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May 11, 2003

Connecting the Dots:
From Health Care and Illness to Wellbeing

Notes for Remarks by
Roy Romanow

On the Occasion of Receiving
The International Foundation’s Public Service Award

Ottawa, May 8, 2003

Check Against Delivery

It’s a great pleasure to join you today to receive this very prestigious award. I am humbled to be in the company of the remarkable cast of previous winners.

In my remarks today, I want to move beyond the health care system and treating illness to discussing all of the other components required for a truly healthy society. But before I do, permit me to comment on what has taken place since I presented my report.

It’s now been several months since I had the privilege of submitting my recommendations as Commissioner on the Future of Health Care in Canada.

There are always some who will be a bit skeptical about commissions. If you’re a fan of the show Yes Minister, you may recall Sir Humphrey’s observation that the purpose of a national commission is to "take a difficult problem and bequeath it to the next generation."

But I can honestly say that my 18 months as Commissioner were among the most challenging and rewarding of my more than three decades in public life.

We engaged tens of thousands of Canadians in a dialogue about the future of health care. They spoke passionately, eloquently and thoughtfully about their desire to transform what exists today into a truly national, more comprehensive, responsive and accountable system.

I met with some of the greatest experts and reviewed the most thorough research in the field of health care reform. This enabled me to separate myth from reality, ideology from sound policy, and knee-jerk reactions from long-term solutions.

What made the Commission a particularly meaningful experience for me was my deep personal belief that medicare is the single greatest symbol of our uniqueness as Canadians.

What makes medicare the quintessential Canadian program is that it is the convergence point where so many of our values come together. That’s why we called the Commission’s report Building on Values.

Medicare demonstrates that as community we can accomplish so much more than we could ever dream of doing as individuals.

It underscores our belief that citizenship confers upon us rights that are based on the strength of our need and not the size of our wallet.

And it highlights one of the new realities of a young century – that economic growth cannot advance at the expense of social cohesion, or social cohesion at the expense of economic growth – the two have to go hand-in-hand.

I was honoured to help prepare a road map for a collective journey by Canadians – a journey to reform and renew our health care system. And I will continue to act as an advocate in this regard.

Over the past few months, the journey has begun. The Health Accord reached by the First Ministers was a critical and necessary first step. So too was the Federal Budget. The initial steps taken by the leadership in this country has provided a good start.

But not everything is proceeding exactly as I had envisioned it. I worry about issues of adequacy of funding, timing regarding the flow of resources, and most importantly, the Health Council.

We proposed the Council to meet the demands of Canadians for accountability in the system – so that they can see clearly and transparently what money is being spent, how it is being spent and whether we’re achieving the health outcomes that we all want.

Let me be clear, lest you think these are the concerns of an overly sensitive former commissioner. While I am proud to advocate for our recommendations, we think something more fundamental is at stake.

When I reflect upon all that I heard, and all that I learned, I am left with a clear sense that it was not just health care people were talking about when they came to our meetings, or wrote, or e-mailed or called to share their views. It was also the health of our political institutions and of our democracy.

I think that a large number of Canadians saw in our consultations an opportunity to participate directly in the democratic process. That their contributions could make a difference. That for once, they were not powerless. That the demise of a program to which they were profoundly attached, and which appeared under threat, was not necessarily a foregone conclusion.

So my biggest hope is that the trust Canadians demonstrated through our process will be rewarded rather than dashed. Without wishing to be too dramatic, I truly believe that in the recurring struggle between democratic participation, on the one hand, and apathy and cynicism on the other, victory will depend on the decisions reached by our Federal and provincial governments on this sacred of Canadian public policy files.

Earlier this week, the Federal and provincial ministers of health announced a postponement regarding plans for the Health Council. Given our recent public health challenges, fair enough; and changes to the political landscape in Canada also may have something to do with this delay.

Frankly, getting this Health Council right, is more important than meeting a deadline for its own sake. My only hope is that Canadians, as well as the many experts who recently workshopped the concept, will get a Health Council that has the independence and resources to provide Canadians with the facts regarding health care expenditures and results. The Council should have a manageable number of members, free of vested interest, political or otherwise. A government controlled health council will fool no one.

