The Canadian Medical Association (CMA) and its Quebec office are pleased to provide this submission to the Committee on Transportation and the Environment on Bill 44: An Act mainly to ensure effective governance of the fight against climate change and to promote electrification. The CMA maintains that governance of the fight against climate change will not be effective unless it integrates the health impacts on the Quebec population. Physicians in Quebec, across Canada, and around the world have a unique role to play in helping advance government and public understanding of the health consequences of climate change and in supporting the development of effective public health responses. The CMA’s submission provides recommendations to better prepare and mitigate the impacts of a changing climate on people’s health and the health care system in Quebec.
How Climate Change Affects Health
The World Health Organization has identified climate change as the biggest threat to global health.
1 In Canada, the immediate health effects of climate change are a growing concern. In this century, Canada will experience higher rates of warming in comparison to other countries around the world. Northern Canada, including northern Quebec (Nunavik), will continue to warm at more than triple the global rate. These warming conditions will lead to an increase in extreme weather events, longer growing seasons, melting of the permafrost, and rising sea levels.2
Physicians are at the front lines of a health care system that is seeing growing numbers of patients experiencing health problems related to climate change, including heat-related conditions, respiratory illnesses, infectious disease outbreaks and impacts on mental health. For example, the heat wave in southern Quebec in 2018 was linked to over 90 deaths.3
Examples of the extent of this issue include:
The number of extremely hot days is expected to double or triple in some parts of Canada in the next 30 years and will lead to an increase in heat-related impacts (e.g., heat stroke, myocardial infarction, kidney failure, dehydration, stroke).4
Air pollution contributes to approximately 2,000 early deaths each year in Quebec by way of heart disease, stroke, lung cancer, and respiratory disease (such as aggravated asthma).5
An increase in vector-borne diseases such as Lyme disease has increased significantly in Quebec, with the number of cases increasing from 125 in 2014 to 338 in 2018.6
Extreme weather events are increasing in frequency, intensity and duration across Quebec and can negatively impact mental health (e.g., anxiety, depression and post-traumatic stress disorder),7 as well as place additional strain on the health care system.
Increasing temperatures are affecting the ice roads used in winter, and other roads built on permafrost in northern Quebec, threatening food security.8
There are sub-populations that are more susceptible to the health-related impacts of climate change. For example, in northern Quebec, climate change is already increasing health risks from food insecurity due to decreased access to traditional foods, decreased safety of ice-based travel, and damage to critical infrastructure due to melting permafrost. For the rest of Canada, the health impacts vary by geographic region, but include a list of issues such as increased risk of heat stroke and death, increases in allergy and asthma symptoms due to a longer pollen season, mental health implications from severe weather events, and increases in infectious diseases, UV radiation, waterborne diseases and respiratory impacts from air pollution. 9
Seniors, infants and children, socially disadvantaged individuals, and people with existing medical conditions such as cardiovascular disease, are at greater risk of being affected by climate change. The susceptibility of a population to the effects of climate change is dependent on their existing vulnerabilities and their adaptive capacity. 10,11
Figure 1. Examples of Health Impact of Climate Change in Canada5
Climate Change: A Health Emergency
Recent polls have demonstrated that Canadians are very concerned about climate change and its impact on health. A 2017 poll commissioned by Health Canada revealed that 79% of Canadians were convinced that climate change is happening, and of those people 53% accepted that it is a current health risk and 40% believe it will be a health risk in the future.12 As well, a 2019 poll commissioned by Abacus Data reports that Quebecers are the most anxious about climate change and think about the climate more often than people living in the rest of Canada. The same poll reports that 59% of people in Quebec believe that climate change is currently an emergency and 12% reported that it will likely become an emergency in a few years.13 These numbers are not surprising considering the intensity and frequency of extreme weather events in Quebec in recent years. The CMA believes climate change is a public health crisis. Over the past few years in Canada, there have been numerous extreme climate events, such as wildfires in British Columbia,
extreme heat waves in Quebec, and storm surges on the east coast. In southern Quebec, a changing climate has also increased the range of several zoonoses, including blacklegged ticks, which are vectors of Lyme disease.14 Physicians across Quebec are seeing patient outcomes affected by the changing climate and are advocating for change. The health impacts of climate change were raised at last year’s COP25 meeting in Madrid, Spain, among an international group of leading environment and health stakeholders, including the CMA. The group collectively called on governments to broaden the scope of their climate change initiatives and investments to include health care.
A lack of progress in reducing greenhouse gas emissions and building adaptive capacity threatens both human lives and the viability of health systems, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. In Quebec, the research consortium Ouranos estimated in 2015 that extreme heat, Lyme disease, West Nile virus and pollen alone will cost the Quebec state an additional $609 million to $1,075 million,15 and could result in up to 20,000 additional lives lost within the next 50 years.
Canada is currently not on track to meet the international targets set out by the Paris Agreement.16 The 2019 report from Lancet Countdown, the largest international health and climate research consortium, states that continued inaction on meeting the targets set out by the Paris Agreement will result in the health of a child born today being impacted negatively by climate change at every stage of its life.
The CMA recommends that adaptation and mitigation measures be prioritized to limit the effects of climate change on public health.
Hearing Health Care Professionals on Climate Change Last June, the CMA was pleased with the announcement made by the Minister of the Environment and the Fight Against Climate Change, Benoit Charette, to create a task force to ensure effective governance of the fight against climate change, including meeting Quebec’s international climate targets.17 Climate change crosses multiple sectors and requires experts from diverse backgrounds to create solutions to adapt and mitigate the impacts of climate change. Considering the overwhelming evidence of the impacts of climate change on human health, it is paramount that a health representative sits on the committee that will be advising the Minister. Physicians and health professionals have a critical role to play in advancing public understanding of the potential impacts of climate change on health and promoting appropriate actions aimed at protecting the health of Canadians. Physicians believe that what’s good for the environment is also good for human health. Protecting human health must be at the core of all environmental and climate change strategies within Quebec.
Recommendation 2: The CMA recommends that a health representative sit on the committee that will be advising the minister.
Dedicated Funding for a Greener Health Care System
The 2019 Lancet Countdown on Health and Climate Change reports that Canada has the third-highest per capita greenhouse gas emissions coming from its health care sector in the world. Health care related emissions account for approximately 4.5% of the country’s total emissions. Hospitals produce a significant proportion of health sector emissions as they are always on, are resource intensive, and have strict ventilation standards. Hospital services also produce large amounts of waste through the use of single-use items (e.g., hospital gowns and surgical supplies).
To remedy this problem, the CMA recommends that experts from research, education, clinical practice, and policy work together to reduce greenhouse gas emissions and that funding be dedicated to measuring the carbon footprint of different institutions and addressing these issues. Health care providers are uniquely positioned to advocate for innovative solutions that will help reduce greenhouse gas emissions by the health sector and improve public health.18 By reducing greenhouse gas emissions from the health system, the Quebec government will better position itself to be consistent with the timelines and goals of the Paris Agreement for zero-emissions for healthcare by 2050.19
The CMA recommends that a portion of the Green Fund’s budget be dedicated to the greening of health systems.
The CMA’s submission highlights the need to better prepare and mitigate the health impacts of a changing climate, as well as the need for a health representative to advise the minister, and the allocation of funding for the greening of health systems in Quebec. Physicians are in a unique position to help the government develop strategies to mitigate the impacts of climate change and ultimately improve population health.
Summary of recommendations
The CMA recommends that adaptation and mitigation measures be prioritized to limit the effects of climate change on public health.
The CMA recommends that a health representative sit on the committee that will be advising the minister.
The CMA recommends that a portion of the Green Fund’s budget be dedicated to the greening of health systems.
1 Costello A, Abbas M, Allen A, Ball S, et al. The Lancet and University College London Institute for Global Health Commission, The Lancet, 2009;373( 9676):1693-1733. Available: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60935-1/fulltext (accessed 2020 Jan 25).
2 Government of Canada. Canada’s Changing Climate Report. Ottawa: Government of Canada; 2019. Available: https://www.nrcan.gc.ca/sites/www.nrcan.gc.ca/files/energy/Climate-change/pdf/CCCR_FULLREPORT-EN-FINAL.pdf (accessed 2020 Jan 25).
3 Institut national de santé publique du Québec. Surveillance des impacts des vagues de chaleur extrême sur la santé au Québec à l’été 2018 [French only]. Québec : Institut national de santé publique du Québec; 2018. Available: https://www.inspq.qc.ca/bise/surveillance-des-impacts-des-vagues-de-chaleur-extreme-sur-la-sante-au-quebec-l-ete-2018 (accessed 2020 Jan 25).
4 Guilbault S, Kovacs P, Berry P, Richardson G, et al. Cities adapt to extreme heat: celebrating local leadership. Ottawa: Health Canada Institute for Catastrophic Loss Reduction; 2016. Available: https://www.iclr.org/wp-content/uploads/PDFS/cities-adapt-to-extreme-heat.pdf (accessed 2020 Jan 25).
5 Health Canada. Health Impacts of Air Pollution in Canada--an Estimate of Premature Mortalities. Ottawa: Health Canada; 2017. Available: https://www.canada.ca/en/health-canada/services/air-quality/health-effects-indoor-air-pollution.html (accessed 2020 Jan 25).
6 Santé et services sociaux Québec. Maladie de Lyme. Tableau des cas humains – Archives 2014 à 2018. [French only]. Available: https://www.msss.gouv.qc.ca/professionnels/zoonoses/maladie-lyme/tableau-des-cas-humains-lyme-archives/ (accessed 2020 Jan 25).
7 Cunsolo A, Ellis N. Ecological grief as a mental health response to climate change-related loss. Nature Climate Change 2018;8:275-81.
8 Rosol R, Powell-Hellyer S, Chan HM. Impacts of decline harvest of country food on nutrient intake among Inuit in Arctic Canada: impact of climate change and possible adaptation plan. Int J Circumpolar Health 2016;75(1):31127. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4937722/pdf/IJCH-75-31127.pdf (accessed 2020 Jan 25).
9 Howard C, Buse C, Rose C, MacNeill A, Parkes, M. The Lancet Countdown on Health and Climate Change: Policy Brief for Canada. London: Lancet Countdown, Canadian Medical Association, and Canadian Public Health Association, 2019. Available: https://storage.googleapis.com/lancet-countdown/2019/11/Lancet-Countdown_Policy-brief-for-Canada_FINAL.pdf. (accessed 2020 Jan 25).
10 Canadian Medical Association (CMA). CMA Policy. Climate Change and Human Health. Ottawa: CMA; 2010. Available: https://policybase.cma.ca/en/permalink/policy9809 (accessed 2020 Jan 25).
11 Health Canada. Climate Change and Health. Ottawa: Health Canada; 2020. Available: https://www.canada.ca/en/health-canada/services/climate-change-health.html (accessed 2020 Jan 26).
12 Environics Health Research. Public Perceptions of Climate Change and Health Final Report. Ottawa: Health Canada; 2017.
13 Abacus Data. Is Climate Change “An Emergency” and do Canadians Support a Made-in-Canada Green New Deal? Ottawa: Abacus Data; 2019. Available: https://abacusdata.ca/is-climate-change-an-emergency-and-do-canadians-support-a-made-in-canada-green-new-deal/ (accessed 2020 Jan 26).
14 Howard C, Rose C, Hancock T. Lancet Countdown 2017 Report: Briefing for Canadian Policymakers. Lancet Countdown and Canadian Public Health Association. Available: https://storage.googleapis.com/lancet-countdown/2019/10/2018-lancet-countdown-policy-brief-canada.pdf. (accessed 2020 Jan 25).
15 Ouranos. Vers l’adaptation. Synthèse des connaissances sur les changements climatiques au Québec [French only]. Montreal: Ouranos; 2015. Available: https://www.ouranos.ca/publication-scientifique/SyntheseRapportfinal.pdf (accessed 2020 Jan 25).
16 Government of Canada. Greenhouse Gas Emissions. Ottawa: Government of Canada; 2018. Available: https://www.canada.ca/en/environment-climate-change/services/environmental-indicators/greenhouse-gas-emissions.html (accessed 2020 Jan 26).
17 Gouvernment du Québec. Press Release: Minister Benoit Charette announces an unprecedented process to develop the forthcoming Electrification and Climate Change Plan. Québec: Gouvernment du Québec;
2019. Available: http://www.environnement.gouv.qc.ca/infuseur/communique_en.asp?no=4182 (accessed 2020 Jan 26).
18 Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLoS Med 2018;15(7):e1002623. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6067712/pdf/pmed.1002623.pdf (accessed 2020 Jan 25). (accessed 2020 Jan 26).
19 Intergovernmental Panel on Climate Change (IPCC). Global Warming of 1.5C--Summary for Policymakers, France: IPCC; 2018. Available: https://www.ipcc.ch/sr15/ (accessed 2020 Jan 25).
Primary care is the backbone of our health care system in Canada and a national priority for this government.
The echoing words of the Speech from the Throne certify that the Government will strengthen health care and “Work with provinces, territories, health professionals and experts in industry and academia to make sure that all Canadians can access a primary care family doctor.” The Health Minister’s mandate letter further confirms that the Government will work “with the support of the Deputy Prime Minister and Minister of Intergovernmental Affairs, the Minister of Finance and the Minister of Seniors, to strengthen Medicare and renew our health agreements with the provinces and territories” to “ensure that every Canadian has access to a family doctor or primary health care team”.
We recognize that strengthening primary care through a team-based, inter-professional approach is integral to improving the health of all people living in Canada. This belief is consistent across our alliance of four major groups: the Canadian Medical Association, the Canadian Nurses Association, the Canadian Association of Social Workers and the College of Family Physicians of Canada. There is nothing more suiting or fortunate than for a team-based approach to be wholeheartedly supported by an even larger team of teams.
We commend the Government’s commitment
to increasing Canadians’ access to primary care.
We have a model to make it happen.
The Primary Health Care Transition Fund 2, a one-time fund over four years, would provide the necessary funding to help establish models of primary care based on the Patient’s Medical Home, a team-based approach that connects the various care delivery points in the community for each patient. This model is rooted in the networking of family physicians, nurse practitioners, nurses, social workers and other health professionals as a team. This is the only way to provide comprehensive primary care to patients. It will enable a more exhaustive approach to patient care, ultimately leading to increased prevention and better health outcomes for Canadians. Consider it the main artery
in meeting the needs of patients and communities.
A commitment to the Primary Health Care Transition Fund 2 gives substance to the promise of building a network of care that addresses immediate health needs while connecting to ongoing social and community health services. This Fund model bolsters Canadians. It is backed by doctors, nurses, and social workers. A phalanx of Canadian care providers stand behind it. An entire country will benefit from it.
In support of the federal government’s commitment to improve Canadians’ access to primary care,
we recommend a one-time fund in the amount of $1.2 billion over four years to expand the establishment of primary care teams in each province and territory.
It is with a sense of urgency that the Canadian Medical Association (CMA) submits
the recommendations herein for emergency federal measures that, taken together,
will ensure Canadians receive appropriate care and that supportive measures are
implemented for public health protection during the COVID-19 pandemic.
While Canada has made significant strides since SARS to establish and implement
effective public health infrastructure, resources and mechanisms, the significant
resource constraints across our health systems present a major challenge in our
current response. Federal emergency measures must be developed in the context
of the current state of health resources: hospitals across the country are already at
overcapacity, millions of Canadians lack access to a regular family doctor, countless
communities are grappling with health care shortages, virtual care is in its infancy,
and so on.
Another core concern is the chronic underfunding and ongoing budget cuts of
public health resources and programming. Public health capacity and leadership at
all levels is fundamental to preparedness to respond to an infectious disease threat,
particularly one of this magnitude.
It is in this context that the Canadian Medical Association recommends that the
following emergency measures be implemented by the federal government to
support the domestic response to the COVID-19 pandemic:
1410, pl. des tours Blair / Blair Towers Place,
bur. / Suite 500, Ottawa ON K1J 9B9
1) FEDERAL RECOMMENDATION AND SUPPORT FOR SOCIAL DISTANCING
In this time of crisis, Canadians look to the federal government for leadership and guidance.
The single most important measure that can be implemented at this time is a consistent
national policy calling for social distancing. This recommendation by the federal government
must be paired with the resources necessary to ensure that no Canadian will be forced to choose
between financial hardship — whether by losing employment or not being able to pay rent —
and protecting their health.
The CMA strongly recommends that the federal government immediately communicate guidance
to Canadians to implement social distancing measures. The CMA further recommends that the
federal government deliver new financial support measures as well as employment protection
measures to ensure that all Canadians may engage in social distancing.
2) NEW FEDERAL EMERGENCY FUNDING TO BOOST PROVINCIAL/
TERRITORIAL CAPACITY AND ENSURE CONSISTENCY
It is the federal government’s role to ensure a coordinated and consistent national response across
jurisdictions and regions. This is by far the most important role for the federal government in
supporting an effective domestic response, that is, protecting the health and well-being of Canadians.
The CMA strongly recommends that the federal government deliver substantial emergency funding to
the provinces and territories to ensure health systems have the capacity to respond to the pandemic.
Across the OECD, countries are rapidly stepping up investment in measures to respond to COVID-19,
including significant investment targeting boosting health care capacity. In considering the
appropriate level of federal emergency funding to boost capacity in our provincial/territorial
systems, the CMA urges the federal government to recognize that our baseline is a position of deficit.
