The Canadian Medical Association (CMA) is pleased to participate in the review of the Clean Air Act, Bill C- 30. The CMA, first founded in 1867, currently represents more than 64,000 physicians across the country. Our mission includes advocating for the highest standard of health and health care for all Canadians and we are committed to activities that will result in healthy public policy.
The Environment: A Key Determinant of Health
The physical environment is a key determinant of a population's health and the medical profession is concerned about environmental conditions that contribute to declining health in individuals and the population as a whole. Physicians have been part of an early warning system of scientists and other health professionals calling attention to the effects on human health of poor air quality because we see the impact in our practice and in our communities.
There is strong evidence that air pollution is the most harmful environmental problem in Canada in terms of human health effects. We know from the smog health studies undertaken by the Ontario Medical Association (OMA), Health Canada and others, about the public health crisis created by polluted air in many parts of Canada. And it is a crisis.
A study by the federal government estimated that 5,900 premature deaths occur annually in eight large Canadian cities. This is a conservative estimate as the study focused on the short-term impact of smog pollutants using time-series studies. This study was never extrapolated to the whole Canadian population, but we know that only approximately one third of the Canadian population, mainly residents of large, urban areas, were included in the analysis.1
The OMA Illness Costs of Air Pollution study estimated that there were 5,800 premature deaths due to air pollution in Ontario alone in 2005, and examined both short-term and long-term health impacts. The OMA projected that the annual figure will grow to 10,000 premature deaths by 2026 unless effective steps are taken to reduce smog.2
In addition to premature deaths, the OMA estimated that there were 16,000 hospital admissions and 60,000 emergency room visits in Ontario in 2005 because of respiratory and cardiovascular illnesses associated with air pollution exposure. During that same year, the OMA also estimated that there were 29 million minor illness days, defined as days where individuals either suffered from asthma symptoms or had to restrict their activities. Most of the people affected by these so-called minor illness days are children.
In British Columbia, the Provincial Officer for Health published a conservative estimate in 2004 that air pollution in B.C. is causing between 140 and 400 premature deaths, 700 to 2,100 hospital stays, and between 900 and 2,750 emergency room visits each year.3
The direct and indirect costs of air pollution on the health of Canadians are estimated to be in the billions of dollars. According to the Ontario Medical Association, in 2005, air pollution costs in Ontario were estimated at:
- $374 million in lost productivity and work time;
- $507 million in direct health care costs;
- $537 million in pain and suffering due to non-fatal illness; and
- $6.4 billion in loss due to premature death.4
In Canada the environment is currently considered to be the most important issue facing society. In a recent poll by the Strategic Counsel for the Globe & Mail/CTV5 a majority of respondents ranked the impact of toxic chemicals, air and water pollution and global warming as life threatening. The environment, while a major concern today for the general public, has been of concern to physicians for some time.
CMA, Health and the Environment
In 1991 the CMA, released a policy paper Health, the Environment and Sustainable Development6 that clearly linked health and the environment. Building on the 1987 Brundtland Report (World Commission on Environment and Development, Our Common Future) that tied sustainable development to the environment and the economy, the CMA inserted health into this pair of interactions and stated that "continued environmental degradation will increase hazard to human health." The paper concluded with a number of recommendations for governments, the health sector, and physicians in support of environmentally sustainable development.
The CMA has continued to give attention to environmental issues urging the government, prior to Canada's ratification of the Kyoto Protocol, to commit to choosing a climate change strategy that satisfies Canada's international commitments while maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives. In 2002, the CMA also recommended that the federal Environment and Health Ministers commit their departments to improved health-based reporting by regularly updating the health effects information for pollutants of concern.
Clean Air Act: A Physicians Perspective
Doctors understand the concept that success from an intervention can be nuanced. In the case of disease, physicians know and accept that there are benefits of treatment even if a patient cannot be cured. Sometimes we just reduce their symptoms, or slow their rate of decline. But when treating the natural environment, so critical to human health, we suggest that you cannot accept a palliative solution. We must aim for cure. We must commit to measures of success in terms of real improvement in health. It is through this lens that the CMA urges that you view the Clean Air Act to ensure that it is health-relevant.
The CMA would like to commend this government for acknowledging the impact of the physical environment on human health and we are encouraged that the Act recognizes the intimate connection between greenhouse gas reductions and improved air quality.
Air pollution does not respect provincial borders therefore it is very important to establish national objectives and Canada wide standards that are strong and consistent across the country. To be health relevant national air quality objectives must result in air quality improvements. To this end, regardless of whether they are called objectives or standards,
national air quality targets must protect the health of all Canadians and must be binding. Voluntary air quality guidelines guarantee no health benefit.