My friends, Canadians want an end to inter-governmental bickering regarding health care spending. They want an end to tax payer paid ads that are used to obfuscate rather than communicate what is really going on. They want real accountability, not a watered down, ineffectual council. And they want something long term.

A skeptical friend of mine, albeit one with a pretty fair network in the political business, has suggested to me that the current considerations are not going well. He put it this way: " Roy, they are going to create an ineffective, short-armed monster, that won’t work; they will jump up and down with feigned joy at its creation, then kill it off with a sunset clause for good measure."

I am not that skeptical but I am a touch nervous. I might feel better if the discussions taking place regarding accountability for our health care system were taking place on C-PAC!

This is no time to dabble. This is not a time for thinking marked by self-interest and "short-termism" on the part of our political leadership. Canadians are waiting and watching with interest and anticipation. So am I.

Let me now turn to what is required to become the healthiest nation on Earth.

Connecting All the Dots

Indeed, one of the key points that I made in my Report is that we have to set a national goal of making Canadians the healthiest people in the world. One of the keys to achieving this goal is a greater emphasis on preventative health measures and improving population health outcomes.

Although I referenced this in my report, I will be the first to admit that even if all of my 47 recommendations are adopted, and even if they are implemented the way I would want them to be, it will only take us part way toward this goal.

A health care system – even the best health care system in the world – will only be one of the ingredients that determine whether your life will be long or short, healthy or sick, full of fulfillment or empty with despair.

If we want Canadians to be the healthiest people in the world, we have to connect all of the dots that will take us there. To connect the dots, we have to know where they are.

If one of you were to ask me for a list of my best tips on how to live a long and healthy life, here’s what I would tell you:

Don’t be poor. Rich people live longer than poor people and they’re healthier at every stage in life.

Pick your parents well. Make sure they nurture your sense of identity and self-esteem and surround you with interesting stimuli. Prenatal and early childhood experiences have a powerful effect on later health and well-being.

Graduate from high school and then go on to college or university. Health status improves with your level of education.

Don’t work in a stressful, low-paid, manual job in which you have little decision-making authority or control. Poor jobs equal poor health.

Don’t lose your job and become unemployed. Unemployed people suffer from stress and isolation and can become poor – and remember what I said about being poor.

Be sure to live in a community where you trust your neighbours and feel that you belong. A civil and trusting community promotes health and life expectancy.

Live in quality housing, but not next to a busy street, in an urban ghetto or near a polluted river. Clean air, water and soil are vital to your health, as are the human-made elements of our physical environment.

No doubt some of you are thinking, "What good are these tips to me as an individual? I had no choice in the family I was born into. I couldn’t influence how I was raised in my early years. I can’t help it if my company shuts down and lays me off. I can’t decide what kind of supports or environment will be available in my community."

But that’s exactly the point.

Healthy lifestyle choices may be important and vital – and they are. A comprehensive, responsive and accountable national health care system may be important and vital – and it is.

But the main factors – the main "determinants" as the experts call them – that will likely shape your health and life span are the ones that affect society as a whole. And if we want Canadians to be the healthiest people in the world, we have to deal with them at that level.

Socio-Economic Status is the Key Determinant of Health.

Let me talk a little bit more about some of the themes that were woven through my list of top health tips.

There is a growing body of evidence that money is the single largest determinant of health. We've known that for a long time.

Back in the early 1960s, researchers began looking at the links between lifestyle and health in 7,000 people in Alameda, California. When they came back 18 years later and looked at the participants who were still living, they found that income was the most powerful influence on health and life span – the poor had more than 1.5 times the risk of dying prematurely as the rich.

Since that time, a lot of similar studies have been conducted, with similar results. Most of you are familiar with the old adage "health is wealth". That may be useful as a metaphor for what is important in life, but as far as a predictor for the future, it’s quite the opposite. The reality is that in the majority of cases "wealth is health".

If you’re at the bottom of the income ladder, odds are you’re going to find yourself at the bottom of the health ladder. If you’re at the top of the income ladder, you’re more than likely going to be at the top of the health ladder. Here in Canada, life expectancy drops for every step down the ladder: the very rich live longer than the somewhat rich; the upper middle class live longer than the merely middle class; and the poorest 20 percent are more likely to die of every possible disease from which people can die.