New emergency federal funding to boost capacity in provincial/territorial health systems should
be targeted to:
rapidly enabling the expansion and equitable delivery of virtual care;
establishing a centralized 24-hour national information hotline for health care workers to obtain
clear, timely and practical information on clinical guidelines, etc.;
expanding the capacity of and resources for emergency departments and intensive care units;
coordinating and disseminating information, monitoring and guidance within and across
rapidly delivering income stabilization for individuals and families under quarantine.
Finally, the inconsistencies in the provision and implementation of guidance and adoption of
public health measures across and within and jurisdictions is highly concerning. The CMA strongly
encourages the federal government enable consistent adoption of pan-Canadian guidance and
measures to ensure the health and safety of all Canadians.
1410, pl. des tours Blair / Blair Towers Place,
bur. / Suite 500, Ottawa ON K1J 9B9
3) ENSURING AN ADEQUATE SUPPLY OF PERSONAL PROTECTIVE
EQUIPMENT FOR CANADIAN HEALTH CARE WORKERS AND
ENSURING APPROPRIATE USAGE
The CMA is hearing significant concerns from front-line health care workers, including physicians,
about the supply and appropriate usage of personal protective equipment. It is the CMA’s
understanding that pan-Canadian efforts are underway to coordinate supply; however, additional
measures by the federal government to ensure adequate supply and appropriate usage are required.
Canada is at the outset of this public health crisis — supply issues at this stage may be exacerbated
as the situation progresses. As such, the CMA strongly recommends that the federal government
take additional measures to support the acquisition and distribution throughout health systems of
personal protective equipment, including taking a leadership role in ensuring our domestic supply via
international supply chains.
4) ESTABLISH EMERGENCY PAN-CANADIAN LICENSURE FOR
HEALTH CARE WORKERS
In this time of public health crisis, the federal government must ensure that regulatory barriers
do not prevent health care providers from delivering care to patients when and where they need
it. Many jurisdictions and regions in Canada are experiencing significant shortages in health
The CMA urges the federal government to support piloting a national licensure program so that
health care providers can opt to practice in regions experiencing higher infection rates or where
there is a shortage of providers. This can be accomplished by amending the Canadian Free Trade
Agreement (CFTA) to facilitate mobility of health care workers.
Specifically, that the following language be added to Article 705(3) of the CFTA:
(j) A regulatory authority of a Party* shall waive for a period of up to 100 days any condition of
certification found in 705(3)(a) - (f) for any regulated health care worker to work directly or
indirectly to address the Covid-19 pandemic or any health care emergency. Any disciplinary matter
emanating from work in any province shall be the responsibility of the regulatory authority of the
jurisdiction where the work is performed. Each Party shall instruct its regulatory authorities to set-up
a rapid check-in/check-out process for the worker.
*Party refers to a signatory of the CFTA
To further enable this measure, the CMA recommends that the federal government deliver targeted
funding to the regulatory colleges to implement this emergency measure as well as targeted funding
to support the provinces/territories in delivering expanded patient care.
1410, pl. des tours Blair / Blair Towers Place,
bur. / Suite 500, Ottawa ON K1J 9B9
5) ESTABLISH AN EMERGENCY NATIONAL MENTAL HEALTH SUPPORT
SERVICE FOR HEALTH PROVIDERS
Health care providers may experience trauma and hardship in meeting the increasing health needs
and concerns of Canadians in this time of crisis. The CMA strongly recommends that the federal
government establish an emergency National Mental Health Support Services hotline for all health
care providers who are at the front lines of patient care during the pandemic. This critical resource
will ensure our health care providers have the help they may need as they care for patients,
including helping them to deal with an increasing patient load.
6) IMPLEMENT A TARGETED TAX CREDIT FOR HEALTH PROVIDERS
EXPERIENCING FINANCIAL LOSS DUE TO QUARANTINE
In addition to supporting income stabilization measures for all Canadians who may benefit from
support, the CMA recommends that the federal government establish a time-limited and targeted
tax credit for health providers who may experience financial loss due to quarantine.
Many health care providers operate independently and may face significant fixed expenses as part of
their care model. As health care providers may have an increased risk of contracting COVID-19, this
may result in significant financial loss. A time-limited tax credit to ease this loss may help ensure
the continued viability of their care model. Further, the CMA supports extending the federal tax
filing timeline in recognition of the fact that health care workers and all Canadians are focused
on emergency matters.
The CMA’s recommendations align with the OECD’s call to action: “Governments need to ensure
effective and well-resourced public health measures to prevent infection and contagion, and implement
well-targeted policies to support health care systems and workers, and protect the incomes of vulnerable
social groups and businesses during the virus outbreak.”
Now is the time to ensure that appropriate leadership continues and that targeted investments are
made to protect the health of Canadians.
The current global pandemic caused by the novel coronavirus has presented the international medical community with unprecedented ethical challenges. The most difficult of these has involved making decisions about access to scarce resources when demand outweighs capacity.
In Canada, it is well accepted that everyone should have an equal opportunity to access and receive medical treatment. This is possible when there are sufficient resources. But in contexts of resource scarcity, when there are insufficient resources, difficult decisions have to be made about who receives critical care (e.g., ICU beds, ventilators) by triaging patients. Triage is a process for determining which patients receive treatment and/or which level of care under what circumstances in contexts of resource scarcity. Priority-setting for resource allocation becomes more ethically complex during catastrophic times or in public health emergencies, such as today’s COVID-19 pandemic, when there is a need to manage a potential surge of patients.
Physicians from China to Italy to Spain to the United States have found themselves in the unfathomable position of having to triage their most seriously ill patients and decide which ones should have access to ventilators and which should not, and which allocation criteria should be used to make these decisions. While the Canadian Medical Association hopes that Canadian physicians will not be faced with these agonizing choices, it is our intent, through this framework, to provide them with guidance in case they do and enable them to make ethically justifiable informed decisions in the face of difficult ethical dilemmas. Invoking this framework to ground decisions about who has access to critical care and who does not should only be made as a last resort. As always, physicians should carefully document their clinical and ethical decisions and the reasoning behind them.
Generally, the CMA would spend many months in deliberations and consultations with numerous stakeholders, including patients and the public, before producing a document such as this one. The current situation, unfortunately, did not allow for such a process. We have turned instead to documents, reports and policies produced by our Italian colleagues and ethicists and physicians from Canada and around the world, as well as provincial level documents and frameworks.
The CMA is endorsing and recommending that Canadian physicians use the guidance provided by Emmanuel and colleagues in the New England Journal of Medicine article dated from March 23rd, as outlined below. We believe these recommendations represent the best current approach to this situation, produced using the highest current standard of evidence by a panel of internationally recognized experts. We also recognize that the situation is changing constantly, and these guidelines may need to be updated as required.
The CMA will continue to advocate for access to personal protective equipment, ventilators and ICU equipment and resources. We also encourage physicians to make themselves aware of any relevant provincial or local documents, and to seek advice from their regulatory body or liability protection provider. It should be noted that some provinces and indeed individual health care facilities will have their own protocols or frameworks in place. At the time of its publication, this document was broadly consistent with those protocols that we were given an opportunity to review.
The CMA recognizes that physicians may experience moral distress when making these decisions. We encourage physicians to seek peer support and practice self-care. In addition, the CMA recommends that triage teams or committees be convened where feasible in order to help separate clinical decision making from resource allocation, thereby lessening the moral burden being placed on the individual physician.
The CMA recommends that physicians receive legal protection to ensure that they can continue providing needed care to patients with confidence and support and without fear of civil or criminal liability or professional discipline. In this time of uncertainty, physicians should be reassured that their good faith efforts to provide care during such a crisis will not put them at increased medical-legal risk. Providing such reassurance is needed so that physicians have the confidence to continue to provide care to their patients.
Recommendation 1: In the context of a pandemic, the value of maximizing benefits is most important. This value reflects the importance of responsible stewardship of resources: it is difficult to justify asking health care workers and the public to take risks and make sacrifices if the promise that their efforts will save and lengthen lives is illusory. Priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus value across expert reports. It is consistent both with utilitarian ethical perspectives that emphasize population outcomes and with nonutilitarian views that emphasize the paramount value of each human life. There are many reasonable ways of balancing saving more lives against saving more years of life; whatever balance between lives and life-years is chosen must be applied consistently.
Limited time and information in a Covid-19 pandemic make it justifiable to give priority to maximizing the number of patients that survive treatment with a reasonable life expectancy and to regard maximizing improvements in length of life as a subordinate aim. The latter becomes relevant only in comparing patients whose likelihood of survival is similar. Limited time and information during an emergency also counsel against incorporating patients’ future quality of life, and quality-adjusted life-years, into benefit maximization. Doing so would require time-consuming collection of information and would present ethical and legal problems. However, encouraging all patients, especially those facing the prospect of intensive care, to document in an advance care directive what future quality of life they would regard as acceptable and when they would refuse ventilators or other life-sustaining interventions can be appropriate.
Operationalizing the value of maximizing benefits means that people who are sick but could recover if treated are given priority over those who are unlikely to recover even if treated and those who are likely to recover without treatment. Because young, severely ill patients will often comprise many of those who are sick but could recover with treatment, this operationalization also has the effect of giving priority to those who are worst off in the sense of being at risk of dying young and not having a full life.
Because maximizing benefits is paramount in a pandemic, we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission. Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians — and some clinicians might refuse to do so. However, many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent. We agree with these guidelines that it is the ethical thing to do. Initially allocating beds and ventilators according to the value of maximizing benefits could help reduce the need for withdrawal.
Recommendation 2: Irrespective of Recommendation 1, Critical Covid-19 interventions — testing, PPE, ICU beds, ventilators, therapeutics, and vaccines — should go first to front-line health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace. These workers should be given priority not because they are somehow more worthy, but because of their instrumental value: they are essential to pandemic response. If physicians and nurses and RTs are incapacitated, all patients — not just those with Covid-19 — will suffer greater mortality and years of life lost. Whether health workers who need ventilators will be able to return to work is uncertain but giving them priority for ventilators recognizes their assumption of the high-risk work of saving others. Priority for critical workers must not be abused by prioritizing wealthy or famous persons or the politically powerful above first responders and medical staff — as has already happened for testing. Such abuses will undermine trust in the allocation framework.
Recommendation 3: For patients with similar prognoses, equality should be invoked and operationalized through random allocation, such as a lottery, rather than a first-come, first-served allocation process. First-come, first-served is used for such resources as transplantable kidneys, where scarcity is long-standing, and patients can survive without the scarce resource. Conversely, treatments for coronavirus address urgent need, meaning that a first-come, first-served approach would unfairly benefit patients living nearer to health facilities. And first-come, first-served medication or vaccine distribution would encourage crowding and even violence during a period when social distancing is paramount. Finally, first-come, first-served approaches mean that people who happen to get sick later on, perhaps because of their strict adherence to recommended public health measures, are excluded from treatment, worsening outcomes without improving fairness. In the face of time pressure and limited information, random selection is also preferable to trying to make finer-grained prognostic judgments within a group of roughly similar patients.
Recommendation 4: Prioritization guidelines should differ by intervention and should respond to changing scientific evidence. For instance, younger patients should not be prioritized for Covid-19 vaccines, which prevent disease rather than cure it, or for experimental post- or pre-exposure prophylaxis. Covid-19 outcomes have been significantly worse in older persons and those with chronic conditions. Invoking the value of maximizing saving lives justifies giving older persons priority for vaccines immediately after health care workers and first responders. If the vaccine supply is insufficient for patients in the highest risk categories — those over 60 years of age or with coexisting conditions — then equality supports using random selection, such as a lottery, for vaccine allocation. Invoking instrumental value justifies prioritizing younger patients for vaccines only if epidemiologic modeling shows that this would be the best way to reduce viral spread and the risk to others.
Epidemiologic modeling is even more relevant in setting priorities for coronavirus testing. Federal guidance currently gives priority to health care workers and older patients but reserving some tests for public health surveillance could improve knowledge about Covid-19 transmission and help researchers target other treatments to maximize benefits.
Conversely, ICU beds and ventilators are curative rather than preventive. Patients who need them face life-threatening conditions. Maximizing benefits requires consideration of prognosis — how long the patient is likely to live if treated — which may mean giving priority to younger patients and those with fewer coexisting conditions. This is consistent with the Italian guidelines that potentially assign a higher priority for intensive care access to younger patients with severe illness than to elderly patients. Determining the benefit-maximizing allocation of antivirals and other experimental treatments, which are likely to be most effective in patients who are seriously but not critically ill, will depend on scientific evidence. These treatments may produce the most benefit if preferentially allocated to patients who would fare badly on ventilation.
Recommendation 5: People who participate in research to prove the safety and effectiveness of vaccines and therapeutics should receive some priority for Covid-19 interventions. Their assumption of risk during their participation in research helps future patients, and they should be rewarded for that contribution. These rewards will also encourage other patients to participate in clinical trials. Research participation, however, should serve only as a tiebreaker among patients with similar prognoses.
Recommendation 6: There should be no difference in allocating scarce resources between patients with Covid-19 and those with other medical conditions. If the Covid-19 pandemic leads to absolute scarcity, that scarcity will affect all patients, including those with heart failure, cancer, and other serious and life-threatening conditions requiring prompt medical attention. Fair allocation of resources that prioritizes the value of maximizing benefits applies across all patients who need resources. For example, a doctor with an allergy who goes into anaphylactic shock and needs life-saving intubation and ventilator support should receive priority over Covid-19 patients who are not frontline health care workers.
Approved by the CMA Board of Directors April 2020
During these unprecedented times, Canada’s physicians, along with all front-line health care workers (FLHCWs), have not only put themselves at risk but have made enormous personal sacrifices while fulfilling a critical role in life-threatening circumstances.
The CMA recognizes and strongly supports the measures the federal government has taken to date to mitigate the health and economic impacts of COVID-19 on Canadians. However, given the unique circumstances that Canada’s FLHCWs face, additional measures are required to acknowledge their role, the risks to themselves and their families, and the financial burden they have taken on through it all.
To gain a better understanding of this issue, the CMA commissioned MNP LLP (MNP) to conduct a thorough economic impact study. They assessed the effects of the COVID-19 pandemic on physician practices in Canada and identified policy options to mitigate these effects.
This brief summarizes the findings, provides an overview of the impact of the COVID-19 pandemic on physician practices across the country and highlights targeted federal measures that can significantly mitigate the evident challenges physicians are experiencing. It is important to note that the recommended measured were developed through the lens of recognizing the important contribution of Canada’s FLHCWs.
UNDERSTANDING HOW THE PANDEMIC
IS IMPACTING PHYSICIAN PRACTICES
Canada’s physicians are highly skilled professionals, providing an important public service and making a significant contribution to the health of Canadians, our nation’s health infrastructure and our knowledge economy. In light of the design of Canada’s health care system, the vast majority of physicians are self-employed professionals operating medical practices as small business owners. Like most small businesses in Canada, physician practices have been negatively impacted by the necessary measures governments have established to contain this pandemic.
Under the circumstances of the pandemic, the provinces postponed non-emergent procedures and surgeries, indefinitely. According to data from the 2019 Physician Workforce Survey conducted by the CMA, approximately 75% of physicians reported practising in settings that would be expected to experience a reduction in patient volumes as a result of COVID-19 measures. This suggests “the vast majority of physicians in Canada anticipate declines in earnings as a result of COVID-19 restrictions.”
Physician practices include a variety of structures, which relate to the practice setting or type. In their economic impact study, MNP estimates that across the range of practice settings, the after-tax monthly earnings of physician practices are estimated to decline between 15% and 100% in the low-impact scenario, and between 25% and 267% in the high-impact scenario. These two scenarios are in comparison to a baseline scenario, prior to the pandemic. The low-impact scenario is based on the reduction of physician services reported during the 2003 experience with the Severe Acute Respiratory Syndrome (SARS) while the high-impact scenario estimates more significant impacts, being approximately double those observed during SARS.
Unlike salaried public sector professionals, such as teachers, nurses or public servants, most physicians operate as small business owners who are solely responsible for the management of their practices. They employ staff, rent office space and have numerous other overhead costs related to running a small business, which they are still responsible for regardless of decreased earnings. According to data published by Statistics Canada in 2019 there were 120,241 people employed in physician offices in Canada and an additional 28,054 employed in medical laboratories. Additionally, physicians manage significant overhead expenses that are unique to medical practice such as practice insurance, licence fees and continuing medical education. It’s important to understand that even hospital-based physicians may be responsible for significant overhead expenses, unlike other hospital staff. Like any small business owner grappling with drastic declines in revenue, physicians may be forced to reduce their staffing levels or even close their practices entirely in response to the COVID-19 pandemic.
ADDRESSING THE GAPS: ENSURING THAT FEDERAL ECONOMIC PROGRAMS CAPTURE PHYSICIAN PRACTICES
To reiterate, the CMA supports the federal government’s decisive and meaningful response to the pandemic, including delivering critical economic relief programs. However, more detailed analysis is revealing that segments of physician practices are not eligible for these critical economic programs, because of technicalities.