The federal government must ensure that there is a regulatory framework in place to ensure that the standards are mandatory across the country.
The annual reporting to Parliament on the attainment of the national air quality objectives and the effectiveness of measures to attain the objectives, as outlined in the Act, is very important. Transparency in reporting is essential to the integrity of any program, but is integral to the determination of health benefit.
The International Panel on Climate Change's Fourth Assessment report released on February 2, 2007, concluded that global warming is unequivocal and that human activity is the main driver, asserting with near certainty - more than 90 percent confidence - that carbon dioxide and other heat-trapping greenhouse gases from human activities have been the main causes of warming since 1950.
Its Third Assessment report: Climate Change 2001: Working Group II: Impacts, Adaptation and Vulnerability noted that global climate change will have a wide range of impacts on human health.
"Overall, negative health impacts are expected to outweigh positive health impacts. Some health impacts would result from changes in the frequencies and intensities of extremes of heat and cold and of floods and droughts. Other health impacts would result from the impacts of climate change on ecological and social systems and would include changes in infectious disease occurrence, local food production and nutritional adequacy, and concentrations of local air pollutants and aeroallergens, as well as various health consequences of population displacement and economic disruption."7
Given the indisputable impact of greenhouse gas increases on climate change and its connection to human health, it is critical to ensure that Canada is moving quickly to reduce greenhouse gas emissions.
The Clean Air Act and the subsequent notice of intent sets out short, medium and long term targets and timelines for the reduction of greenhouse gas emissions in Canada.
The target setting approach proposed in the Act, based on emission intensity in the short and medium term is not health relevant. To be health relevant, targets should be presented in the context of overall emissions, i.e., emissions reductions minus emissions increases.
An emission reduction from a particular source is only health-relevant if we can guarantee that there is not a corresponding emissions increase at another source nearby, because it is the absolute exposure that an individual experiences that affects the risk of an adverse health effect. Just as slowing the progression of a disease can never be considered a cure, attempting only to limit the growth of those emissions cannot result in true success by any measure.
It is not until 2050 that the government has committed to achieving an absolute reduction in greenhouse gas emissions of between 45 - 65% of 2003 levels. Based on the emission intensity targets in the Clean Air Act, emissions and air pollution levels will, in fact, continue to rise as will the health consequences. In order to protect the health of Canadians the government needs to set policies, with targets and timelines that maximize absolute reductions in greenhouse gases, which are consistent with the scale and urgency of the challenge. To ensure that prescribed policies result in the intended environment and health outcomes, short and medium-term targets for absolute emission reductions would benchmark progress and allow for mid-course corrections, if they were needed.
With respect to indoor air quality, physicians have long been proponents of initiatives to reduce exposure to contaminants such as second-hand tobacco smoke. The CMA is concerned about the impact on human health of exposure to high levels of radon and the associated increased risk of lung cancer. The intention to develop measures to address indoor air quality through a national radon strategy is a positive step. It is important that our patients are made aware of such threats in their homes, and also that they are presented with a way to reduce their exposure.
Environmentally related illness is essentially the combined result of exposure and vulnerability. We are vulnerable because we are human beings; each human being has different physical strengths and weaknesses. Some vulnerabilities to environmental influences are genetic, and some the results of pre-existing disease. There is not much that government can do about this part of the equation.
Our exposure, on the other hand is related to the air we breathe, water we drink and food we eat. This is where the federal government is critical, and where the measures of success will be the most important.
Proxy measures for the health outcomes that matter must be relevant from a health perspective. Health-based success can only be measured by quantifiable reductions in the exposure levels of contaminants in our air as well as in our water and soil.
Clean air is absolutely fundamental to a healthy population - without it all else is irrelevant. Actions to curb air pollution must be taken in all sectors and levels of society in a concerted, non-partisan effort with the health of the population and the planet as our yardstick of success.
Thank you for the opportunity to provide our comments on Bill C-30, the Clean Air Act. We look forward to working with you to improve the Clean Air Act and ensure that the measure of its success will benefit the health of Canadians.
Colin J. McMillan, MD, CM, FRCPC, FACP
1 S. Judek, B. Jessiman, D. Stieb, and R. Vet. 2005. Estimated Number of Excess Deaths in Canada Due
to Air Pollution". Health Canada and Environment Canada. http://www.hc-sc.gc.ca/ahc-asc/media/
2 Ontario Medical Association. 2005. The Illness Costs of Air Pollution: 2005-2026 Health and Economic
Damage Estimates. Toronto: OMA.