If rich people live healthier and longer lives than poor people, is it logical to assume that wealthier countries generally have healthier populations than poorer countries? The answer is yes – but only up to a point.

In developing countries, as the average income goes up, life expectancy does also. But in developed countries there is something more important than the average income, and that’s the size of the gap between rich and poor. In countries where the gap is large, life expectancy is not as high as in countries where average income may be lower but the gaps between rich and poor are smaller.

In a country like Canada, a finding like that should send alarm bells sounding across the country. We have a wide gap between rich and poor and the gap is growing by the year. Just two years ago, a study carried out by a York University Professor showed that of all of the years of life lost in Canada before the age of 75, about 23% can be traced to differences in income.

So if we’re serious – if we’re really serious – about making Canadians the healthiest people in the world, then we have to be serious about closing the gap between rich and poor.

The Early Years are a Key Determinant

You may be wondering why there is such a strong link between money and health. Or as one researcher put it, "If low income leads to poor health, how? There is no artery from your wallet to your heart."

Well, maybe not in a literal sense, but certainly in a metaphorical sense. The amount of money that you or your family have is the lead domino in a whole line of dominos – the quality of your early childhood years, your education, the type of job you have, the kind of housing and community you live in, the type of recreation and fitness programs you have access to – all of which directly affect your health.

Let’s look at some of these. We are very fortunate in Canada to have some of the world’s leading experts on child development.

Experts like Dr. Dan Keating from the University of Toronto and Dr. Clyde Hertzman from UBC, and have provided overwhelming evidence that the early years are the most important ones in setting the stage for a healthy life.

And Dr. Fraser Mustard and the Honorable Margaret McCain put it very clearly to us in their landmark study, The Early Years, "…the period from conception to six years sets a base for learning, behaviour and health over the life cycle."

We know for a fact that a child subject to deprivation or stress is far more likely to experience mental illness, obesity, adult on-set diabetes, heart disease and a shortened life span. Even if these children move into a better environment after childhood, they suffer poor health throughout their lives. We’re going to see the health consequences of childhood poverty for the entire next generation.

So if we’re serious – if we’re really serious – about making Canadians the healthiest people in the world, we have to be serious about investing in the early years education and child care.

Fortunately, in the past year we’ve seen some positive steps in this direction. The Federal Budget commitment to a national childcare program, and the federal/provincial/territorial agreement that followed it, are encouraging signs that the message is beginning to get through.

And the recently announced First Duty projects in Toronto hold promise because they intend to fully integrate early years education, child care and children’s services so that parents and their children have seamless and timely access to the key educational and health supports they need.

And as many of you know, Quebec has led the way in Canada regarding child care and family friendly policies. But we still have a long way to go to catch up to other countries.

The Quality of Work is a Key Determinant

Let’s skip ahead from the early years to the working years. There’s a very strong connection between your experience at work and the state of your health – I’m sure anyone who has ever come home from work with a stress headache can attest to that.

Sometimes the connection between job and health is pretty direct. If you work in a noisy or unsafe environment, if you’re exposed to toxic chemicals or hazardous materials, or if you do repetitive physical work, it’s obviously going to affect your health.

But sometimes the connection is more subtle. Many years ago, a groundbreaking study was conducted among 17,000 British civil servants. All 17,000 worked in the same building; all had a good standard of living. All had good job security – which should tell you just how long ago the study was conducted.

The research was done over a 20-year period and the findings were fascinating. As you moved down the ladder of the civil service, each rank of worker had poorer health, more sick days, and higher mortality rates than the rank immediately above it. Even those just one rank down from the top had heart disease rates four times higher than those at the top.

Even among those that engaged in risky health behaviour like smoking, there were fewer cases of cancer, heart disease and stroke among the higher ranks than lower ranks.

What could have caused this startling difference? Is there something inherent in a pyramid-like organization that causes those at the bottom to be sicker and die younger than those at the top? The answer is yes. The big difference is that in the higher ranks the work is more challenging and rewarding, and people have more control over decisions and more support to take risks.

So if we’re serious – if we’re really serious – about making Canadians the healthiest people in the world, we have to take a good look at what is going on in our workplaces, and how we can make the quality of work a more meaningful and rewarding experience for all Canadians.