At this time, the CMA has identified three key segments of physician practice models who may
not currently be eligible for the economic relief programs because of technicalities. These are:
1. hospital-based specialists
2. physician practices that operate as a small business but may not meet technical criteria
3. physicians delivering locum medical care
These technical factors reflect the complexity of the health system infrastructure in Canada. Although hospital-based specialists may receive some form of salary, they may still be structured as a small business and be responsible for paying overhead fees to the hospital. Many physicians may operate as a small business and remit a statement of self-employment, and they may not have a business number or a business bank account. As is common amongst other self-employed professionals, many physicians operate practices within cost-sharing structures. The CMA is deeply concerned that these structures are presently being excluded for the federal government’s critical economic relief programs. As a result, this exclusion is affecting the many employees of practices structured as cost-sharing arrangements. Finally, physicians providing care in other communities, known as locum practice, would also be responsible for overhead expenses.
It is the CMA’s understanding that the federal government is seeking to be inclusive in delivering economic relief programs to mitigate the impacts of the pandemic, such as closures or unemployment. For physician practices, eligibility for federal economic relief programs would extend the reach of these mitigation measures to maintaining Canada’s critical health resources and services, as physician practices are responsible for a
significant portion of health system infrastructure.
As such, the CMA respectfully recommends that the federal government ensure that these critical economic programs be made available to all segments of physician practices.
To this end, the CMA recommends that
the federal government expand eligibility
for the federal economic relief program to:
1. Include hospital-based specialists paying fees for overhead expenses to the hospitals
(e.g., staff, equipment, space);
2. capture physician-owned medical practices using a “personal” banking account as well
as those in cost-sharing structures to access programs; and,
3. include physicians who provide locum medical care.
NEW FEDERAL TAX MEASURES TO SUPPORT AND RECOGNIZE FRONT-LINE HEALTH CARE WORKERS
It is also important to note that the impact of COVID-19 on FLHCWs goes well beyond the financial impacts.
All FLHCWs face numerous challenges trying to carry out their work during these difficult times. They put their health and the health of their families at risk. They make enormous sacrifices, sometimes separating themselves from their families to protect them. These risks and sacrifices can strain an individual’s mental health, especially when coupled with anxiety over the lack of proper personal protective equipment (PPE). A survey conducted by the CMA at the end of April showed that almost 75% of physicians who responded to the survey indicated feeling very or somewhat anxious about the lack of PPE. FLHCWs deserve to be recognized for their unique role during
Given the enormous sacrifices and risks that FLHCWs are making every day, the federal government should enact measures to recognize their significant contributions during these unprecedented times.
The CMA recommends that the federal government implement the following
new measures for all FLHCWs:
1. An income tax deduction for FLHCWs put at risk during the COVID-19 pandemic,
in recognition of their heroic efforts. All FLHCWs providing in-person patient care during the pandemic would be eligible to deduct a designated amount against their income earned. This would be modelled on the deduction provided to members
of the Canadian Armed Forces serving in moderate- and high-risk missions.
2. A non-taxable grant to support the families of FLHCWs who die in the course of responding to the COVID-19 pandemic or who die as a result of an occupational illness or psychological impairment related to this work. The grant would also apply to cases in which the death of an FLHCW’s family member is attributable to the FLHCW’s work in responding to the pandemic. The CMA is recommending that access to the Memorial Grant program, or a similar measure, be granted to FLHCWs and
their family member(s).
3. A temporary emergency accommodation tax deduction for FLHCWs who incur additional accommodation costs as well as a home renovation credit in recognition of the need for FLHCWs to adhere to social distancing to prevent the spread of COVID-19 to their family members. The CMA recommends all FLHCWs earning income while working at a health care facility or in a capacity related thereto
(e.g., paramedics or janitorial staff) be eligible for the deduction and credit.
4. Provide additional child-care relief to FLHCWs by doubling the child-care deduction.
The CMA recommends the individuals listed above be eligible for the enhanced deduction.
It is important that any measures enacted be simple for the government to implement and administer as well as simple for FLHCWs to understand and access. The recommendations above will ensure that relief applies to a wide range of Canada’s FLHCWs who are battling COVID-19.
More details on these recommendations are provided in Appendix A to this brief.
INCREASING FEDERAL HEALTH FUNDING
TO SUPPORT SYSTEM CAPACITY
It is due to the action of the federal and provincial/territorial governments, together with Canadians, in adhering to public health guidance that our health systems have been able to manage the health needs of Canadians during the pandemic. However, as governments and public health experts consider how we may proceed in lifting certain restrictions, we are beginning to comprehend the enormity of the effort and investment required to resume health care services. During the pandemic, a significant proportion of health care services, such as surgeries, procedures and consults considered “non-essential” have been delayed. As health services begin to resume, health systems will be left to grapple with a significant spike in already lengthy waiting times. Further, all health care facilities will need to adopt new guidance to adhere to physical distancing, which may necessitate longer operating hours, increasing staff levels and/or physical renovations. Given these issues, the CMA is gravely concerned that Canada’s already financially struggling health systems will face significant funding challenges at a time when provincial/
territorial governments are grappling with recession economies. The CMA is strongly supportive of new
federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians
as the pandemic continues.
As outlined in this brief, the overwhelming majority of Canada’s physician practices will be
negatively impacted financially by COVID-19. The indefinite postponement of numerous medical procedures, coupled with restrictions related to physical distancing resulting in reduced patient
visits, will have a material effect on physician practices, risking their future viability. As well,
all FLHCWs will be severely impacted by COVID-19 personally, through risks to themselves and their families. Many families of FLHCWs will also be impacted financially, from increased child-care costs
to, tragically, costs associated with the death of a loved one because of COVID-19.
In light of these substantial risks and sacrifices, the CMA urges the adoption of the above-mentioned recommendations designed to recognize the special contribution of Canada’s FLHCWs during these
Racism is a structural determinant of health and drives health and social inequities. The recent incidents of anti-Black violence, racism and discrimination in the US and Canada also shed light on the structural inequities and racism that exist within the medical profession and the health system.
The profession of medicine is grounded in respect for all people. This commitment recognizes that everyone has equal and inherent worth, the right to be valued and respected, and the right to be treated with dignity.
It’s critical that our medical culture – and society more broadly – upholds these values. But today, we’re reminded that there’s much more to do as a profession, and as a global community, to get us there.
Earlier this year, we launched our first-ever policy on equity and diversity in medicine Opens in a new window to help break down the many broad and systemic barriers that remain, to reduce discrimination and bias within our profession, and to create physically and psychologically safe environments for ourselves, our colleagues and our patients.
Alongside this policy comes a commitment to holding ourselves accountable to recognizing and challenging behaviours, practices and conditions that hinder equity and diversity, including racism.
Instances of racism, intolerance, exclusion, violence and discrimination have no place in medicine, and no place in our society. The Canadian Medical Association condemns racism in all its forms. Today, we stand alongside all those who have been affected by these appalling and inexcusable actions and beliefs.
Dr. Sandy Buchman
President, Canadian Medical Association
Subject: Improving Long-term Care for People in Canada
Dear Minister Hajdu and Minister Schulte,
We are writing to you with recommendations for responding to the staggering effects COVID-19 has had on our health-care system, particularly in long-term care (LTC) homes across Canada. These recommendations were recently unveiled by the Canadian Nurses Association (CNA) on May 27 through a report entitled 2020 Vision: Improving Long-term Care for People in Canada (attached to this letter). We invite you to read it and consider the proposals we are bringing forward.
As you know, Canada has had unacceptable rates of COVID-19-related deaths in LTC; by late April, 79% of the country’s deaths due to COVID-19 were linked to outbreaks in these homes. These tragic numbers are in part a result of decades of neglect of the LTC sector and a growing mismatch between the level of care required by people living in those settings, and the level of care available. Furthermore, the recent reports from the military deployed to Ontario and Quebec’s long-term care homes have emphasized the shocking and horrific conditions that exist in some nursing homes in Canada.
We applaud the Prime Minster’s recent commitment to work closely and support the province’s efforts to improve standards of care for older people in long-term care
homes across the country. Moreover, further decisive action needs to be undertaken. To address the flaws COVID-19 has revealed in the support and care systems available to Canada’s older people, we recommend that your Government take immediate action on three important fronts:
The Government of Canada should immediately appoint a commission of inquiry on aging;
Federal public health leaders must work with provincial, territorial and Indigenous governments and public health leaders to review the country’s COVID-19 response and organize preparations for the next pandemic;
Federal, provincial and territorial governments must increase investments in community, home and residential care to meet the needs of our aging population.
As the Prime Minister indicated last week, providing support in the short term and having broader discussions in the long term is critical. We believe many solutions can be put in place now in some long-term care homes if they had better funding, for example. In the long term, a deeper look to identify the best models for delivering better health and social services will support safe and dignified aging for every person in Canada.
We recognize the challenges involved to address the issues in the support and care systems for older people in Canada. The benefits of redesigning how we provide care for older people (Canada’s largest growing demographic) and others with complex continuing care needs will go beyond improving their lives and health. A good long-term care system, in tandem with effective, well-organized community and home care, will ease pressure on the acute-care system and eliminate many of the gaps in the continuum of care that too often result in previously independent older people landing in the hospital or long-term care.
Acting on these three recommendations will help to provide a solid foundation on which to build a safe and dignified future for Canada’s older people. Canada is known
for its humanitarian work around the world. It’s time we brought those values home, to care for the people to whom this country and each one of us owes so much.
We look forward to discussing these proposals with you and your staff as soon as possible. Sincerely,
RN, MN, PhD, CCHN(C) President Canadian Nurses Association
RN, BSN, MN, PhD(c) President,
Canadian Association for Rural and Remote Nursing
Canadian Association of Social Workers
RN, BN, ASMH, Med President Canadian Family Practice Nurses Association
RPN, MN, PhD(c)President,
Lori Schindel Martin,
RN, PHD President
Canadian Gerontological Nursing Association
BN, RN, CPMHN(C) Past President
Canadian Federation of Mental Health Nurses
RN, BScN, President
Canadian Indigenous Nurses Association
MD CCFP (PC) FCFP President Canadian Medical Association
Canadian Public Health Association
Miranda R Ferrier
MD CM, CCFP, FCFP, CAE, ICD. D
Executive Director & Chief Executive Officer College of Family Physicians of Canada
Ontario Personal Support Workers Association
Canadian Support Workers Association
RPN-GPNC(C), BAHSc (Hons), MHSc(c)
Professional Advocacy Director
Gerontological Nursing Association
MN, NP, President NPAC-AIIPC
Nurse Practitioner Association of Canada
That the government create a one-time Health Care and Innovation Fund to resume health care services, bolster public health capacity and expand primary care teams, allowing Canadians wide-ranging access to health care.
That the government recognize and support the continued adoption of virtual care and address the inequitable access to digital health services by creating a Digi-Health Knowledge Bank and by expediting broadband access to all Canadians.
That the government act on our collective learned lessons regarding our approach to seniors care and create a national demographic top-up to the Canada Health Transfer and establish a Seniors Care Benefit.
That the government recognize the unique risks and financial burden experienced by physicians and front line health care workers by implementing the Frontline Gratitude Tax Deduction, by extending eligibility of the Memorial Grant and by addressing remaining administrative barriers to physician practices accessing critical federal economic relief programs.
Five months ago COVID-19 hit our shores. We were unprepared and unprotected. We were fallible and vulnerable. But, we responded swiftly.
The federal government initiated Canadians into a new routine rooted in public health guidance.
It struggled to outfit the front line workers. It anchored quick measures to ensure some financial stability.
Canadians tuned in to daily updates on the health crisis and the battle against its wrath.
Together, we flattened the curve… For now.
We have experienced the impact of the first wave of the pandemic. The initial wake has left Canadians, and those who care for them, feeling the insecurities in our health care system.
While the economy is opening in varied phases – an exhaustive list including patios, stores, office spaces, and schools – the health care system that struggled to care for those most impacted by the pandemic remains feeble, susceptible not only to the insurgence of the virus, but ill-prepared to equally defend the daily health needs of our citizens.
The window to maintain momentum and to accelerate solutions to existing systemic ailments that have challenged us for years is short. We cannot allow it to pass. The urgency is written on the faces of tomorrow’s patients.
Before the onset of the pandemic, the government announced intentions to ensure all Canadians would be able to access a primary care family doctor. We knew then that the health care system was failing.
The pandemic has highlighted the criticality of these recommendations brought forward by the Canadian Medical Association. They bolster our collective efforts to ensure that Canadians get timely access to the care and services they need. Too many patients are succumbing to the gaps in our abilities to care for them. Patients have signaled their thirst for a model of virtual care. The magnitude of our failure to meet the needs of our aging population is now blindingly obvious. Many of the front line health care workers, the very individuals who put themselves and their families at risk to care for the nation, are being stretched to the breaking point to compensate for a crumbling system.
The health of the country’s economy cannot exist without the health of Canadians.
Long wait times have strangled our nation’s health care system for too long. It was chronic before COVID-19. Now, for far too many, it has turned tragic.
At the beginning of the pandemic, a significant proportion of health care services came to a halt. As health services are resuming, health care systems are left to grapple with a significant spike in wait times. Facilities will need to adopt new guidance to adhere to physical distancing, increasing staff levels, and planning and executing infrastructure changes. Canada’s already financially atrophied health systems will face significant funding challenges at a time when provincial/territorial governments are concerned with resuscitating economies.
The CMA is strongly supportive of new federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians as the pandemic and life continues. We need to invigorate our health care system’s fitness to ensure that all Canadians are confident that it can and will serve them.
Creating a new Health Care and Innovation Fund would focus on resuming the health care system, addressing the backlog, and bringing primary care, the backbone of our health care system, back to centre stage.
The CMA will provide the budget costing in follow-up as an addendum to this submission.
RECOMMENDATION 1 Creating a one-time Health Care and Innovation Fund
It took a global pandemic to accelerate a digital economy and spark a digital health revolution in Canada. In our efforts to seek medical advice while in isolation, Canadians prompted a punctuated shift in how we can access care, regardless of our location or socio-economic situation. We redefined the need for virtual care.
During the pandemic, nearly half of Canadians have used virtual care. An incredible 91% were satisfied with their experience. The CMA has learned that 43% of Canadians would prefer that their first point of medical contact be virtual.
The CMA welcomes the $240 million federal investment in virtual care and encourages the government to ensure it is linked to a model that ensures equitable access.
A gaping deficit remains in using virtual care. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify digital opportunities to improve health care delivery, including what regulatory changes are required across provincial/territorial boundaries. To take full advantage of digital health capabilities, it will be essential for the entire population, to have a functional level of digital health literacy and access to the internet.
The continued adoption of virtual care is reliant on our ability to educate patients on how to access it. It will be further contingent on consistent and equitable access to broadband internet service.
Create a Digi-Health Knowledge Bank
Virtual care can’t just happen. It requires knowledge on how to access and effectively deliver it, from patients and health care providers respectively. It is crucial to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy, with the appointment of the Financial Literacy Leader within the Financial Consumer Agency of Canada, can serve as a template for digital health literacy.
We recommend that the federal government establish a Digi-Health Knowledge Bank to develop indicators and measure the digital health of Canadians, create tools patients and health care providers can use to enhance digital health literacy, continually monitor the changing digital divide that exists among some population segments.
Pan-Canadian broadband expansion
It is critical to bridge the broadband divide by ensuring all those in Canada have equitable access to affordable, reliable and sustainable internet connectivity. Those in rural, remote, Northern and Indigenous communities are presently seriously disadvantaged in this way. With the rise in virtual care, a lack of access to broadband exacerbates inequalities in access to care. This issue needs to be expedited before we can have pride in any other achievement.
RECOMMENDATION 2 Embedding virtual care in our nation’s health care system
Some groups have been disproportionately affected by the COVID-19 crisis. Woefully inadequate care of seniors and residents of long-term care homes has left a shameful and intensely painful mark on our record. Our health care system has failed to meet the needs of our aging population for too long.
The following two recommendations, combined with a focus on improving access to health care services, will make a critical difference for Canadian seniors.
A demographic top-up to the Canada Health Transfer
The Canada Health Transfer (CHT) is the single largest federal transfer to the provinces and territories. It is critical in supporting provincial and territorial health programs in Canada. As an equal per-capita-based transfer, it does not currently address the imbalance in population segments like seniors.
The CMA, hand-in-hand with the Organizations for Health Action (HEAL), recommends that a demographic top-up be transferred to provinces and territories based on the projected increase in health care spending associated with an aging population, with the federal contribution set to the current share of the CHT as a percentage of provincial-territorial health spending. A top-up has been calculated at 1.7 billion for 2021. Additional funding would be worth a total of $21.1 billion to the provinces and territories over the next decade.
Seniors care benefit
Rising out-of-pocket expenses associated with seniors care could extend from 9 billion to 23 billion by 2035. A Seniors Care Benefits program would directly support seniors and those who care for them. Like the Child Care Benefit program, it would offset the high out-of-pocket health costs that burden caregivers and patients.
RECOMMENDATION 3 Ensuring that better care is secured for our seniors
The federal government has made great strides to mitigate the health and economic impacts of COVID-19. Amidst the task of providing stability, there has been a grand oversight: measures to support our front line health care workers and their financial burden have fallen short.
The CMA recommends the following measures:
1. Despite the significant contribution of physicians’ offices to Canada’s GDP, many physician practices have not been eligible for critical economic programs. The CMA welcomes the remedies implemented by Bill C-20 and recommends the federal government address remaining administrative barriers to physicians accessing federal economic relief program.