3 B.C. Provincial Health Officer. 2004. Every Breath You Take: Air Quality in British Columbia, A Public Health Perspective. 2003 Annual Report. Victoria: Ministry of Health Services.
4 Ontario Medical Association , 2005
5 GLOBE/CTV POLL Climate concerns now top security and health One in four label environmental issues as most important, The Globe and Mail, Fri 26 Jan 2007, Page: A1, Section: National News , Byline: Brian Laghi
6 Health, the Environment and Sustainable Development, Canadian Medical Association , 1991
7 WMO Intergovernmental Panel on Climate Change, Climate Change 2001, IPPC Third Assessment Report: Working Group II: Impacts, Adaptation and Vulnerability, accessed Feb 7, 2007 http://www.grida.no/climate/ipcc_tar/wg2/348.htm
Thank you Madam Chair and Committee members for the opportunity to speak to you today. I am Briane Scharfstein, Associate Secretary General at the Canadian Medical Association (CMA) and a family physician by training. I am speaking on behalf of the CMA and our 67,000 physician members across the country.
We commend the Senate for striking this Committee. We are concerned that the aging population has not received sufficient national policy attention. With regard to today's discussion I would note that the CMA has advocated for the elimination of mandatory retirement and we are pleased to see that in general, provincial jurisdictions have eliminated mandatory retirement based on what has become an arbitrary age cutoff. With some obvious exceptions, such as athletics, competence is not related to age per se for most areas of human endeavour. Where human activity may pose risk to the safety of others we believe that the best approach is to develop evidence-based tools and procedures that can be used to assess competence on an ongoing basis.
While physicians play a significant role on a variety of fronts related to aging, I am going to focus my remarks on two specific areas:
* Ensuring the competence of physicians; and
* Fitness to operate motor vehicles and the role of physicians.
Turning first to the competence of the medical workforce, physicians are making diagnoses and performing procedures on a daily basis, both of which may entail a significant amount of risk for our patients. I would add that this is being done in an era where medical knowledge is rapidly increasing.
As a profession that continues to enjoy a high degree of delegated self-regulation, we recognize the importance of ensuring that physicians are and remain competent across the medical career lifecycle. This entails both an individual and collective obligation to:
* engage in lifelong learning;
* recognize and report issues of competence in one's self and one's peers; and
* participate in peer review processes to assure ongoing competence.
First and foremost, physicians have an individual ethical and professional obligation to maintain their competence throughout their career lifecycle. The CMA Code of Ethics calls on physicians to:
* practise the art and science of medicine competently, with integrity and without impairment;
* engage in lifelong learning to maintain and improve professional knowledge skills and attitudes;
* report to the appropriate authority any unprofessional conduct by colleagues; and
* be willing to participate in peer review of other physicians and to undergo review by your peers1
I would stress the importance of peer review in medicine, which is one of the defining characteristics of a self-regulating profession. Simply put, physicians are expected to hold themselves and their colleagues accountable for their behaviour and for the outcomes they achieve on behalf of their patients.2
The individual accountability that physicians have to themselves and to each other is reinforced by a collective accountability for lifelong learning and peer review that is mandated by the national credentialing bodies and by the province/territorial licensing bodies.
With regard to lifelong learning, both national credentialing bodies require evidence of ongoing continuing professional development as a condition of maintaining credentials. The College of Family Physicians of Canada operates a Maintenance of Proficiency program that requires its certificants to earn 250 credits over five years.3 The Royal College of Physicians and Surgeons of Canada operates a Maintenance of Certification Program that requires its Fellows to achieve 400 credits over a five year period with a minimum 40 in any single year.4
The Canadian Medical Protective Association, the mutual defence organization that provides liability coverage for the vast majority of physicians in Canada also plays a role in identifying high risk areas of medical practice and providing a range of educational materials and programs designed to mitigate such risk.5
Each province and territory has a licensing body - usually known as a College of Physicians and Surgeons that is established to protect the public interest. These colleges operate mandatory peer review programs that ensure that physician's practices are reviewed at regular intervals. These programs typically involve a review of the physician's practice profile based on administrative data, a visit to the physician's office by a medical colleague in a similar type of practice and an audit of a sample of patient charts, followed by a report with recommendations.
In addition, most jurisdictions now have or will soon have in place a program pioneered in Alberta that provides a 360o assessment by administering questionnaires to a sample of a physician's patients, colleagues, and co-worker health professionals. These probe several aspects of competence and reports are provided back to the physician.6
Peer review is even more rigorous in the health care institutions where physicians carry out practices and procedures that involve the greatest potential risk to patients. Physicians are initially required to apply for hospital privileges that are reviewed annually by a credentials committee. These committees have the authority to renew, modify or cancel a physician's privileges. In between annual reviews a physician's day-to-day performance is subject to review by a variety of quality assurance processes and audit/review committees such as morbidity and mortality. Health care institutions in turn are subject to regular scrutiny by the Canadian Council on Health Services Accreditation which would include the oversight of physician practice among its review parameters.