Physical Environments are a Key Determinant

There are many more factors that affect your health than can be cured by a medical prescription from your doctor or even a policy prescription from your health minister. Things like lifetime access to good quality recreation and fitness programs and school-based physical education, and a secure supply of healthy, nutritious, and affordable food, are fundamental to personal wellbeing.

But I just want to touch on one more factor today, and that’s the quality of our physical environment. A clean and safe environment is vital to our health. Contaminants in our air, water, food and soil can cause everything from cancer to birth defects to respiratory illness to gastrointestinal ailments. Asthma in children, for example, has skyrocketed over the past 20 years. And hospital admissions for respiratory illness climb each summer in lockstep with smog levels.

Quality affordable housing is also critical part of our physical environment. People who are homeless aren’t healthy. People who live in sub-standard housing that is overcrowded, cold and damp are not healthy. The Victorians understood this. Their most effective weapons against infectious diseases were programs to improve housing standards.

And yet, in Canada – as in most of the world – if you want to find those with the worst health, then go look in the worst parts of the housing stock. Or worse yet, look to the streets of our cities.

So if we’re really serious about making Canadians the healthiest people in the world, we have to improve the quality of our physical environment, including investing more in affordable housing.

Where do we Begin

So where do we begin? How do we start drawing together all of the elements that add up to that rather broad umbrella that we call our health and wellbeing?

We begin with a paradigm shift. As Einstein said, you’ll never solve a problem if you use the same thinking that got you there in the first place.

We have to recognize that our health is a capital resource and we have to invest in it every bit as much as we would in our knowledge industries or any other 21st century resources.

We have to take a holistic approach and invest "upstream" at the broad determinants level. That’s where the financial investment will be smaller, the results bigger, and the payoff longer. If we only put our money "downstream", the investment will be larger, the results smaller, and the payoff shorter.

So we can’t just define health and wellbeing to mean just doctors and hospitals, pills and prescriptions. We have to connect all of the dots and deal with the picture as a whole.

That’s a difficult challenge. Societies as a whole, and governments in particular, are much more comfortable when they can fit everything into a neat box. Economic issues go into "the economy box", children’s issues go into "the children’s box", education goes into "the education box", the environment goes into "the environment box", health care goes into "the health care box" and so on…

Then, once we have everything neatly into its own box, then the cardboard turns into concrete! A friend of mine, someone who used to work in government, describes this as a "hardening of the categories, where never the brains shall meet".

The problem with that approach is that the real world doesn’t exist in neat little boxes. The real world is built around a variety of factors, all of which touch each other. It’s like when you throw a handful of stones into the water and the ripples from each move out to touch and reshape the others.

So if we really want Canadians to be the healthiest people in the world, it’s not enough that we "think outside of the box". We have to get rid of the boxes altogether.

We start with a change in government attitude. Governments have to view the decisions they make through the prism of "will it invest in the wellbeing of our society – in our health and overall quality of life – or will it diminish those things?" I would hope that the new Health Council uses this prism to comment on policies outside of the traditional health care box.

This sea change is essential. There has to be the will to see the big picture. But just as important is a sea change in government structure. There has to be a way to deliver results.

Governments have to create structures that will allow them to think and act across disciplines. A promising experiment in this regard is the National Roundtable on the Environment and the Economy. The Roundtable brings together representatives from government, industry, Native Canadians, academic and non-governmental organizations. It brings home the point that environmental health and economic growth are all part of the same picture.

Ontario used to have two Premier’s Councils, one on the Economy and one on Health. Eventually, they morphed into one, recognizing the importance of integrating social, health, economic, and environmental issues into a holistic approach.

The council, which was chaired by the Premier, brought together business, labour, social, environmental, and economic leaders — both experts and grassroots —along with key cabinet ministers.

We need such forums to become the rule, instead of the exception that proves the rule. The sooner we have more roundtables and fewer boxes, the better off we’ll all be.

And the SARS issue has reminded us in a dramatic way, that our Canadian roundtables and innovations in population health need to be part of global innovation and creative and effective interdependence. Viruses and bacteria do not recognize international boundaries. We need to globalize wellbeing as well as globalize efforts to deal with threats to wellbeing.