2. We recommend that the government implement the Frontline Gratitude Tax Deduction, an income tax deduction for frontline health care workers put at risk during the COVID-19 pandemic. In person patient care providers would be eligible to deduct a predetermined amount against income earned during the pandemic. The Canadian Armed Forces already employs this model for its members serving in hazardous missions.
3. It is a devastating reality that front line health care workers have died as a result of COVID-19. Extending eligibility for the Memorial Grant to families of front line health care workers who mourn the loss of a family member because of COVID-19, as a direct result of responding to the pandemic or as a result of an occupational illness or psychological impairment related to their work will relieve any unnecessary additional hardship experienced. The same grant should extend to cases in which their work contributes to the death of a family member.
RECOMMENDATION 4 Cementing financial stabilization measures for our front line health care workers
Those impacted by COVID-19 deserve our care. The health of our nation’s economy is contingent on the health standards for its people. We must assert the right to decent quality of life for those who are most vulnerable: those whose incomes have been dramatically impacted by the pandemic, those living in poverty, those living in marginalized communities, and those doubly plagued by experiencing racism and the pandemic. We are not speaking solely for physicians. This is about equitable care for every Canadian impacted by the pandemic.
Public awareness and support have never been stronger. We are not facing the end of the pandemic; we are confronting an ebb in our journey. Hope and optimism will remain elusive until we can be confident in our health care system.
Re: Recommendations for Canada’s long-term recovery plan
Dear Prime Minister Trudeau,
We would like first to thank and commend you for your leadership throughout this pandemic. Your government’s
efforts have helped many people in Canada during this unprecedented time and have prevented Canada from facing
outcomes similar to those seen in other countries experiencing significant pandemic-related hardship and suffering.
We are writing to you with recommendations as you develop a plan for Canada’s long-term recovery and the
upcoming Speech from the Throne on September 23rd.
The COVID-19 pandemic has further exposed and amplified many healthcare shortfalls in Canada such as care for
older adults and mental health-care. Added to that, the economic fallout is impacting employment, housing, and
access to education. These social determinants of health contribute to and perpetuate inequality, which we see the
pandemic has already exacerbated for vulnerable groups. Action is needed now to address these challenges and
improve the health-care system to ensure Canada can chart a path toward an equitable economic recovery.
To establish a foundation for a stronger middle class, Canada must invest in a healthier and fairer society by
addressing health-care system gaps that were unmasked by COVID-19. We firmly believe that the measures we are
recommending below are critical and should be part of your government’s long-term recovery plan:
1. Ensure pandemic emergency preparedness
2. Invest in virtual care to support vulnerable groups
3. Improve supports for Canada’s aging population
4. Strengthen Canada’s National Anti-Racism Strategy
5. Improve access to primary care
6. Implement a universal single-payer pharmacare program
7. Increase mental health funding for health-care professionals
We know the months ahead will be challenging and that COVID-19 is far from over. As a nation, we have an
opportunity now, with the lessons from COVID-19 still unfolding, to bring about essential transformations to our
health-care system and create a safer and more equitable society.
1. Ensure pandemic emergency preparedness
We commend you for your work with the provinces and territories to deliver the $19 billion Safe Restart Agreement
as it will help, in the next six to eight months, to increase measures to protect frontline health-care workers and
increase testing and contact tracing to protect Canadians against future outbreaks. Moving forward, as you develop a
plan for Canada’s long-term recovery, we strongly recommend the focus remains in fighting the pandemic. Beyond
the six to eight months rollout of the Safe Restart Agreement, it is critical that a long-term recovery plan includes provisions to ensure a consistent and reliable availability of personal protective equipment (PPE) and large-scale
capacity to conduct viral testing and contact tracing.
2.Invest in virtual care to support vulnerable groups
The sudden acceleration in virtual care from home is a silver lining of the pandemic as it has enabled increased
access to care, especially for many vulnerable groups. While barriers still exist, the role of virtual care should
continue to be dramatically scaled up after COVID-19 and Canada must be cautious not to move backwards. Even
before the pandemic, Canadians supported virtual care tools. In 2018, a study found that two out of three people
would use virtual care options if available.i During the pandemic, 91% of Canadians who used virtual care reported
We welcome your government’s $240 million investment in virtual health-care and we encourage that a focus be
given to deploying technology and ensuring health human resources receive appropriate training in culturally
competent virtual care. We also strongly recommend accelerating the current 2030 target to ensure every person in
Canada has access to reliable, high-speed internet access, especially for those living in rural, remote, northern and
3.Improve supports for Canada’s aging population
Develop pan-Canadian standards for the long-term care sector
The pandemic has exposed our lack of preparation for managing infectious diseases anywhere, especially in the longterm
care sector. The result is while just 20% of COVID-19 cases in Canada are in long-term care settings, they
account for 80% of deaths — the worst outcome globally. Moreover, with no national standards for long-term care,
there are many variations across Canada in the availability and quality of service.iii We recommend that you lead the
development of pan-Canadian standards for equal access, consistent quality, and necessary staffing, training and
protocols for the long-term care sector, so it can be delivered safely in home, community, and institutional settings,
with proper accountability measures.
Meet the health-care needs of our aging population
Population aging will drive 20% of increases in health-care spending over the next years, which amounts to an
additional $93 billion in spending.iv More funding will be needed to cover the federal share of health-care costs to
meet the needs of older adults. This is supported by 88% of Canadians who believe new federal funding measures
are necessary.v That is why we are calling on the federal government to address the rising costs of population aging
by introducing a demographic top-up to the Canada Health Transfer. This would enhance the ability of provinces and
territories to meet the needs of Canada’s older adults and invest in long-term care, palliative care, and community
and home care.
4.Strengthen Canada’s National Anti-Racism Strategy
Anti-Black racism exists in social structures across Canada. Longstanding, negative impacts of these structural
determinants of health have created and continue to reinforce serious health and social inequities for racialized
communities in Canada. The absence of race and ethnicity health-related data in Canada prevents identification of
further gaps in care and health outcomes. But where these statistics are collected, the COVID-19 pandemic has
exploited age-old disparities and led to a stark over-representation of Black people among its victims. We are calling
for enhanced collection and analysis of race and ethnicity data as well as providing more funding under Canada’s
National Anti-Racism Strategy to address identified health disparities and combat racism via community-led
5. Improve access to primary care
Primary care is the backbone of our health-care system. However, according to a 2019 Statistics Canada surveyvi,
almost five million Canadians do not have a regular health care provider. Strengthening primary care through a teambased,
interprofessional approach is integral to improving the health of all people living in Canada and the
effectiveness of health service delivery. We recommend creating a one-time fund of $1.2 billion over four years to
Page 3 of 4
expand the establishment of primary care teams in each province and territory, with a special focus in remote and
underserved communities, based on the Patient’s Medical Home visionvii.
6. Implement a universal single-payer pharmacare program
People across Canada, especially those who are vulnerable, require affordable access to prescription medications that
are vital for preventing, treating and curing diseases, reducing hospitalization and improving quality of life.
Unfortunately, more than 1 in 5 Canadians reported not taking medication because of cost concerns, which can lead
to exacerbation of illness and additional health-care costs. We recommend a comprehensive, universal, public system
offering affordable medication coverage that ensures access based on need, not the ability to pay.
7.Increase mental health funding for health-care professionals
During the first wave of COVID-19, 47% of health-care workers reported the need for psychological support. They
described feeling anxious, unsafe, overwhelmed, helpless, sleep-deprived and discouraged.viii Even before COVID-
19, nurses, for instance, were suffering from high rates of fatigue and mental health issues, including PTSD.ix
Furthermore, health-care workers are at high risk for significant work-related stress that will persist long after the
pandemic due to the backlog of delayed care. Immediate long-term investment in multifaceted mental health supports
for health-care professionals is needed.
We look forward to continuing to work with you and your caucus colleagues on transforming the health of people in
Canada and the health system.
Tim Guest, M.B.A., B.Sc.N., RN
Canadian Nurses Association (CNA)
Tracy Thiele, RPN, BScPN, MN,
Canadian Federation of Mental Health
Lori Schindel Martin, RN, PhD,
Canadian Gerontological Nursing
E. Ann Collins, BSc, MD
Canadian Medical Association (CMA)
Canadian Support Workers Association
Dr. Cheryl L. Cusack RN, PhD
Community Health Nurses of Canada
Lenora Brace, MN, NP
Nurse Practitioner Association of
~ r. Cheryl
Hon. Chrystia Freeland, Minister of Finance
Hon. Patty Hajdu, Minister of Health
Hon. Deb Schulte, Minister of Seniors
Hon. Navdeep Bains, Minister of Innovation, Science and Industry
Ian Shugart, Clerk of the Privy Council and Secretary to Cabinet
Dr. Stephen Lucas, Deputy Minister of Health
Dr. Theresa Tam, Chief Public Health Officer of Canada
Committee Appearance – Justice and Human Rights:
Bill C-7 – Amending the Criminal Code Regarding Medical Assistance in Dying
November 5, 2020
Dr. E. Ann Collins
President of the Canadian Medical Association
Committee Appearance – Justice and Human Rights
Bill C-7 – Amending the Criminal Code Regarding Medical Assistance in Dying
Thank you, Madam Chair.
It’s my honour to appear before you today. I’m Dr. Ann Collins. Over the past three decades practising medicine, I have taught family medicine, run a family practice, served with the Canadian Armed Forces and worked in nursing home care. Today, in my capacity as President of the Canadian Medical Association, I represent our 80,000 physician members.
In studying Bill C-7, it is incumbent upon us now to consider the effects on patients that the passing of this bill will have, but also the effects on the medical professionals who provide medical assistance in dying - MAiD.
When the original MAiD legislation was developed as Bill C-14, the CMA was a leading stakeholder. We have continued that commitment with Bill C-7. Having examined Bill C-7, we know that, in a myriad of ways, the results of our extensive consultations with our members align with the findings of the government’s roundtables.
Fundamentally, the CMA supports the government’s prudent and measured approach to responding to the Truchon-Gladu decision. This thoughtful and staged process undertaken by the government is consistent with the CMA’s position for a balanced approach to MAiD.
Nicole Gladu, whose name is now inextricably tied to the decision, spoke as pointedly as perhaps anyone could when she affirmed that it is up to people like her, and I quote, “To decide if we prefer the quality of life to the quantity of life." Not everyone may agree with this sentiment, but few can argue that it is a powerful reminder of the real stakeholders when it comes to considerations of this bill. This applies just as critically to those who are currently MAiD providers and those who will become providers. They are our members, but we can’t lose sight of the fact that we must all support both patients and providers.
Through our consultations, we learned that many physicians felt that clarity was lacking. Recent federal efforts to provide greater clarity for physicians are exceedingly welcome. The CMA is pleased to see new non-legislative measures lending more consistency to the delivery of MAiD across the country. The quality and availability of palliative care, mental health care, care for those suffering from chronic illness, and persons with disabilities, to ensure that patients have access to other, appropriate health care services is crucial.
The CMA holds firm on our convictions on MAiD from Bill C-14 to C-7.
We believe firstly that the choice of those Canadians who are eligible should be respected.
Secondly, we must protect the rights of vulnerable Canadians. This demands strict attention to safeguards.
And lastly, an environment must exist that insists practitioners abide by their moral commitments.
These three tenants remain equally valid.
Our consultations with members demonstrate strong support for allowing advance requests by eligible patients who may lose capacity before MAiD can be provided.
The CMA believes in the importance of safeguards to protect the rights of vulnerable Canadians and those who are eligible to seek MAiD.
The CMA also supports expanding data collection to provide a more thorough account of MAiD in Canada, however, this effort must not create an undue administrative burden on physicians.
The CMA views the language in the bill, which explicitly excludes mental illness from being considered an “illness, disease or disability,” problematic and has the potential to be stigmatizing to those living with a mental illness. We trust that Parliament will carefully consider the specific language used in the bill.
Finally, the CMA endorses the government’s staged approach to carefully examine more complex issues. However, we must move forward to ensure practitioners are given the tools that will be required to safely administer MAiD on a wider spectrum, such as support for developing clinical practice guidelines which aid physicians in exercising sound clinical judgment. Such guidance would also serve to reinforce consistency in the application of the legal criteria.
In conclusion, Madam Chair, allow me to thank the committee for the invitation to participate in today’s proceedings and to share the perspective of Canada’s physicians. The pursuit of a painless and dignified end-of-life is a noble one. The assurance that the providers of this privilege are supported is an ethical imperative.
Committee Appearance – Senate Legal and Constitutional Affairs Committee:
Bill C-7 – An Act to Amend the Criminal Code (medical assistance in dying)
November 23, 2020
Dr. Sandy Buchman
Past President of the Canadian Medical Association
Monday, November 23, 2020
Thank you, Madam Chair.
I appear before the committee today as the past president of the Canadian Medical Association with the honour and responsibility of speaking for all our members - the frontline physicians.
My name is Dr. Sandy Buchman. I am a palliative care physician in Toronto. I am also a MAiD Assessor and Provider.
It is incumbent upon us now to consider the effects that the passing of Bill C-7 will have on patients, but also the effects on the medical professionals who provide medical assistance in dying - MAiD.
When the original MAiD legislation was developed as Bill C-14, the CMA was a leading stakeholder. We have continued that commitment with Bill C-7. Having examined Bill C-7, we know that, in a myriad of ways, the results of our extensive consultations with our members align with the findings of the government’s roundtables.
Nicole Gladu, whose name is now inextricably tied to the government’s decision on MAiD, spoke as unequivocally as perhaps anyone could when she affirmed that it is up to people like her, and I quote, “To decide if we prefer the quality of life to the quantity of life."
Perhaps not everyone agrees with this sentiment. Few can argue, though, that it is a powerful reminder of the real stakeholders when it comes to considerations of this bill. This applies no less critically to those who are currently MAiD providers or those who will become providers. These practitioners are our members.
But we can’t overlook the fact that there must be complete support of both patients and providers.
Fundamentally, the CMA supports the government’s prudent and measured approach to responding to the Truchon-Gladu decision. This thoughtful and staged process undertaken by the government is consistent with the CMA’s position for a balanced approach to MAiD.
Through our consultations however, we learned that many physicians felt there is a lack of overall clarity. Recent federal efforts to provide precision for physicians are exceedingly welcome.
The CMA is pleased to see new non-legislative measures lending more consistency to the delivery of MAiD across the country. The quality and availability of palliative care, mental health care, and care and resources for those suffering from chronic illness, and for persons with disabilities, to ensure that all patients have access to other, appropriate health care services is crucial.
The CMA remains firm on our convictions on MAiD from Bill C-14 to C-7.
We believe that the choice of those Canadians who are eligible should be respected.
We also believe that the rights of vulnerable Canadians must be protected. This demands strict attention to safeguards.
And we believe that an environment must exist that fosters the insistence that practitioners abide by their moral commitments.
Each of these three tenants is equally unassailable.
Our members are in strong support of allowing advance requests by eligible patients who may lose capacity before MAiD can be provided.
The CMA believes in the importance of safeguards to protect the rights of vulnerable Canadians and those who are eligible to seek MAiD.
Expanding data collection to provide a more thorough account of MAiD in Canada is important. However, this effort must not create an undue administrative burden on physicians.
The CMA views some of the language in the bill as precarious. The CMA recommends amending the language in section 2.1 which states “mental illness is not considered to be an illness, disease or disability” to avoid the unintended consequence of having a stigmatizing effect. The legislation should also clearly indicate that the exclusion is for mental illness as a sole underlying medical condition, not mental illness as a comorbidity.
To be clear, the CMA is not recommending a revision to the legislative intent. We trust that Parliament will carefully consider the specific language used in the bill.
Finally, the CMA endorses the government’s staged approach to carefully examine more complex issues. We must move forward, though, by ensuring that practitioners are given the tools that will be required to safely administer MAiD on a wider spectrum. Support for developing clinical practice guidelines that aid physicians in exercising sound clinical judgment are a prime example. Such guidance would also serve to reinforce consistency in the application of the legal criteria.
In conclusion, Madam Chair, allow me to thank the committee for the invitation to participate in today’s proceedings. Sharing the perspective of Canada’s physicians is a privilege. That together we pursue a painless and dignified end-of-life is noble. The assurance that the providers of this practice are supported is an ethical imperative.
Dear Minister Freeland:
We are a national consortium of experts who serve and advocate for the needs and rights of older people. We are delighted by the recent appointment of a new Minister of Seniors, and send our congratulations to the Honourable Filomena Tassi. We are also encouraged by our Government’s commitment to support the health and economic well-being of all Canadians, and heartened by your promise to listen to, and to be informed by feedback from Canadians. It is in this spirit that we are writing today regarding the need for Canada to provide support and leadership with a goal of developing and ratifying a United Nations (UN) Convention on the Rights of Older Persons.
In the context of massive global demographic shifts and an aging population, insightful and careful reflection by the leaders of our organizations has led to universal and strong support for the creation and implementation of a UN Convention to specifically recognize and protect the human rights of our older persons.
