence Action Plan, now known as Vision 2000,
[English]
where there have been negotiations with the provinces, with other departments and then with public groups as to what should be the clearly stated objectives and targets for that program. Those led to the publication of those objectives in the Canada-Ontario agreement.
[Translation]
There is also the Canada-Quebec Agreement.
[English]
In the Arctic similar things are going on, but the objectives tend to be identified on a community-by-community basis because in the north things work differently than they do south of 60.
The issue of fetal alcohol syndrome brings out a very important point: everything is connected to everything else in terms of determinants. Fetal alcohol syndrome, while it's preventable, is so tied in with poverty, education, nutrition, and in many cases increased exposure to environmental contaminants because of where those people live. They tend to be less desirable locations, and the kinds of stress those people are under in terms of poverty and education lead to greater environmental contaminant exposure.
So when we look at a particular syndrome as a department, our effort now is to try to look at all of those things and how they fit together. It does mean that a lot of the work requires that single-stream scientists have to become more multi-stream. I think there has been a lot of ``regrooving'', if you like, of many of our scientists to make them aware of those other disciplines. Now as they go out to talk to the public on topics, they have to know about all of those topics. It's not enough to go to people in a public consultation and say you only look after drinking water and you'll have to find someone else who can answer their question. We simply have to be able to answer people's questions in an integrated way.
More and more, we have scientists who are developing that - some are better at it than others - but who are now able to go out and talk with the public and hear their concerns. If we don't hear back from the public what their concerns are, we're simply not doing our job.
The Chairman: Is there anybody else?
Thanks very much, Joe and your team, for coming. This is just the beginning. It's been very helpful.
We're going to break to allow the transition, but we will have a very quick meeting after.
[Proceedings continue in camera]