CMA speech - Jane Philpott - August 21, 2017

Speech

Today the federal government and the Government of Manitoba agreed to new targeted federal funding over 10 years for investments in home and community care and mental health and addictions. Now all provinces and territories will be receiving significant investments to make meaningful improvements in these domains.Good morning. I'm honoured to be back at the CMA General Council meeting this year.

I'd like to begin by acknowledging the original inhabitants and caretakers of this land. I'm thankful for the opportunity to gather on Huron traditional territory.

It is significant that this General Council is taking place here in Quebec City where the CMA held its first meeting 150 years ago. This is an historic meeting and apparently one of the largest gatherings of doctors in CMA history.

I want to welcome Dr. Laurent Marcoux to his role as your incoming president. I very much look forward to working with you.

I also want to celebrate Dr. Granger Avery for his dedicated service as president of the CMA. We have had many good conversations on topics ranging from cannabis use to seniors' care. I thank you for your service.

Before I start my presentation, I have good news to share: Today the federal government and the Government of Manitoba agreed to new targeted federal funding over 10 years for investments in home and community care and mental health and addictions. Now all provinces and territories will be receiving significant investments to make meaningful improvements in these domains.

Over the next 10 years, our government will provide provinces and territories with an additional $11B of targeted funding. For Manitoba this means an additional $400M: $218M for better home care; and $182M to improve access to mental health and addiction services.

I'm also pleased to announce that we've reached an agreement on a Common Statement of Principles on Shared Health Priorities with the provinces and territories. It outlines our priorities for the federal investments in home and community care, as well as mental health and addictions, including a focus on youth mental health.

The Common Statement of Principles documents the plan for federal, provincial and territorial governments to work together and to track progress with national metrics for these key priorities.

Now for today's topic… I chose an interest I share with Dr. Avery - the topic of population health - specifically the health of vulnerable people.

Here's my bottom line: For Canada to thrive, we need to improve the health of our most vulnerable people. To do so successfully, we need Canada's doctors to be actively engaged in population health.

We entered medical school with a desire to serve people in need, to improve people's health. Most doctors see this as our top priority - providing high quality care for individual patients.

Curiously, when it comes to the health of the population as a whole, it is not entirely clear what role doctors have.

What obligation do we bear toward people who don't find their way into our clinics or hospitals or who don't get there soon enough? Who is responsible for the health of vulnerable populations? If not doctors, is it hospitals, regional health authorities, public health departments, governments, or patients themselves?

Surely improving population health is a shared responsibility.

Speaking from my own experience, I was trained to address the health needs of individual patients who found their way to the clinic or hospital. But I was taught little about how to care for a community. It was clinical experience that made me think about population health. This began when I spent the first decade of my career in Niger Republic, West Africa. As I cared for toddlers with severe malnutrition, children suffering from preventable infections or adults dying from AIDS, I quickly realized that I needed to know more about population health. I needed to learn how to protect the health of vulnerable people.

Many of you devote yourselves, at considerable personal cost, to caring for vulnerable and marginalized people. As I travel the country, I meet many doctors and other health professionals, who are dedicated, not only to caring for individuals, but also addressing gaps in health systems to better serve our most vulnerable populations. I want to acknowledge and highlight your inspiring work today.

Let's start with clarifying what I mean by vulnerable populations. Canada's National Collaborating Centre for Determinants of Health defines vulnerable populations as groups at a higher risk for poor health as a result of barriers they experience to social, economic, political and environmental resources.

Many groups are in this category: people who are jobless or homeless, people who suffer from chronic illness, citizens in remote communities, some racial and religious minorities, LGBTQ2 individuals, and more.

People from these groups are financially vulnerable as well - far from even the margins of the middle class. Our government is committed to growing the middle class. To succeed, we must focus on vulnerable individuals and marginalized groups. But it's more than a political objective. Growth of the middle class is essential to the stability of our economy, the safety of our communities and the improvement of health for all Canadians.

As doctors, we have exceptional opportunities to impact the lives of Canada's most vulnerable people. I have three questions to consider:

  • Who is responsible for the health needs of vulnerable people?
  • What role do doctors have in promoting population health?
  • How do we adapt health systems (and collaborate with other social systems) to achieve better care for our most vulnerable citizens - and ultimately help people enjoy a better quality of life?

I'm going to discuss three areas in which vulnerable people have been, and will continue to be, a focus for the federal health portfolio.

  • Indigenous health
  • The epidemic of opioid overdose deaths
  • Youth mental wellness

Indigenous Health

Of all the challenges that confront me as federal health minister, the most daunting is the need to address to deplorable gaps in health outcomes faced by First Nations, Inuit and Metis peoples in Canada.

Let me start by acknowledging, as called for by the Truth and Reconciliation Commission, that the current state of Indigenous health in Canada is a direct result of government policies in our collective past, including the policy of residential schools.