In summary, the medical profession subscribes to the notion that competence is something that must regularly be reviewed and enhanced across the medical career life cycle, and that such reviews and assessments must be grounded in evidence that is gathered from peers and other validated tools.
Turning to our patients, one area that our members are regularly called on to assess competence is the determination of medical fitness to operate motor vehicles. To assist physicians in carrying out this societal responsibility, the CMA recently released our 7th edition of the Driver's Guide.7 What you will note about this 134 page guide is that the section on aging is only 3 pages long. The focus of the guide is on how substances such as alcohol and medications and a range of disease conditions such as cardiovascular and cerebrovascular disease may impose risks on fitness to operate a range of motor vehicles including automobiles, off-road vehicles, planes and trains. It provides graduated guidelines that relate to the severity and stage of the condition. As is noted in the section on aging, while the guide acknowledges the greater prevalence of health conditions in older age groups and hence the higher crash rates among the 65 and over age group, it states that the high crash rates in older people cannot be explained by age-related changes alone. In fact, by avoiding unnecessary risk and possessing the most experience, healthy senior drivers are among the safest drivers on the road. Rather, it is the presence and accumulation of health-related impairments that affect driving that is the major cause of crashes for older people. Because older age per se does not lead to higher crash rates, age-based restrictions on driving are not supportable.
Rather than focusing on arbitrary age cutoffs what are required are evidence-based tools such as the Driver's Guide that can be used to detect and assess conditions that may present at any point in the life cycle.
I would like to return to the physician workforce and the practical implications of arbitrary age cutoffs. As you may know Canada is experiencing a growing shortage of physicians - the effects of which are about to be compounded as the first of the baby boomers turn 65 in 2011. Currently we rank 24th out of the 30 OECD countries in terms of physician supply per 1,000 population - our level of 2.2 physicians per 1,000 is one third below the OECD average of 3.0.
As of January 2008, according to the CMA physician Master File there are just over 8,200 licensed physicians in Canada who are aged 65 or older. They represent more than 1 in 10 (13%) of all licensed physicians. Moreover, they are very active; they work on average more than 40 hours per week and in addition more than 40% of them still have on-call responsibilities each month. These doctors make vital contributions to our health care system.
In conclusion, the CMA believes that the public interest is best served by ensuring that all competent physicians, regardless of age, are able to practice medicine. Artificial barriers to practice based on age are simply discriminatory and counter productive in an era of health human resource shortages.
Finally Madam Chair, we hope that the CMA will be invited back to appear before your committee. We have long been concerned with the access of the senior population to health care services and I will leave you with a copy of our policy on principles of medical care of older persons.8 We also hope you will examine the issue of long-term care which has had little if any national policy attention. I will also leave you with a copy of our recent technical background report on pre-funding of long-term care that we tabled at the Federal Minister of Finance's Roundtable in November 2007.9
Thank you again for this opportunity and I would be pleased to answer any questions.
1 Canadian Medical Association. CMA Code of ethics.(Update 2004). http://policybase.cma.ca/PolicyPDF/PD04-06.pdf. Accessed 01/23/08.
2 Canadian Medical Association. Medical professionalism (Update 2005). http://policybase.cma.ca/dbtw-wpd/Policypdf/PD06-02.pdf. Accessed 01/23/08.
3 College of Family Physicians of Canada. Mainpro(r)Maintenance of Proficiency. http://www.cfpc.ca/English/cfpc/cme/mainpro/maintenance%20of%20proficiency/default.asp?s=1. Accessed 01/23/08.
4 Royal College of Physicians and Surgeons of Canada. Maintenance of Certification Program. http://rcpsc.medical.org/opd/moc-program/index.php. accessed 01/23/08.
5 Canadian Medical Protective Association. Risk management @ a glance. http://www.cmpa-acpm.ca/cmpapd03/pub_index.cfm?FILE=MLRISK_MAIN&LANG=E. Accessed 01/23/08.
6 College of Physicians and Surgeons of Alberta. Physician Achievement Review Program. http://www.cpsa.ab.ca/collegeprograms/par_program.asp. Accessed 01/23/08.
7Canadian Medical Association. Determining medical fitness to operate motor vehicles. CMA Driver's Guide 7th edition.Ottawa, 2006.