A UN Convention on the Rights of Older Persons will:
enshrine their rights as equal with any other segment of the population with the same legal rights as any other human being;
categorically state that it is unacceptable to discriminate against older people throughout the world;
clarify the state’s role in the protection of older persons;
provide them with more visibility and recognition both nationally and internationally, which is vitally important given the rate at which Canadian and other societies are ageing;
advance the rights of older women at home and as a prominent factor in Canada’s foreign policy;
have a positive, real-world impact on the lives of older citizens who live in poverty, who are disproportionately older women, by battling ageism that contributes to poverty, ill-health, social isolation, and exclusion;
support the commitment to improve the lives of Indigenous Peoples; members of the LGBTQ community, and visible and religious minorities; and,
provide an opportunity for Canada to play a leadership role at the United Nations while at the same time giving expression to several of the Canadian government’s stated foreign policy goals.
We have projected that the cost and impact of not having such a Convention would have a significant negative impact on both the physical and mental health of older Canadians. The profound and tragic consequence would have a domino effect in all domains of their lives including social determinants of health, incidence and prevalence of chronic diseases, social and psychological functioning, not to mention massive financial costs to
society. There is recognition of this need internationally and ILC-Canada, along with other Canadian NGOs and organizations have been active at the UN to help raise awareness of the ways a UN Convention on the Rights of Older Persons would contribute to all countries.
Changes have already been implemented by our Government that are consistent and aligned with a UN Convention, such as improving the income of vulnerable Canadian seniors, funding for long term care and support for community based dementia programs. These initiatives are all in keeping with support for a Convention on the Rights of Older Persons. They are also reflective of our country’s commitment to engage more fully with the United Nations and provide Canada the stage to demonstrate leadership on a vital international issue. It is an opportunity to champion the values of inclusive government, respect for diversity and human rights including the human rights of women.
Scientific evidence demonstrates that human rights treaties help to drive positive change in the lives of vulnerable groups of people. In many countries in the world, older people are not adequately protected by existing human rights law, as explicit references to age are exceedingly rare. Even in countries like Canada, where there are legal frameworks that safeguard older people, a Convention would provide an extra layer of protection, particularly if the Convention has a comprehensive complaints mechanism.
Older adults need to be viewed as a growing but underutilized human resource. By strengthening their active role in society including the workforce, they have tremendous capacity, knowledge, and wisdom to contribute to the economy and general well-being of humankind.
We are requesting you meet with our representatives, to discuss the vital role of a UN Convention on the Rights of Older Persons and the role your government could play in improving the lives of older people in Canada and around the world. The fact that Canada is ageing is something to celebrate. We are all ageing, whether we are 20 or 85. This is a ”golden opportunity” to showcase Canada as a nation that will relentlessly pursue doing the “right thing” for humanity by supporting a UN Convention that ensures that our future is bright.
Please accept our regards, and thank you for your attention to this request. We await your response. Sincerely,
Margaret Gillis, President, International Longevity Centre Canada
Dr. Kiran Rabheru, Chair of the Board, International Longevity Centre Canada
Linda Garcia, Director, uOttawa LIFE Research Institute
cc: The Right Honourable Justin Trudeau Prime Minister of Canada
The Honourable Filomena Tassi Minister of Seniors
The Honourable Jean Yves Duclos
Minister for Families, Children and Social Development
Ambassador Marc-Andre Blanchard
Permanent Representative to Canada at the United Nations
The Honourable Ginette Petitpas Taylor
International Longevity Centre Canada
Dr. Kiran Rabheru
Chair of the Board, International Longevity Centre Canada
Linda Garcia, PhD
LIFE Research Institute
Dr. Laurent Marcoux
Canadian Medical Association
Andrew Padmos, BA, MD, FRCPC, FACP
Chief Executive Officer
Dani Prud’Homme Directeur général FADOQ
Peter Lukasiewicz Chief Executive Officer Gowling WLG
Dr. Dallas Seitz, MD, FRCPC
Dr. Frank Molnar
President, Canadian Geriatrics Society
Dr. David Conn
Canadian Coalition for Senior’s Mental Health
Director - Canadian Coalition for Seniors’ Mental Health
Chief Executive Officer, Speech-Language & Audiology Canada
President Canadian Nurses Association
Janice Christianson-Wood, MSW, RSW Title/Organization: President, Canadian Association of Social Workers / Présidente, l’Association canadienne des travail-
Chief Executive Officer/Chef de la direction
Ondina Love, CAE
Chief Executive Officer Canadian Dental Hygienists Association
National Association of Federal Retirees /Association nationale
des retraités fédéraux
Laura Tamblyn Watts
National Initiative for the Care of the Elderly
Dr. Keri-Leigh Cassidy
Founder Fountain of Health
Dr. Beverley Cassidy Geriatric Psychiatris Seniors Mental Health
Dalhousie University Dept of Psychiatry
Jenny Neal and Janet Siddall
CO Chairs, Leadership Team Grandmothers Advocacy Network (GRAN)
President and CEO
Dr. Becky Temple, MD, CCFP, CCPE
Medical Director Northeast, Northern Health Medical Lead Privilege Dictionary Review, BCMQI
J. Van Aerde, MD, MA, PhD, FRCPC
Clinical Professor of Pediatrics - Universities of Alberta & British Columbia, Canada
Associate Faculty - Leadership Studies - Royal Roads Univ, Victo- ria, BC, Canada
Past-President - Canadian Society of Physician Leaders Editor-in-Chief / Canadian Journal of Physician Leadership
Dr. Rollie Nichol, MD, MBA, CCFP, CCPE
Associate Chief Medical Officer, Alberta Health Services
Dr. Shannon Fraser, MSc, FRCSC, FACS
Secretary / Treasurer, CSPL Chief General Surgery Jewish General Hospital
Linda Gobessi MD FRCPC
Geriatric Psychiatry Community Services of Ottawa Ottawa
Executive Director / Directrice générale
Services communautaires de géronto- psychiatrie d’ Ottawa Geriatric Psychiatry Community Services of Ottawa
Ging-Yuek Robin Hsiung, MD MHSc FRCPC FACP FAAN
Ralph Fisher and Alzheimer Society of BC Professor Director of Clinical Research
Director of Fellowship in Behavioural Neurology UBC Hospital Clinic for Alzheimer and Related Disorders
Division of Neurology, Department of Medicine University of British Columbia
Senior Social Worker Baycrest Health Sciences
Harinder Sandhu, D.D.S., Ph.D
Professor and Past Director
Schulich Dentistry & Vice Dean, Schulich School of Medicine & Dentistry
Dr. Christopher Frank,
Chair of Geriatric Education and Recruitment Initiative
Jennie Wells, MD
Associate Professor, University of Western Ontario Department of Medicine
Chair/Chief Division of Geriatric Medicine Parkwood Institute
Laura Diachun, MD
Program Director, Undergrad Geriatric Education University of Western Ontario
Department of Medicine, Division of Geriatric Medicine Parkwood Institute
Sheri-Lynn Kane, MD Program Director Internal Medicine Dept of Medicine Education Office
Niamh O’Regan, MB ChB,
Assistant Professor, University of Western Ontario Parkwood Institute
Michael Borrie, MB ChB, FRCPC
Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine
Jenny Thain, MRCP (Geriatrics)
Assistant Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine Victoria Hospital
Peter R. Butt MD CCFP FCFP
Assoc. Professor, Department of Family Medicine, College of Medicine,
University of Saskatchewan
Mamta Gautam, MD, MBA, FRCPC, CCPE Dept of Psychiatry, University of Ottawa Psychiatrist, Psychosocial Oncology Program, The Ottawa Hospital
President and CEO, PEAK MD Inc.
Dr. Shabbir Amanullah
Arun V. Ravindran, MBBS, MSc, PhD, FRCPC, FRCPsych
Professor and Director, Global Mental Health and the Office of Fellowship Training, Department of Psychiatry,
Graduate Faculty, Department of Psychology and Institute of Medical Sciences, University of Toronto
Sarah Thompson, MD, FRCPC Geriatric Psychiatrist Seniors’ Mental Health Team
Addictions and Mental Health Program
Louise Plouffe, Ph.D.
Director of Research, ILC Canada (retired)
Kimberley Wilson, PhD, MSW
Assistant Professor, Adult Development & Aging, Department of Family Relations & Applied Nutrition, University of Guelph
Andrew R. Frank M.D. B.Sc.H. F.R.C.P.(C)
Cognitive and Behavioural Neurologist Medical Director, Bruyère Memory Program Bruyère Continuing Care
Diane Hawthorne Family Physician BSc, MD, CCFP, FCFP
Dr. Ken Le Clair
Prof Emeritus Queens University and. Lead Policy Physician Consultant to Ontario. Seniors Behavioral Support Initative Queens University
Health equity is created when individuals have the opportunity to achieve their full health potential; equity is undermined when preventable and avoidable systematic conditions constrain life choices.1 These conditions are known as the social determinants of health. The World Health Organization (WHO) defines the social determinants of health as the circumstances in which people are born, develop, live and age.2 In 2002, researchers and policy experts at a York University conference identified the following list: income and income distribution; early life; education; housing; food security; employment and working conditions; unemployment and job security; social safety net; social inclusion/exclusion; and health services. 3
Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.4 Any actions to improve health and tackle health inequity must address the social determinants and their impact on daily life.5
THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH STATUS
Social status is one of the strongest predictors of health at the population level. There is a social gradient of health such that those with higher social status experience greater health than those with lower social status. The social gradient is evident not only when comparing the most disadvantaged to the most advantaged; within each strata, even among those holding stable middle-class jobs, those at the lowest end fare less well than those at the higher end. The Whitehall study of civil servants in the United Kingdom found that lower ranking staff have a greater disease burden and shorter life expectancy than higher-ranking staff.6 Differences in medical care did not account for the differences in mortality.7 This gradient has been demonstrated for just about any health condition.8
Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.9 In 2001, people in the neighbourhoods with the highest 20% income lived about three years longer than those in the poorest 20% neighbourhoods (four years for men; two years for women).10 Dietary deficiencies, common in food insecure households, can lead to an increased chance of chronic disease and greater difficulty in disease management. It is estimated that about 1.1 million households in Canada experience food insecurity, with the risk increasing in single-parent households and in families on social assistance.11
Studies suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.12 Effective early childhood development offers the best opportunity to reduce the social gradient and improve the social determinants of health,13 and offers the greatest return on investment.14
Low income contributes not only to material deprivation but social isolation as well. Without financial resources, it is more difficult for individuals to participate in cultural, educational and recreational activities or to benefit from tax incentives. Suicide rates in the lowest income neighbourhoods are almost twice as high as in the wealthiest neighbourhoods.15 This social isolation and its effects are most striking in Canada's homeless population. Being homeless is correlated with higher rates of physical and mental illness. In Canada, premature death is eight to 10 times higher among the homeless.16
The gradient in other social determinants can have an adverse impact as well. A study conducted in the Netherlands estimated that average morbidity and mortality in the overall population could be reduced 25-50% if men with lower levels of education had the same mortality and morbidity levels as those men with a university education.17 Employment status also follows this gradient, such that having a job is better than being unemployed. 18 Unemployment is correlated with increased blood pressure, self-reported ill health, drug abuse, and reductions in normal activity due to illness or injury.19 Unemployment is associated with increases in domestic violence, family breakups and crime. Finally, job security is relevant.20 Mortality rates are higher among temporary rather than permanent workers.21
Canada's Aboriginal people face the greatest health consequences as a result of the social determinants of health. Poverty, inadequate or substandard housing, unemployment, lack of access to health services, and low levels of education characterize a disproportionately large number of Aboriginal peoples.22 The crude mortality rate for First Nations is higher and life expectancy lower than the Canadian average.23 Aboriginal peoples experience higher rates of chronic disease, addictions, mental illness and childhood abuse.24 Aboriginal peoples have higher rates of suicide, with suicide being the leading cause of potential years of life lost in both the First Nations and Inuit populations.25
THE SOCIAL DETERMINANTS OF HEALTH AND CANADA'S HEALTH SYSTEM
These differences in health outcomes have an impact on the health care system. Most major diseases including heart disease and mental illness follow a social gradient with those in lowest socio-economic groups having the greatest burden of illness.26 Those within the lowest socio-economic status are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized for care of that disease.27 Chronic diseases such as diabetes account for 67% of direct health care costs and 60% indirect costs.28
Research has shown that Canadians with low incomes are higher users of general practitioner, mental health, and hospital services.29 People in the lowest income group were almost twice as likely as those in the highest income group to visit the emergency department for treatment. 30 Part of this may be caused by differences in access to care. Low-income Canadians are more likely to report that they have not received needed health care in the past 12 months.31 Those in the lowest income groups are 50% less likely than those in the highest income group to see a specialist or get care in the evenings or on weekends, and 40% more likely to wait more than five days for a doctor's appointment.32
Barriers to health care access are not the only issue. Research in the U.K.33 and U.S.34 has found that compliance with medical treatment tends to be lower in disadvantaged groups, leading to pain, missed appointments, increased use of family practice services and increased emergency department visits, and corresponding increases in cost. In the U.S., non-adherence has been attributed to 100,000 deaths annually.35 Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.36
These differences have financial costs. In Manitoba for example, research conducted in 1994 showed that those in the lowest income decile used services totaling $216 million (12.2%). In the same year, those in the highest income decile consumed $97 million (5.5%) of expenditures. If expenditures for the bottom half of the population by income had been the same as the median, Manitoba would have saved $319 million or 23.1% of their health care budget. 37 According to a 2011 report, low-income residents in Saskatoon consume an additional $179 million in health care costs than middle income earners.38
To reduce the burden of illness and therefore system costs, Canada needs to improve the underlying social and economic determinants of health of Canadians. However, until these changes have time to improve the health status of the population, there will still be a large burden of illness correlated to these underlying deficiencies. As a result, the health system will need to be adequately resourced to address the consequences of the social determinants of health.
AREAS FOR ACTION
The WHO Commission on the Social Determinants of Health identified four categories through which actions on social determinants can be taken. These include:
* reducing social stratification by reducing inequalities in power, prestige, and income linked to socio-economic position;
* decreasing the exposure of individuals and populations to the health-damaging factors they may face;
* reducing the vulnerability of people to the health damaging conditions they face; and
* intervening through health care to reduce the consequences of ill health caused by the underlying determinants.39
All of these areas offer possibilities for action by the physician community. The following section provides suggestions for action by the medical profession through: CMA and national level initiatives; medical education; leadership and research; and clinical practice.
CMA and national level initiatives
Despite the strong relationship between the social determinants of health and health, little in the way of effective action has resulted. CMA and its partners can and should, advocate for research and push for informed healthy public policy, including health impact assessments for government policies. Additionally, targeted population health programs aimed at addressing the underlying determinants should be supported.
All Canadians need a better understanding of the health trends and the impacts of various social and economic indicators. Information about the differences in specific health indicators, collected over time,40 is essential to the task of describing underlying health trends and the impacts of social and economic interventions. Data within primary care practices could be assembled into (anonymous) community-wide health information databases, to address this need.
CMA recommends that:
1. The federal government recognize the relationship of the social determinants of health on the demands of the health care system and that it implement a requirement for all cabinet decision-making to include a Health Impact Assessment.
2. Options be examined for minimizing financial barriers to necessary medical care including pharmaceuticals and medical devices necessary for health.
3. Federal and provincial/territorial governments examine ways to improve the social and economic circumstances of all Canadians.
4. Efforts be made to educate the public about the effect of social determinants on individual and population health.
5. Appropriate data be collected and reported on annually. This data should be locally usable, nationally comparable and based on milestones across the life course.
Medical education is an effective means to provide physicians with the information and tools they require to understand the impact of social determinants on the health of their patients and deal with them accordingly.41 In 2001, Health Canada published a report in which they stated that the primary goal of medical education should be the preparation of graduates who know how to reduce the burden of illness and improve the health of the communities in which they practice.42 Among the report's recommendations was a call for greater integration of the social determinants in medical curricula.43 Although the CanMEDS framework has been a part of the Royal College of Physicians and Surgeons of Canada's accreditation process since 2005, challenges to the integration of these competencies remain.44
The report called for a greater emphasis on providing medical students with firsthand experiences in the community and with distinct populations (service learning),45 which addresses the difficulties in teaching the social aspects of medicine within a traditional classroom or hospital setting.46 Many such programs exist across the country.47 However, these programs are still limited and there is a need to increase the availability of longitudinal programs which allow students to build on the skills they develop throughout medical school.
Increasingly residency programs which focus on the social determinants of health are being offered.48 These programs are a means of providing physicians with the proper tools to communicate with patients from diverse backgrounds49 and reduce behaviours that marginalized patients have identified as barriers to health services.50 It also provides residents with physician role models who are active in the community. However, medical residents note a lack of opportunities to participate in advocacy during residency.51 Further, while experiential programs are effective in helping to reduce barriers between physicians and patients from disadvantaged backgrounds, greater recruitment of medical students from these marginalized populations should also be explored and encouraged.
Finally, physicians in practice need to be kept up to date on new literature and interventions regarding the social determinants. Innovations which help address health equity in practice should be shared with interested physicians. In particular, there is a need for accredited continuing medical education (CME) and a means to encourage uptake.52
CMA recommends that:
6. Greater integration of information on the social determinants and health inequity be provided in medical school to support the CanMEDS health advocate role
7. All medical schools and residency programs offer service learning programs, to provide students with an opportunity to work with diverse populations in inner city, rural and remote settings, and to improve their skills in managing the impact of the social determinants on their patients.
8. CME on the social determinants of health and the physician role in health equity be offered and incentivized for practising physicians.