And leadership at all levels is required. As recommended in my final report, policy-makers must work to transform the primary care system. Key to connecting the dots with our health care system and the holistic wellbeing strategy I am advancing, is the need for our front-line care providers to be empowered to play a leadership role in advancing a broader prevention and wellness agenda.

We Have to Measure Wellbeing

I want to turn to one very important piece of the picture. What we measure counts!

There is a non-profit research group based in Halifax called GPI Atlantic. It’s Director, Ron Colman, has made what I would regard as a very profound observation. He said, "Indicators are powerful. What we count and measure reflects our values as a society and determines what makes it onto the policy agendas of governments."

I would add to that, that what we count and measure determines what we can be held accountable for. As I said in my report, Canadians are demanding new levels of accountability – which is why I proposed that we amend the Canada Health Act to include "accountability" as a new core principle.

Right now, the most commonly cited measure of Canada’s wellbeing is our GDP. I sometimes think that GDP must stand for Gross Distortion of Prosperity, because it provides a very misleading picture of our national wellbeing. It certainly was not created as a measure of wellbeing but it is often taken as a sign of "how we are doing" as a nation.

GDP counts all economic activity as a gain. It makes no distinction between activity that brings benefits, and activity that causes harm. Crime, pollution, accidents, sickness, natural disasters and war – all make the GDP go up simply because money is being spent on prisons, lawyers, doctors, drugs, hospitals, pollution cleanup and weapons.

Cigarette sales boost Canada’s GDP by $10-billion a year. Fast food sales contribute another $12-billion. Medical treatments for smoking and obesity-related illnesses chip in $6-billion. If the GDP were calculated by accountants instead of economists, these would all be treated as liabilities instead of assets.

We need new measuring tools to track changes in the key factors that affect our wellbeing and quality of life.

Fortunately, there are many groups across the country now engaged in developing new indices – far more accurate indices than the GDP – for measuring our quality of life and wellbeing. There are a host of projects, from the local to the national level, some dealing with the full spectrum of quality of life issues, others dealing exclusively with sub-themes.

My good friends at the Atkinson Foundation, among others like the CPRN, have been working particularly hard to encourage the various groups to work together to create a single Canadian Index of Wellbeing.

This new index would be based on the full range of values that Canadians regard as important to their quality of life. It would provide rock-solid data at the national, provincial and local level. The Index would be calculated and reported regularly, promoted widely and understood easily by the general public. And if this work can be developed in concert with similar efforts in other countries, we will be able to situate our progress in a global context.

A real Canadian Index of Wellbeing would engage Canadians in a meaningful debate about what it means to have global-leading quality of life and sustainability. It would provide policy-shapers and decision-makers with the information they need to measure the full benefits and costs of policy changes.

From workplace water coolers to government policy rooms, it would put the accountability spotlight on the kind of progress that Canada truly needs.Most importantly, it would contribute to the ongoing process of building a country based on true Canadian values and concerns.

The Next Revolution in Health Care

Ladies and gentlemen, as I said at the beginning of my comments, I was honoured to see the response of Canadians to my work as Commissioner on the Future of Health Care in Canada. I was especially gratified to see the way it galvanized opinion and sparked action for change.

But I feel as if my work is just beginning. I want to see us move beyond reforming health care to deal with the many determinants that affect the wellbeing and quality of life of Canadians.

How important is it that we do this?

Well, historians and health experts tell us that we have had two great revolutions in the course of public health. The first was the control of infectious diseases, notwithstanding our current challenges. The second was the battle against non-communicable diseases.

The third great revolution is about moving from an illness model to all of those things that both prevent illness and promote a holistic sense of wellbeing.

In my view, the wellness model needs to be informed:

1) by inspired leaders who genuinely share power with those less fortunate;

2) by a commitment to social inclusion and Civil Society that provide opportunities for all Canadians to participate in the things that count in our neighborhoods across this great county; and,

3) by an understanding that hopelessness kills and hopefulness with opportunity is a prescription for good health.

That’s my kind of revolution. It’s the kind that will ensure that Canadians are the healthiest people in the world. It’s also the kind of revolution that understands that the exceptional health we seek and how we achieve it, can provide a Canadian model for the world to emulate. I intend to be a part of that revolution. I hope you will too.

Thank you very much.