8 Canadian Medical Association. Principles for medical care of older persons. http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD00-03.pdf. Accessed 01/23/08.
9 Canadian Medical Association. Pre-funding long-term care in Canada: technical backgrounder. Presentation to the Federal Minister of Finance's roundtable, Oshawa, ON, November 23, 2007.
On behalf of the CMA, I thank you very much for the opportunity to be here today and commend the Subcommittee for focusing on the critical issue of child health.
My presentation today will focus on three areas:
1. What the CMA has done and plans to do in the area of children's health;
2. Why the CMA has chosen to focus on the early years as a priority; and
3. What the CMA recommends to the Subcommittee and government for action in the area of children's health.
The CMA's Role & Next Steps
Physicians see the adverse effects of poor child health all too often and we strongly believe that all children should have access to the best possible start in life. That healthy start includes opportunities to grow and develop in a safe and supportive environment with access to health services as needed.
The CMA is proud to have been a partner in the Child Health Initiative (CHI), an alliance between the CMA and the Canadian Paediatric Society (CPS) and the College of Family Physicians of Canada (CFPC) that has pressed for improvements in child health and the development of Child Health Goals.
The CHI held the Child and Youth Health Summit last year where it developed a child health charter based on three principles:
* a safe and secure environment;
* good health and development; and
* a full range of health resources available to all.
The Charter states that all children should have things such as clean water, air and soil; protection from injury and exploitation; and prenatal and maternal care for the best possible health at birth. Further, the charter recognizes the need for proper nutrition for proper growth and long term health; early learning opportunities and high-quality care, at home and in the community; and a basic health care including immunization, drugs, mental and dental health.
Delegates at the Summit also endorsed the Child Health Declaration and the Child and Youth Health Challenge, a call to action to make the charter a reality.
Going forward, the CMA will invest considerable time and effort to develop policy targeting children from birth to five years of age.
To that end the CMA will host the Child Health Expert Consultation and Strategy Session on June 5-6, 2008. The purpose of this consultation is to create a discussion paper to:
* First, identify how CMA can help physicians improve the health of children under five; and second,
* Identify the key determinants of early child health and identify goals and recommend ways to achieve optimal health outcomes for children under five.
This paper will inform a Roundtable Discussion of Child Health Experts in Fall 2008 where we hope to produce a final report on the Key Determinants of Children's Health for the Early Years.
We then hope to be invited to come before this Subcommittee once again to present this report and discuss our conclusions and recommendations.
Why the Early Years
The CMA is focusing on the period from birth to five years old because it is a critical time for children and when the physicians of Canada are perhaps in the best position to make a difference.
Recent human development research suggests that the period from conception to age six has the most important influence of any time in the life cycle on brain development. As well, we are all well aware that Canada could be and should be performing better in comparison to other OECD nations in a number of key areas such as infant mortality, injury and child poverty.
We also know that:
* Early screening for hereditary or congenital disease must take place between the ages of zero and five in order to provide effective intervention; and
* Brain and biological pathways in the prenatal period and in the early years affect physical and mental health in adult life.
Physicians are well positioned to identify and optimize certain conditions for healthy growth and development. Physicians can identify and prescribe effective interventions following many adverse childhood experiences in order to improve health outcomes for children and as they grow into adults.
The CMA believes that there are a number of actions government could be taking today in the area of children's health.
First, Canada should not be at the bottom of the list of developed countries when it comes to spending, as a percentage of GDP, on early childhood programs and development. Investing in early development is essential for an optimal start to life and a physically, mentally and socially healthy childhood.
Second, we need to improve our surveillance capability to better monitor changes in children's health because we can't manage what we can't measure. That is why the CMA recommends the creation of an annual report card on child health in Canada.
Third, nearly one child in six lives in poverty in Canada. This can impact a child's growth and development, his or her physical and mental health and ultimately the ability to succeed as teenagers and adults. Governments can and must do more.
Finally, there are a number of recommendations within the recently released Leitch Report in areas such as injury prevention, environment vulnerabilities, nutrition, aboriginal and mental health. The CMA strongly supports these recommendations and urges this Subcommittee to consider them.
However, if there are two recommendations within the Leitch Report that the CMA believes government could and must act upon immediately, they would be the creation of a National Office of Child Health and a Pan-Canadian Child Health Strategy.
In conclusion, the CMA strongly supports the Subcommittee's work and its focus on child health.
Again, we hope to return to see you again this fall with specific recommendations to address child health determinants, especially those affecting children from birth to age five.
Canada can and should be among the leading nations on earth in terms of children's health status. Our children deserve no less.