Leadership and research
Within many communities in Canada, there are physicians who are working to address social determinants and health equity within the patient populations they serve. This is done in many cases through collaboration with partners within and outside of the health care system. Providing these local physician leaders with the tools they need to build these partnerships, and influence the policies and programs that affect their communities is a strategy that needs to be explored.
Evidence-based research about health equity, the clinical setting and the role of physicians is underdeveloped. Interested physicians may wish to participate in research about practice level innovations, as a means of contributing to the evidence base for 'health equity' interventions or simply to share best practices with interested colleagues. Further, physicians can provide the medical support to encourage the adoption of early childhood development practices for example, which support later adult health. In time, research will contribute to training, continuing medical education and potentially to clinical practice guidelines.
Physicians can provide leadership in health impact assessments and equity audits within the health care system as well. Data is essential to identify health equity challenges within a program, to propose and test measures that address the issues underlying the disparities. Formal audits and good measurement are essential to develop evidence-based policy improvements.53 Innovative programs such as those within the Saskatoon Health Region and the Centre for Addiction and Mental Health in Toronto are examples of using these tools to improve access and reduce inequities.
CMA recommends that:
9. Physicians who undertake leadership and advocacy roles should be protected from repercussions in the workplace, e.g., the loss of hospital privileges.
10. Physician leaders explore opportunities to strengthen the primary care public health interface within their communities by working with existing agencies and community resources.
11. Physician leaders work with their local health organizations and systems to conduct health equity impact assessments in order to identify challenges and find solutions to improve access and quality of care.
12. Physicians be encouraged to participate in or support research on best practices for the social determinants of health and health equity. Once identified, information sharing should be established in Canada and internationally.
In consultation with identified health equity physician champions, a number of clinical interventions have been identified which are being undertaken by physicians across the country. These interventions could be undertaken in many practice settings given the right supports, and could be carried out by various members of the collaborative care team.1
First, a comprehensive social history is essential to understand how to provide care for each patient in the context of their life.54 There are a number of tools that can be used for such a consultation and more are in development.55 However, consolidation of the best ideas into a tool that is suitable for the majority of health care settings is needed. There is some concern that asking these questions is outside of the physician role. The CanMEDS health advocate role clearly sees these types of activities as part of the physician role.56 The 'Four Principles of Family Medicine' defined by the College of Family Physicians of Canada, affirms this role for physicians as well.57
Community knowledge was identified as a strategy for helping patients. Physicians who were aware of community programs and services were able to refer patients if/when social issues arose.58 Many communities and some health providers have developed community resource guides.59 For some physicians, developing a network of community resources was the best way to understand the supports available.
As a corollary, physicians noted their work in helping their patients become aware of and apply for the various social programs to which they are entitled. The programs vary by community and province/territory, and include disability, nutritional supports and many others. Most if not all of these programs require physicians to complete a form in order for the individual to qualify. Resources are available for some of these programs,60 but more centralized supports for physicians regardless of practice location or province/territory are needed.
Physicians advocate on behalf of their patients by writing letters confirming the medical limitations of various health conditions or the medical harm of certain exposures.61 For example, a letter confirming the role of mold in triggering asthma may lead to improvements in the community housing of an asthmatic. Additionally, letters might help patients get the health care services and referrals that they require. As identified leaders within the community, support from a physician may be a 'game-changer' for patients.
Finally, the design of the clinic, such as hours of operation or location, will influence the ability of people to reach care.62
CMA recommends that:
13. Tools be provided for physicians to assess their patients for social and economic causes of ill health and to determine the impact of these factors on treatment design.
14. Local databases of community services and programs (health and social) be developed and provided to physicians. Where possible, targeted guides should be developed for the health sector.
15. Collaborative team-based practice be supported and encouraged.
16. Resources or services be made available to physicians so that they can help their patients identify the provincial/territorial and federal programs for which they may qualify.
17. Physicians be cognizant of equity considerations when considering their practice design and patient resources.
18. All patients be treated equitably and have reasonable access to appropriate care, regardless of the funding model of their physician.
Socio-economic factors play a larger role in creating (or damaging) health than either biological factors or the health care system. Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians and retain a sustainable publicly funded health care system. Addressing inequalities in health is a pillar of CMA's Health Care Transformation initiative. Physicians as clinicians, learners, teachers, leaders and as a profession can take steps to address the problems on behalf of their patients.
1 A full review of the consultations is provided in the companion paper The Physician and Health Equity: Opportunities in Practice.
1 Khalema, N. Ernest (2005) Who's Healthy? Who's Not? A Social Justice Perspective on Health Inequities. Available at: http://www.uofaweb.ualberta.ca/chps/crosslinks_march05.cfm
2 World Health Organization (2008) Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Available at: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf
3 Public Health Agency of Canada (N.D.) The Social Determinants of Health: An Overview of the Implications for Policy and the Role of the Health Sector. Available at: http://www.phac-aspc.gc.ca/ph-sp/oi-ar/pdf/01_overview_e.pdf
4 Keon, Wilbert J. & Lucie Pépin (2008) Population Health Policy: Issues and Options. Available at: http://www.parl.gc.ca/Content/SEN/Committee/392/soci/rep/rep10apr08-e.pdf
5 Friel, Sharon (2009) Health equity in Australia: A policy framework based on action on the social determinants of obesity, alcohol and tobacco. The National Preventative Health Taskforce. Available at: http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/0FBE203C1C547A82CA257529000231BF/$File/commpaper-hlth-equity-friel.pdf
6 Wilkinson, Richard & Michael Marmot eds. (2003) Social Determinants of Health: The Solid Facts: Second Edition. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf
7 Khalema, N. Ernest (2005) Who's Healthy?...
8 Dunn, James R. (2002) The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Available at: http://www.opha.on.ca/our_voice/collaborations/makeconnxn/HDP-proj-full.pdf
10 Wilkins, Russ; Berthelot, Jean-Marie; and Ng E. . Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Health Reports 13 [Supplement]: pp. 45-71
11 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health: The Canadian Facts. Available at: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf
12 Raphael, Dennis (2003) "Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy." Policy Options. March 2003 pp.35-40.
13 World Health Organization (2008) Closing the gap in a generation...
14 Hay, David I. (2006) Economic Arguments for Action on the Social Determinants of Health. Canadian Policy Research Networks. Available at: http://www.cprn.org/documents/46128_en.pdf
15 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
17 Whitehead, Margaret & Goran Dahlgren (2006) Concepts and principles for tackling social inequities in health: Levelling up Part 1. World Health Organization Europe. Available at: http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf
18 Wilkinson, Richard & Michael Marmot eds. (2003) "Social Determinants of Health...
19 Ferrie, Jane E. (1999) "Health consequences of job insecurity." In Labour Market Changes and Job Security: A Challenge for Social Welfare and Health Promotion. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98411/E66205.pdf
20 Marmot, Michael (2010) Fair Society Healthy Lives: The Marmot Review: Executive Summary. Available at: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLivesExecSummary.pdf
21 World Health Organization (2008) Closing the gap in a generation...
22 Aboriginal Healing Foundation, Frequently Asked Questions (Ottawa: Canadian Government Publishing Directorate, 2009) Available at: http://www.ahf.ca/faq
23Health Council of Canada, "The Health Status Of Canada's First Nations, Métis And Inuit Peoples", 2005, Available at:http://healthcouncilcanada.ca.c9.previewyoursite.com/docs/papers/2005/BkgrdHealthyCdnsENG.pdf
24 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
25Health Council of Canada, (2005)"The Health Status Of Canada's First Nations, Métis And Inuit Peoples...
26 Dunn, James R. (2002) The Health Determinants Partnership...
27 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions. http://secure.cihi.ca/cihiweb/products/PHC_Experiences_AiB2012_E.pdf
28 Munro, Daniel (2008) "Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health." The Conference Board of Canada. Available at: http://www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb
29 Williamson, Deanna L. et.al. (2006) "Low-income Canadians' experiences with health-related services: Implications for health care reform." Health Policy. 76(2006) pp. 106-121.
30 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians...
31 Williamson, Deanna L. et.al. (2006) "Low-income Canadians'...
32 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
33 Neal, Richard D. et.al. (2001) "Missed appointments in general practice: retrospective data analysis from four practices." British Journal of General Practice. 51 pp.830-832.
34 Kennedy, Jae & Christopher Erb (2002) "Prescription Noncompliance due to Cost Among Adults with Disabilities in the United States." American Journal of Public Health. Vol.92 No.7 pp. 1120-1124.
35 Bibbins-Domingo, Kirsten & M. Robin DiMatteo. Chapter 8: Assessing and Promoting Medication Adherence. pp. 81-90 in King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients...
36 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
37 Dunn, James R. (2002) The Health Determinants Partnership...
38 Saskatoon Poverty Reduction Partnership (2011) from poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Available at: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf
39 World Health Organization (2005) Action On The Social Determinants Of Health: Learning From Previous Experiences. Available at: http://www.who.int/social_determinants/resources/action_sd.pdf
40 Braveman, Paula (2003) "Monitoring Equity in Health and Healthcare: A Conceptual Framework."Journal of Health, Population and Nutrition. Sep;21(3):181-192.
41 Royal College of Physicians (2010) How doctors can close the gap: Tackling the social determinants of health through culture change, advocacy and education. Available at: http://www.marmotreview.org/AssetLibrary/resources/new%20external%20reports/RCP-report-how-doctors-can-close-the-gap.pdf
42 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools. Available at: http://www.medicine.usask.ca/leadership/social-accountability/pdfs%20and%20powerpoint/SA%20-%20A%20vision%20for%20Canadian%20Medical%20Schools%20-%20Health%20Canada.pdf
44 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate: Translating the Quest for Social Responsibility into Medical Education and Practice." Academic Medicine. Vol.86 No.9 pp.1108-1113.
45 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools...
46 Meili, Ryan; Fuller, Daniel; & Jessica Lydiate. (2011) "Teaching social accountability by making the links: Qualitative evaluation of student experiences in a service-learning project." Medical Teacher. 33; 659-666.
47 Ford-Jones, Lee; Levin, Leo; Schneider, Rayfel; & Denis Daneman (2012) "A New Social Pediatrics Elective-A Tool for Moving to Life Course Developmental Health." The Journal of Pediatrics. V.160 Iss. 3 pp.357-358; Meili, Ryan; Ganem-Cuenca, Alejandra; Wing-sea Leung, Jannie; & Donna Zaleschuk (2011) "The CARE Model of Social Accountability: Promoting Cultural Change." Academic Medicine. Vol.86 No.9 pp.1114-1119.
48 Cuthbertson, Lana "U of A helps doctors understand way of life in the inner city." Edmonton Journal Dec 22, 2010. Available at: http://www2.canada.com/edmontonjournal/news/cityplus/story.html?id=943d7dc3-927b-4429-878b-09b6e00595e1
49 Willems, S.; Maesschalck De, S.; Deveugele, M.; Derese, A. & J. De Maeseneer (2005) "Socio-economic status of the patient and doctor-patient communication: does it make a difference?" Patient Education and Counseling. 56 pp. 139-146.
50 Bloch, Gary; Rozmovits, Linda & Broden Giambone (2011) "Barriers to primary care responsiveness to poverty as a risk factor for health." BioMed Central Family Practice. Available at: http://www.biomedcentral.com/content/pdf/1471-2296-12-62.pdf; Schillinger, Dean; Villela, Theresa J. & George William Saba. Chapter 6: Creating a Context for Effective Intervention in the Clinical Care of Vulnerable Patients. pp.59-67. In King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients.
51 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate...
52 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
53 Meili, Ryan (2012) A Healthy Society: How A Focus On Health Can Revive Canadian Democracy. Saskatoon: Canada. Purich Publishing Limited. pp.36
54 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
55 Bloch, Gary (2011) "Poverty: A clinical tool for primary care "Family & Community Medicine, University of Toronto. Available at: http://www.healthprovidersagainstpoverty.ca/system/files/Poverty%20A%20Clinical%20Tool%20for%20Primary%20Care%20%28version%20with%20References%29_0.pdf ; Bricic, Vanessa; Eberdt, Caroline & Janusz Kaczorowski (2011) "Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study." International Journal of Family Medicine. Available at: http://www.hindawi.com/journals/ijfm/2011/812182/ ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, female health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, male health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders
56 Frank, Dr. Jason R. ed. (2005) "The CanMEDS 2005 Physician Competency Framework: Better standards. Better physicians. Better Care." Office of Education: The Royal College of Physicians and Surgeons of Canada. Available at: http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf
57 Tannenbaum, David et.al. (2011) "Triple C Competency-based Curriculum: Report of the Working Group on Postgraduate Curriculum Review-Part 1
58 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
59 Doyle-Trace L, Labuda S. Community Resources in Cote-des-Neiges. Montreal: St Mary's Hospital Family Medicine Centre, 2011. (This guide was developed by medical residents Lara Doyle-Trace and Suzan Labuda at McGill University.); Mobile Outreach Street Health (N.D.) Pocket MOSH: a little MOSH for your pocket: A Practitioners Guide to MOSH and the Community We Serve. Available at: http://www.cdha.nshealth.ca/mobile-outreach-street-health
60 Health Providers Against Poverty (N.D.) Tools and Resources. Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders
61 Meili, Ryan (2012) A Healthy Society: How A Focus...pp.61; UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
62 Rachlis, Michael (2008) Operationalizing Health Equity: How Ontario's Health Services Can Contribute to Reducing Health Disparities. Wellesley Institute. Available at: http://wellesleyinstitute.com/files/OperationalizingHealthEquity.pdf
Restricting Marketing of Unhealthy Foods and Beverages to Children and Youth in Canada: A Canadian Health Care and Scientific Organization Policy Consensus Statement
Federal government to immediately
begin a legislative process to restrict all
marketing targeted to children under the
age of 13 of foods and beverages high in
saturated fats, trans-fatty acids, free
sugars or sodium and that in the interim
the food industry immediately ceases
marketing of such food to children.
PURPOSE OF STATEMENT
This policy consensus statement was developed to
reflect the growing body of evidence linking the
promotion and consumption of diets high in
saturated fats, trans-fatty acids, free sugars or
sodium1 to cardiovascular and chronic disease
(hypertension, dyslipidemia, diabetes mellitus,
obesity, cancer, and heart disease and stroke)—
leading preventable risk factors and causes of death
and disability within Canada and worldwide. (1-3)
(1) For the remainder of the document, reference to foods
high in saturated fats, trans-fatty acids, free sugars or
sodium will be framed as foods high in fats, sugars or
The current generation of Canadian children is
expected to live shorter, less healthy lives as a
result of unhealthy eating. (4) Canadians’
overconsumption of fat, sodium and sugar, rising
rates of childhood obesity, growing numbers of
people with cancer, heart disease and stroke, and
the combined strain they exert on the health care
system and quality of life for Canadians necessitates
immediate action for Canadian governments and
policy-makers. Restricting the marketing of
unhealthy foods and beverages directed at children
is gaining increasing international attention as a
cost-effective, population-based intervention to
reduce the prevalence and the burden of chronic
and cardiovascular diseases through reducing
children’s exposure to, and consumption of,
disease-causing foods. (2,5,6)
In May 2010, the World Health Organization (WHO
released a set of recommendations on the
marketing of foods and non-alcoholic beverages to
children (5) and called on governments worldwide
to reduce the exposure of children to advertising
messages that promote foods high in saturated fats,
trans-fatty acids, free sugars or sodium and to
reduce the use of powerful marketing techniques. In
June 2012, the follow-up document, A Framework
for Implementing the Set of Recommendations on
the Marketing of Foods and Non-Alcoholic
Beverages to Children, (7) was released.
The policy aim should be to reduce the impact
on children of marketing of foods high in
saturated fats, trans-fatty acids, free sugars,
WHO (2010): Recommendation 1
What this policy consensus statement offers is the
perspective of many major national health care
professional and scientific organizations to guide
Canadian governments and non-government
organizations on actions that need to be taken to
protect the health of our future generations, in part
by restricting the adverse influence of marketing of
foods high in fat, sugar or sodium to Canadian
children and youth.
SUMMARY OF EVIDENCE AND RATIONALE
-Young children lack the cognitive ability to
understand the persuasive intent of marketing
or assess commercial claims critically. (8) in
1989 the Supreme Court of Canada ruled that
“advertisers should not be able to capitalize
upon children’s credulity” and “advertising
directed at young children is per se
-The marketing and advertising of information or
products known to be injurious to children’s
health and wellbeing is unethical and infringes
on the UN Convention on the Rights of the Child
which stipulates that, “In all actions concerning
children … the best interests of the child shall
be a primary consideration.” (9)
- Unhealthy food advertising during children’s
television programs in Canada is higher than in
many countries, with children being exposed to
advertisements for unhealthy foods and
beverages up to 6 times per hour. (10)
- Unhealthy food and beverage advertising
influences children’s food preferences,
purchase requests and consumption patterns
and has been shown to be a probable cause of
childhood overweight and obesity by the WHO.
- The vast majority of Canadians (82%) want
government intervention to place limits on
advertising unhealthy foods and beverages to
- The regulation of food marketing to children is
an effective and cost-saving population-based
intervention to improve health and prevent
- Several bills have been introduced into the
House of Commons to amend the Competition
Act and the Food and Drug Act to restrict
commercial advertising, including food, to
children under 13 years of age. None have yet
been passed. (15)
- Canada’s current approach to restricting
advertising to children is not effective and is not
in line with the 2010 WHO recommendations on
the marketing of foods and beverages to
children, nor is it keeping pace with the direction
of policies being adopted internationally, which
ban or restrict unhealthy food and beverage
marketing targeted to children. (16,17)
The Supreme Court of Canada concluded
that “advertising directed at young
children is per se manipulative”
Irwin Toy Ltd. v. Québec (AG), 1989
FOOD MARKETING TO CHILDREN: A TIMELY
OPPORTUNITY FOR CANADA
Childhood obesity and chronic disease prevention
are collective priorities for action of federal,
provincial and territorial (F/P/T) governments.
Strategy 2.3b of the 2011 Federal, Provincial and
Territorial Framework for Action to Promote Healthy
Weights stipulates “looking at ways to decrease the
marketing of foods and beverages high in fat, sugar
and/or sodium to children. “(5, p. 31)
The 2010 Sodium Reduction Strategy for Canada
has also identified the need to “continue to explore
options to reduce the exposure of children to
marketing for foods that are high in sodium" as a
key activity for F/P/T governments to consider. (19,
In their 2010 set of recommendations, the WHO
stipulated that governments are best positioned to
lead and ensure effective policy development,
implementation and evaluation. (6)
To date, there has been no substantive movement
by the federal government to develop coordinated
national-level policies that change the way
unhealthy foods and beverages are produced,
marketed and sold. Current federal, provincial and
industry-led self-regulatory codes are inconsistent
in their scope and remain ineffective in their ability
to sufficiently reduce children’s exposure to
unhealthy food marketing, nor have they been
adequately updated to address the influx of new
marketing mediums to which children and youth in
Canada are increasingly subjected.
Quebec implemented regulations in 1980 restricting
all commercial advertising. (20) Although the ban
has received international recognition and is viewed
as world leading, several limitations remain, in part
due exposure of Quebec children to marketing from
outside Quebec, weak enforcement of the
regulations and narrow application of its provisions.
Accordingly, the undersigned are calling on the
federal government to provide strong leadership
and establish a legislative process for the
development of regulations that restrict all
commercial marketing of foods and beverages high
in saturated fats, trans-fatty acids, free sugars or
sodium to children.
Strong federal government action and commitment
are required to change the trajectory of chronic
diseases in Canada and institute lasting changes in
public health. Specifically:
Efforts must be made to ensure that
children…are protected against the impact
of marketing [of foods with a high content
of fat, sugar and sodium] and given the
opportunity to grow and develop in an
enabling food environment — one that
fosters and encourages healthy dietary
choices and promotes the maintenance of
healthy weight. (7, p. 6)
Such efforts to protect the health of children must
go beyond the realm of federal responsibility and
involve engagement, dialogue, leadership and
advocacy by all relevant stakeholders, including all
elected officials, the food and marketing sector,
public health, health care professional and scientific
organizations, and most importantly civil society.
The undersigned support the development of
policies that are regulatory in nature to create
national and/or regional uniformity in
implementation and compliance by industry.
“Realizing the responsibility of governments
both to protect the health of children and to
set definitions in policy according to public
health goals and challenges — as well as to
ensure policy is legally enforced — statutory
regulation has the greatest potential to achieve
the intended or desired policy impact.”
WHO (2012), p. 33
The following outline key definitions and
components of an effective and comprehensive
policy on unhealthy food and beverage marketing
to children and should be used to guide national
policy scope and impact.
- Age of Child: In the context of broadcast
regulations, the definition of “age of child”
typically ranges from under 13 years to under
16 years. In Canada, Quebec’s Consumer
Protection Act (20) applies to children under
13 years of age. Consistent with existing
legislation, this report recommends that policies
restricting marketing of unhealthy foods and
beverages be directed to children less than
13 years of age at a minimum.
While the science on the impact of marketing on
children over 13 is less extensive, emerging
research reveals that older children still require
protection and may be more vulnerable to newer
forms of marketing (i.e., digital media ), in which
food and beverage companies are playing an
increasingly prominent role. (21-23) Strong
consideration should be given to extending the
age of restricting the marketing of unhealthy
food and beverage to age 16.
- Unhealthy Food and Beverages: In the absence
of a national standardized definition for “healthy”
or “unhealthy” foods, this document defines
unhealthy foods broadly as foods with a high
content of saturated fats, trans-fatty acids, free
sugars or sodium, as per the WHO
recommendations. (5) It is recommended that a
robust and comprehensive definition be
developed by an interdisciplinary stakeholder
- Focus on Marketing: Marketing is more than
advertising and involves:
…any form of commercial communication or
message that is designed to, or has the
effect of, increasing the recognition, appeal
and/ or consumption of particular products
and services. It comprises anything that acts
to advertise or otherwise promote a product
or service. (6, p. 9)
This definition goes beyond the current legal
definition of advertisement outlined in the Food
and Drug Act as “any representation by any
means whatever for the purpose of promoting
directly or indirectly the sale or disposal of any
food, drug, cosmetic or device.” (24)
- Marketing Techniques, Communication Channels
and Locations: Legislation restricting unhealthy
food marketing needs to be sufficiently
comprehensive to address the broad scope of
marketing and advertising techniques that have a
particularly powerful effect on children and
youth. This includes, but is not limited to, the
. Direct electronic marketing (email, SMS)
. Mobile phones
. Video and adver-games
. Characters, brand mascots and/or celebrities,
including those that are advertiser-generated
. Product placement
. Point-of-purchase displays
. Cinemas and theatres
. Competitions and premiums (free toys)
. Children’s institutions, services, events and
activities (schools, event sponsorship)
. “Viral and buzz marketing” (25,26)
. Directed to Children: The criteria used by the
Quebec Consumer Protection Act (20) to
determine whether an advertisement is “directed
at children” offers a starting point in developing
national legislation regarding child-directed
media. The loopholes in the Quebec Consumer
Protection Act criteria, namely allowing
advertising of unhealthy foods and beverages
directed at adults during children’s programming,
will necessitate the development of an
alternative approach or set of criteria that
reflects the range of media to which children are
exposed and when they are exposed, in addition
to the proportion of the audience that is made up
Quebec Consumer Protection Act
To determine whether or not an
advertisement is directed at persons under
thirteen years of age, account must be taken
of the context of its presentation, and in
a)the nature and intended purpose of the
b)the manner of presenting such
c)the time and place it is shown.
1. Federal Government Leadership
1.1 Immediately and publicly operationalize the
WHO set of recommendations on the marketing
of foods and non-alcoholic beverages to
In working toward the implementation of the
WHO recommendations, the federal
government is strongly urged to accelerate
implementation of the WHO Framework for
Implementing the Set of Recommendations on
the Marketing of Foods and Beverages to
Children. To this end, the Government of
Canada is urged to:
1.2 Convene a Federal, Provincial and Territorial
Working Group on Food Marketing to Children
to develop, implement and monitor policies to
restrict unhealthy food and beverage marketing
to children. As stipulated within the WHO
The government-led working group should
ultimately reach consensus on the priorities
for intervention, identify the available policy
measures and decide how they best can be
implemented. (7, p.13)
1.3 In developing policies, it is recommended that
the working group:
- Develop standardized criteria and an
operational definition to distinguish and
classify “unhealthy” foods. Definitions
should be developed using objective,
evidence-based methods and should be
developed and approved independent of
- Develop a set of definitions/specifications
that will guide policy scope and
implementation. Consistent with the WHO
recommendations, the working group is
encouraged to apply the policy
specifications identified above.
- Set measurable outcomes, targets and
timelines for achievement of targets for
industry and broadcasters to restrict
unhealthy food marketing to children in all
forms and settings. It is recommended that
policies be implemented as soon as possible
and within a 3-year time frame.
- Establish mechanisms for close monitoring
and enforcement through defined rewards
and/or penalties by an independent
regulatory agency that has the power and
infrastructure to evaluate questionable
advertisements and enforce penalties for
(2) Such an infrastructure could be supported
though the Canadian Radio-television and
Telecommunications Commission (CRTC), similar
to the authority of the US Federal Trade
Commission (FTC), the Canadian Food
Inspection Agency or the Food and Drug Act via
the development of an advertising investigation
The nature and extent of penalties imposed should be sufficiently
stringent to deter violations. Enforcement
mechanisms should be explicit, and infringing
companies should be exposed publicly.
- Develop evaluation mechanisms to assess
process, impact and outcomes of food
marketing restriction policies. Components
should include scheduled reviews (5 years or
as agreed upon) to update policies and/or
strategies. To showcase accountability,
evaluation findings should be publicly
1.4 Provide adequate funding to support the
successful implementation and monitoring of
the food marketing restriction policies.
1.5 Collaborate with the Canadian Institutes of
Health Research and other granting councils to
fund research to generate baseline data and
address gaps related to the impact of marketing
in all media on children and how to most
effectively restrict advertising unhealthy foods
to children. (27)
1.6 Fund and commission a Canadian economic
modeling study to assess the cost-effectiveness
and the relative strength of the effect of
marketing in comparison to other influences on
children’s diets and diet-related health
outcomes. Similar studies have been
undertaken elsewhere and highlight cost–
benefit savings from restricting unhealthy food
1.7 Call on industry to immediately stop marketing
foods to children that are high in fats, sugar or
2. Provincial, Territorial and Municipal
2.1 Wherever possible, incorporate strategies to
reduce the impact of unhealthy food and
beverage marketing to children into provincial
and local (public) health or related strategic
action plans, and consider all settings that are
frequented by children.
2.2 Pass and/or amend policies and legislation
restricting unhealthy food and beverage
marketing to children that go beyond
limitations stipulated in federal legislation and
regulations and industry voluntary codes.
2.3 Until federal legislation is in place, strike a P/T
Steering Committee on Unhealthy Food
Marketing to Children to establish
interprovincial consistency related to key
definitions and criteria and mechanisms for
enforcement, as proposed above.
2.4 Collaborate with local health authorities, non-
governmental organizations and other
stakeholders to develop and implement
education and awareness programs on the
harmful impacts of marketing, including but not
limited to unhealthy food and beverage
2.5 Call on industry to immediately stop marketing
foods to children that are high in fats, sugar or
3. Non-governmental Organizations
(NGOs), Health Care Organizations,
Health Care Professionals
3.1 Publicly endorse this position statement and
advocate to all Canadian governments to
restrict marketing of unhealthy foods to
children and youth in Canada.
3.2 Collaborate with governments at all levels to
facilitate implementation and enforcement of
federal/provincial/municipal regulations or
3.3 Wherever possible, incorporate and address
the need for restrictions on unhealthy food
and beverage marketing to children into
position papers, strategic plans, conferences,
programs and other communication mediums.
3.4 Support, fund and/or commission research to
address identified research gaps, including the
changing contexts and modes of marketing
and their implications on the nutritional status,
health and well-being of children and youth
3.5 Call on industry to immediately stop the
marketing of foods high in fat, sugar or
4. Marketing and Commercial Industry
4.1 Immediately cease marketing foods high in fats,
sugar or sodium.
4.2 Amend the Canadian Children’s Food and
Beverage Advertising Initiative (CAI) nutrition
criteria used to re-define “better-for-you
products” to be consistent with currently
available international standards that are
healthier and with Canadian nutrient profiling
standards, once developed.
BACKGROUND AND EVIDENCE BASE
Non-communicable diseases (diabetes, stroke,
heart attack, cancer, chronic respiratory disease)
are a leading cause of death worldwide and are
linked by several common risk factors including high
blood pressure, high blood cholesterol, obesity,
unhealthy diets and physical inactivity. (1,2,3 28)
The WHO has predicted that premature death from
chronic disease will increase by 17% over the next
decade if the roots of the problem are not
Diet-related chronic disease risk stems from long-
term dietary patterns which start in childhood
(8,28). Canadian statistics reveal children, consume
too much fat, sodium and sugars (foods that cause
chronic disease) and eat too little fiber, fruits and
vegetables (foods that prevent chronic disease). (3)
There is evidence that (television) advertising of
foods high in fat, sugar or sodium is associated with
childhood overweight and obesity. (6,11) Children
and youth in Canada are exposed to a barrage of
marketing and promotion of unhealthy foods and
beverages through a variety of channels and
techniques – tactics which undermine and
contradict government, health care professional
and scientific recommendations for healthy eating.
Available research indicates that food marketing to
children influences their food preferences, beliefs,
purchase requests and food consumption patterns.
(8,29) A US study showed that children who were
exposed to food and beverage advertisements
consumed 45% more snacks than their unexposed
counterparts. (30) Similarly, preschoolers who were
exposed to commercials for vegetables (broccoli
and carrots) had a significantly higher preference
for these vegetables after multiple exposures (n=4)
compared to the control group. (31)
Economic modeling studies have shown that
restricting children’s exposure to food and beverage
advertising is a cost effective population based
approach to childhood obesity prevention, with the
largest overall gain in disability adjusted life years.
(13,14). Canada has yet to conduct a comparable
Marketing and Ethics
Foods and beverages high in fats, sugars or sodium
is one of many health compromising products
marketed to children. It has been argued that policy
approaches ought to extend beyond marketing of
unhealthy foods and beverages to one that restricts
marketing of all products to children, as practiced in
Quebec (7,26,32). Article 36 of the Convention on
the Rights of the Child, to which Canada is a
signatory, states that, “children should be protected
from any activity that takes advantage of them or
could harm their welfare and development.” (9)
Restricting marketing of all products has been
argued to be the most comprehensive policy option
in that it aims to protect children from any
commercial interest and is grounded in the
argument that children have the right to a
commercial-free childhood (7, 25,26,32). The focus
on restricting unhealthy food and beverage
marketing was based in consultations with national
health organizations whose mandates, at the time
of writing, were more aligned with a focus on
unhealthy foods and beverages.
This policy statement is not opposed to, and does
not preclude further policy enhancements to
protect children from all commercial marketing, and
therefore encourages further advocacy in this area.
In order to inform the debate and help underpin
future policy direction, further research is needed.
Canada’s Food and Beverage Marketing
Television remains a primary medium for children’s
exposure to advertising, with Canadian children
aged 2–11 watching an average of 18 hours of
television per week. (26) In the past two decades,
the food marketing and promotion environment has
expanded to include Internet marketing, product
placement in television programs, films and DVDs,
computer and video games, peer-to-peer or viral
marketing, supermarket sales promotions, cross-
promotions between films and television programs,
use of licensed characters and spokes-characters,
celebrity endorsements, advertising in children’s
magazines, outdoor advertising, print marketing,
sponsorship of school and sporting activities,
advertising on mobile phones, and branding on toys
and clothing. (25,26)
A systematic review of 41 international studies
looking at the content analysis of children’s food
commercials found that the majority advertised
unhealthy foods, namely pre-sugared cereals, soft
drinks, confectionary and savoury snacks and fast
food restaurants. (33) In an analysis of food
advertising on children’s television channels across
11 countries, Canada (Alberta sample) had the
second-highest rate of food and beverage
advertising (7 advertisements per hour), 80% of
which were for unhealthy foods and beverages
defined as “high in undesirable nutrients and/or
Illustrating the influence of food packaging in
supermarkets, two Canadian studies found that for
six food product categories 75% of the products
were directed solely at children through use of
colour, cartoon mascots, pointed appeals to parents
and/or cross-merchandising claims, games or
activities. Of the 63% of products with nutrition
claims, 89% were classified as being “of poor
nutritional quality” due to high levels of sugar, fat,
or sodium when judged against US-based nutrition
criteria. Less than 1% of food messages specifically
targeted to children were for fruits and vegetables.
Food is also unhealthily marketed in schools. A
recent study of 4,936 Canadian students from
grades 7 to 10 found that 62% reported the
presence of snack-vending machines in their
schools, and that this presence was associated with
students’ frequency of consuming vended goods.
(36) In another Canadian analysis, 28% of
elementary schools reported the presence of some
form of advertising in the school and 19% had an
exclusive marketing arrangement with Coke or
Pepsi. (37) Given children’s vulnerability, a key
tenant of the WHO recommendations on marketing
to children is that “settings where children gather
should be free from all forms of marketing of foods
high in saturated fats, trans-fatty acids, and free
sugars or sodium.” (6, p.9) and need to be included
in development of food marketing policies directed
The Canadian public wants government oversight in
restricting unhealthy food marketing to children. A
nation-wide survey of over 1200 Canadian adults
found 82% want limits placed on unhealthy food
and beverage advertising to children; 53% support
restricting all marketing of high-fat, high-sugar or
high-sodium foods aimed directly at children and
Canada’s Commercial Advertising Environment
Internationally, 26 countries have made explicit
statements on food marketing to children and 20
have, or are in the process of, developing policies in
the form of statutory measures, official guidelines
or approved forms of self-regulation. (38) The
differences in the nature and degree of these
restrictions is considerable, with significant
variation regarding definition of child, products
covered, communication and marketing strategies
permitted and expectations regarding
implementation, monitoring and evaluation. (38,39)
With the exception of Quebec, Canada’s advertising
policy environment is restricted to self-regulated
rather than legislative measures with little
monitoring and oversight in terms of measuring the
impact of regulations on the intensity and
frequency of advertising unhealthy foods and
beverages to children. (39)
Nationally, the Food and Drug Act and the
Competition Act provide overarching rules on
commercial advertising and (loosely) prohibit selling
or advertising in a manner that is considered false,
misleading or deceptive to consumers. These laws,
however, contain no provisions dealing specifically
with unhealthy food advertising or marketing to
children and youth. (26) The Consumer Package
and Labeling Act outlines federal requirements
concerning the packaging, labeling, sale,
importation and advertising of prepackaged non-
food consumer products. Packaging and labels,
however, are not included under the scope of
advertising and therefore not subject to the
administration and enforcement of the Act and
Such loopholes have prompted the introduction of
three private member's bills into the House of
Commons to amend both the Competition Act and
the Food and Drugs Act. Tabled in 2007, 2009 and
2012, respectively, none of the bills have, to date,
advanced past the First Reading. (15)
The Canadian Code of Advertising Standards (Code)
and the Broadcast Code for Advertising to Children
(BCAC) together cover Canadian broadcast and non-
broadcast advertising. (23) While both have explicit
provisions/clauses to cover advertising directed to
children (12 years and younger), neither address or
explicitly cover unhealthy food and beverage
advertising. Further excluded are other heavily
used and persuasive forms of marketing directed to
children, including in-store promotions, packaging,
logos, and advertising in schools or at events, as
well as foreign media. (40)
Formed in 2008, the Canadian Children’s Food and
Beverage Advertising Initiative (CAI) defines
marketing standards and criteria to identify the
products that are appropriate or not to advertise to
children under 12 years old. Under this initiative,
participating food companies (N=19) are
encouraged to direct 100% of their advertising to
children under 12 to “better-for-you” products. (41)
In 2010, the scope of CAI was expanded to include
other media forms, namely video games, child-
directed DVDs and mobile media.
Despite reportedly high compliance by CAI
participants, (41) several fundamental loopholes
undermine its level of protection and effectiveness,
- Participation is voluntary, exempting non-
participators such as President’s Choice,
Wendy’s and A&W, from committing to CAI core
- Companies are allowed to create their own
nutrient criteria for defining “better-for-you” or
“healthier dietary choice” products. (32) A 2010
analysis revealed that up to 62% of these
products would not be acceptable to promote to
children by other countries’ advertising nutrition
- Companies are able to adopt their own
definition of what constitutes “directed at
children” under 12 years. (32) Participants'
definitions of child audience composition
percentage range from 25% to 50%, significantly
more lenient than current Quebec legislation
and other international regulatory systems.
- The initiative excludes a number of marketing
and advertising techniques primarily directed at
children, namely advertiser-generated
characters (e.g., Tony the Tiger), product
packaging, displays of food and beverage
products, fundraising, public service messaging
and educational programs. (26,27)
The Quebec Consumer Protection Act states that
“no person may make use of commercial
advertising directed at persons under thirteen years
of age.” (26) Despite its merits, the effectiveness of
the Quebec ban has been compromised. In its
current form, the ban does not protect children
from cross-border leakage of child-directed
advertisements from other provinces. (40) One
study found that while the ban reduced fast food
consumption by US$88 million per year and
decreased purchase propensity by 13% per week,
the outcomes primarily affected French-speaking
households with children, not their English-speaking
counterparts. (44) A more recent study looking at
the ban’s impact on television advertising arrived at
similar conclusions and found that Quebec French
subjects were exposed to significantly fewer candy
and snack promotions (25.4%, p<0.001) compared
to the Ontario English (33.7%) and Quebec English
(39.8%) groups. (40)
The ban has further been criticized for having a
weak definition of “advertisement”, which allows
adult-targeted advertisements for unhealthy foods
during children’s programming (37) and having
weak regulatory and monitoring structures. (37,40)
In assessing the effectiveness of Quebec’s
legislation in reducing children’s exposure to
unhealthy food advertising, it is important to note
that the ban was not developed to target or reduce
the marketing of foods and beverages specifically,
but rather to reduce the commercialization of
Public Policy: The Way Forward
Several legislative approaches have been
undertaken internationally to restrict unhealthy
food and beverage marketing. (7,43,45) While
more research is needed with regards to the impact
of restricting unhealthy food and beverage
marketing on child health outcomes (i.e., obesity), a
US study estimated that between 14-33% of
instances of childhood obesity could be prevented
by eliminating television advertising for unhealthy
food. (46) An Australian study found that a
restriction on non-core-food advertisement
between 7am and 8:30pm could reduce children’s
exposure to unhealthy food advertising by almost
80%. (47) An evaluation of the UK regulations
which restricts television advertising of all foods
high in fat, sugar and sodium found that since its
introduction there has been a 37% reduction in
unhealthy food advertisement seen by children.
Restrictions on food marketing are being
increasingly advocated internationally. A 2011
International Policy Consensus Conference
identified regulating marketing to children as a key
policy strategy to prevent childhood obesity. (48) A
similar recommendation was made at the
September 2011 United Nations high-level meeting
on the prevention and control of non-
communicable diseases. Restrictions on television
advertising for less healthful foods has also been
identified as an effective (Class I; Grade B)
population-based strategy to improve dietary
behaviors in children by the American Heart
Within Canada, non-governmental and other health
organizations are assuming an equally active role.
Among others, the Chronic Disease Prevention
Alliance of Canada, the Dietitians of Canada, the
Alberta Policy Coalition for Chronic Disease
Prevention, the Simcoe Board of Health, the
Thunder Bay and District Board of Health and the
Kingston, Frontenac, Lennox and Addington Board
of Health have issued position papers or statements
urging the federal government to implement more
stringent regulations on food and beverage
marketing to children. (26,42,48)
The current voluntary, industry self-regulated and
ineffective system of restricting the marketing and
advertising of foods and beverages fails to protect
Canadian Children and thereby contributes to the
rising rates of childhood obesity and the likelihood
of premature death and disability in our children’s
and future generations. Strong federal government
leadership and nationwide action from other levels
of government and other key stakeholders are
needed. Regulation restricting unhealthy food
advertising is internationally supported, with a
growing evidence base for expanding such
regulation to all forms of food marketing.
This policy statement offer an integrated, pragmatic
and timely response to the national stated priorities
of childhood obesity and chronic disease prevention
in Canada and supports the F/P/T vision of making
Canada, “…a country that creates and maintains the
conditions for healthy weights so that children can
have the healthiest possible lives.” (4)
This policy statement was funded by The Heart and Stroke
Foundation of Canada (HSFC) and the Institute of
Circulatory and Respiratory Health (CIHR) Chair in
Hypertension Prevention and Control, prepared with the
assistance of an ad hoc Expert Scientific Working Group,
reviewed and approved by the Hypertension Advisory
Committee and endorsed by the undersigned national
HYPERTENSION ADVISORY COMMITTEE
Manuel Arango, Heart and Stroke Foundation of Canada
Norm Campbell, Canadian Society of Internal Medicine
Judi Farrell, Hypertension Canada
Mark Gelfer, College of Family Physicians of Canada
Dorothy Morris, Canadian Council of Cardiovascular Nurses
Rosana Pellizzari, Public Health Physicians of Canada
Andrew Pipe, Canadian Cardiovascular Society
Maura Rickets, Canadian Medical Association
Ross Tsuyuki, Canadian Pharmacists Association
Kevin Willis, Canadian Stroke Network
Norm Campbell, HSFC/CIHR Chair in Hypertension
Prevention and Control, Chair
Tara Duhaney, Policy Director, Hypertension Advisory
1. World Health Organization. Diet, Nutrition, and the
Prevention of Chronic Diseases. WHO Technical
Report Series No. 916. Geneva, WHO; 2003.
http://www.who.int/hpr/NPH/docs/who_fao_expert_report.pdf. Accessed December 2011
2. World Health Organization. 2008-2013 Action Plan
for the Global Strategy for the Prevention and
Control of Noncommunicable Diseases. Geneva:
WHO; 2008. Available at:
2008.pdf. Accessed December 2011
3. Public Health Agency of Canada. Tracking Heart
Disease and Stroke in Canada. Ottawa, 2009.
Available at: http://www.phac-
eng.pdf. Accessed January 2012
4. Olshansky SJ, Passaro DJ, Hershow RC et al. A
potential decline in life expectancy in the United
States in the 21st century. N Engl J Med. 2005;
5. Public Health Agency of Canada. Curbing Childhood
Obesity: A Federal, Provincial and Territorial
Framework for Action to Promote Healthy Weights.
Ottawa, PHAC; 2011 Available at: http://www.phac-
Accessed January 2012
6. World Health Organization. Set of recommendations
on the marketing of foods and non-alcoholic
beverages to children. Geneva: WHO; 2010.
http://www.who.int/dietphysicalactivity/publications/recsmarketing/en/index.html. Accessed December 2011
7. World Health Organization. A Framework for
Implementing the Set of Recommendations on the
Marketing of Foods and Non-Alcoholic Beverages to
Children. Geveva: WHO; 2012. Available at:
http://www.who.int/dietphysicalactivity/MarketingFramework2012.pdf. Accessed June 2012
8. Kunkel D, Wilcox B, Cantor J, Palmer E, Linn S,
Dowrick P. Report of the APA Taskforce on
Advertising and Children. Washington: American
Psychological Association; 2004. Available at:
http://www.apa.org/pi/families/resources/advertising-children.pdf. Accessed January 2012
9. United Nations. Convention on the Rights of the
Child. Geneva: United Nations, 2009 Available at:
Accessed February, 2012
10. Kelly B, Halford JCG, Boyland E, Chapman K, Bautista-
Castaño I, Berg C, et al. Television food advertising to
children: A global perspective. Am J Public Health.
2010;100:1730-5. Available at:
11. McGinnis JM, Gootman JA, Kraak VI (Eds.) Food
Marketing to Children and Youth: Threat or
Opportunity? Committee on Food Marketing and the
Diets of Children and Youth. Washington, DC: IOM;
12. Ipsos Reid. Canadians’ Perceptions of, and Support
for, Potential Measures to Prevent and Reduce
Childhood Obesity. Prepared for the Public Health
Agency of Canada. Ottawa, November 2011.
http://www.sportmatters.ca/files/Reports/Ipsos%20Obesity%202011.pdf. Accessed February 2012
13. Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-
Barron V, Chisholm D. Tackling of Unhealthy Diets,
physical inactivity, and obesity: Health effects and
cost-effectiveness. Lancet 2010; 376 (9754): 1775-
84 Available at:
14. Magnus A, Habby MM, Carter R, Swinburn B. The
cost-effectiveness of removing television advertising
of high fat and/or high sugar food and beverages to
Australian children. Int J Obes.2009; 33: 1094-1102.
15. Parliament of Canada. Private Member’s Bills.
Accessed April 2012
16. Conrad S. Innovations in Policy Evaluation:
Examining the food and beverages included in the
Canadian Children’s Food and Beverage Advertising
Initiative. Ottawa: Public Health Agency of Canada;
17. Alberta Policy Coalition for Cancer Prevention. Using
Public Policy to Promote Healthy Weights for
Canadian Children. Submission to the “Our Health,
Our Future – National Dialogue on Healthy Weights”
18. Public Health Agency of Canada. The integrated pan-
Canadian healthy living strategy. 2005. Available at:
strat/pdf/hls_e.pdf. Accessed January 2012
19. Health Canada. Sodium Reduction Strategy for
Canada: Recommendations of the Sodium Working
Group. Ottawa, Ontario, July 2010. Available at:
http://publications.gc.ca/collections/collection_2010/sc-hc/H164-121-2010-eng.pdf. Accessed December
20. Quebec Consumer Protection Office. The Consumer
Protection Act: Application Guide for Sections 248
and 249. Quebec, 1980
21. Montgomery K, Chester J. Interactive Food and
Beverage Marketing: Targeting Adolescents in the
Digital Age. J Adolesc Health. 2009: S18-S29.
22. Harris JL, Brownell KD, Bargh JA. The Food Marketing
Defense Model: Integrating Psychological Research
to Protect Youth and Inform Public Policy. Soc Issues
Policy Rev. 2009; 3(1): 211-271. Available at:
23. Pechman C, Levine L, Loughlin S, Leslie F. Impulsive
and Self-Conscious: Adolescents' Vulnerability to
Advertising and Promotion. Journal of Public Policy
and Marketing. 2005; 24 (2): 202-221. Available at:
24. Health Canada. Food and Drugs Act . R.S., c. F-27.
Ottawa: Health Canada; 1985. Available at:
Accessed February 2012
25. Mackay S, Antonopoulos N, Martin J, Swinburn B. A
comprehensive approach to protecting children from
unhealthy food advertising. Melbourne, Australia:
Obesity Policy Coalition; 2011. Available at:
email1%20final%2013.04.11.pdf. Accessed January
26. Cook B. Policy Options to Improve the Children’s
Advertising Environment in Canada. Report for the
Public Health Agency of Canada Health Portfolio Task
Group on Obesity and Marketing. Toronto; 2009.
27. Toronto Board of Health. Food and Beverage
Marketing to Children. Staff Report to the Board of
Health. Toronto: Board of Health; 2008. Available at:
http://www.toronto.ca/legdocs/mmis/2008/hl/bgrd/backgroundfile-11151.pdf. Accessed January 2012
28. The Conference Board of Canada. Improving Health
Outcomes: The Role of Food in Addressing Chronic
Diseases. Conference Board of Canada, 2010.
177_FoodandChronicDisease.pdf. Accessed June 2012
29. Cairns G, Angus K, Hastings G, Caraher M.
Systematic reviews of the evidence on the nature,
extent and effects of food marketing to children. A
retrospective summary. Appetite. 2012 (in press).
30. Harris JL, Bargh JA, Brownell KD. Priming Effects of
Television Food Advertising on Eating Behavior.
Health Psychol. 2009; 28(4):404-13. Available at:
31. Nicklas TA, Goh ET, Goodell LS et al. Impact of
commercials on food preferences of low-income,
minority preschoolers. J Nutr Educ Behav. 2011;
32. Elliott C. Marketing Foods to Children: Are We
Asking the Right Questions. Child Obes. 2012; 8(3):
33. Hastings G, Stead M, McDermott L, Forsyth A,
Mackintosh AM, Rayner M, Godfrey C, Caraher M,
Angus K. Review of research on the effects of food
promotion to children. Final Report to the UK Food
Standards Agency. Glasgow, Scotland: University of
Strathclyde Centre for Social Marketing; 2003.
http://www.food.gov.uk/multimedia/pdfs/promofoodchildrenexec.pdf. Accessed February 2012
34. Elliott C. Marketing fun foods: A profile and analysis
of supermarket food messages targeted at children.
Can Public Policy. 2008; 34:259-73
35. Elliott C. Assessing fun foods: Nutritional content
and analysis of supermarket foods targeted at
children. Obes Rev. 2008; 9: 368-377. Available at:
36. Minaker LM, Storey KE, Raine KD, Spence JC, Forbes
LE, Plotnikoff RC, McCargar LJ. Associations between
the perceived presence of vending machines and
food and beverage logos in schools and adolescents'
diet and weight status. Public Health Nutr. 2011;
37. Cook B. Marketing to Children in Canada: Summary
of Key Issues. Report for the Public Health Agency of
Canada. 2007. Available at:
Accessed January 2012
38. Hawkes C, Lobstein T. Regulating the
commercial promotion of food to children: a
survey of actions worldwide. Int J Pediatr
Obes. 2011; 6(2):83-94.
39. Hawkes C, Harris J. An analysis of the content of
food industry pledges on marketing to children.
Public Health Nutr. 2011; 14:1403-1414. Available
40. Potvin-Kent M, Dubois, L, Wanless A. Food
marketing on children's television in two
different policy environments. Int J of Pediatr
Obes. 2011; 6(2): e433-e441. Available at:
41. Advertising Standards Canada. Canadian children’s
food and beverage advertising initiative: 2010
compliance report. Available at:
2010ComplianceReport.pdf. Accessed March 2012
42. Dietitians of Canada. Advertising of Food and
Beverage to Children. Position of Dietitians of
Canada. 2010. Available at:
paper.aspx. Accessed January 2012
43. Hawkes C. Marketing food to children: a global
regulatory environment. World Health Organization.
2004(b). Available at:
http://whqlibdoc.who.int/publications/2004/9241591579.pdf. Accessed February 2012
44. Dhar T, Baylis K. Fast-food Consumption and the Ban
on Advertising Targeting Children: The Quebec
Experience. Journal of Marketing Research. 2011; 48
(5): 799-813. Available at:
45. World Health Organization. Marketing of Food and
Non-Alcoholic Beverages of Children. Report of a
WHO Forum and Technical Meeting. Geneva: WHO;
2006. Available at:
pdf. Accessed January 2012
46. Veerman JL, Van Beeck, Barendregt JJ, Mackenbach
JP. By how much would limiting TV food advertising
reduce childhood obesity? Eur J Public Health. 2009;
19(4): 365-9. Available at:
47. Kelly B, King L, Mauman A, Smith BJ, Flood V. The
effects of different regulation systems on television
food advertising to children. Aust N Z J Public
Health. 2007; 31(4): 340-343.
48. Alberta Policy Coalition for Chronic Disease
Prevention. Canadian Obesity Network -
International Consensus: Take Action to Prevent
Childhood Obesity (Press Release). 2011. Available
49. Mozaffarian D, Afshin A, Benowitz NL et al.
Population Approaches to Improve Diet, Physical
Activity, and Smoking Habits: A Scientific Statement
From the American Heart Association. Circulation.