By a host of measures - life expectancy, chronic diseases such as diabetes, infectious diseases such as tuberculosis, infant mortality rates, suicide rates, mental health issues - it is easily demonstrated that First Nations, Inuit and Metis peoples have suffered from both negligence and systemic discrimination when it comes to healthcare.

Of course poor health in Indigenous peoples also derives from a broad range of social inequities - including conditions of housing, employment, education, community infrastructure and much more.

So what have we done in the health portfolio? I'll share an example of steps we're taking. It focuses on the period of birth. Some of the most poignant stories I hear relate to families being separated at or around a child's birth. About two-thirds of mothers in Nunavut and half of those in the Northwest Territories have to leave their home community - far from their land, language and lineage - to give birth.

When I visited Norway House Hospital, Manitoba, one of two remaining federal hospitals, the tour was led by the Chief of Staff. As I reviewed with her the needs of the hospital, she spoke with conviction: "Of all we need… laboratory equipment, better facilities, more staff… if I could ask for only one thing it's this: please allow these young women to take someone with them when they leave home to give birth in Winnipeg.

Another wise doctor reported the wisdom of elders - that Indigenous communities need to hear the cries of birth, not just the cries of death.

The first part of our response was a new policy so that the Non-Insured Health Benefits for First Nations and Inuit Canadians now covers the cost of transport for a family member to accompany women when they give birth far from home.

Going further, Budget 2017 provided more money for maternal child health - including resources for projects to expand midwifery - with the aim that in time, as we work with local leaders, the joyful cries of birth can increasingly be restored to remote Indigenous communities.

In fact, Budget 2017 included $828M in new investments to improve the health of people in Inuit and First Nations communities. This represents the largest increase in this area in more than a decade.. It will provide many opportunities to work with communities to address a wide range of issues - from the fight against tuberculosis to the expansion of telemedicine and home care for Aboriginal persons.

When I consider the living conditions and social opportunities (or lack thereof) experienced by many First Nations, Inuit and Metis peoples, I am ashamed. I acknowledge the tremendous amount of preventable suffering, injustice and loss of life in Indigenous communities. But the future offers the opportunity and obligation to do better, to do right.

This includes growing a robust Indigenous health workforce. I'm deeply grateful for doctors who are dedicated to serving the health needs of First Nations, Inuit and Metis Canadians. In particular, I'm thankful for the growing number of Indigenous doctors who are playing a critical role to help transform health services in Indigenous communities in recognition of the right to self-determination.

Canadians can be assured of the enduring commitment of our government to reconciliation with First Nations, Inuit and Metis peoples of Canada - based on the recognition of rights.

Epidemic of Opioid Overdose Deaths

The second issue of urgent concern is the epidemic of opioid overdose deaths. In this case, the people who are vulnerable include those who are harmed by drugs that are prescribed or illicitly acquired.

This is a complex issue to which I could devote an entire presentation. I cannot do it justice in a few comments. But I raise it to acknowledge the unprecedented national public health emergency with rapidly rising rates of deaths caused by apparent opioid overdose - at least 2400 in 2016, and the 2017 numbers are likely to surpass this.

This challenge requires a response from all orders of government and all of society including health professionals. Determined to stop the steady stream of deaths, our government has taken concrete action.

We launched a new Canadian Drugs and Substances Strategy, that includes the pillar of harm reduction. We mobilized a federal Opioid Response Team. Bill C37 came into effect in May 2017 and facilitates access to supervised consumptions sites for communities that need this evidence-based tool of harm reduction. We've approved 15 supervised consumption sites this year, for a total of 17 sites across the country now.

We made Naloxone available without prescription and made sure it is available in multiple formats. We are ensuring that all forms of evidence-based medication-assisted treatment are available for people with addiction - including overturning a ban on the use of pharmaceutical-grade heroin and allowing it to be imported in bulk. We strongly encourage provinces, territories and health practitioners to take up these tools and expand access to harm reduction as well as comprehensive treatment for people with problematic substance use.

Our approach to the crisis needs to be comprehensive, collaborative, compassionate and evidence-based. Doctors have a huge role, including promoting awareness that social inequity and unresolved trauma are often at the root of high-risk drug use. This includes homelessness, poverty, violence and sexual abuse. Addiction is not a crime, nor a mark of moral failure. It is a health issue. For many, it is a mechanism to manage unbearable pain, when life offers few alternatives. To resolve this crisis, we must overcome stigma as a barrier to care. You are among the most influential voices in society. It is my plea that you work within your spheres of influence to promote the message that people who use drugs are people who do not need judgement. They need what all Canadians expect from health systems - that is, compassionate care.

As with each of these vulnerable groups, I want to take a moment to thank an incredible cadre of doctors to whom we are deeply indebted - those of you who have taken an interest in caring for people with addiction and high-risk drug use. Your passion for justice and your determination to push the boundaries of health systems - because you care so much - is an inspiration to me. You have respectfully pushed me to make sure we constantly improve our approach to drug policy. You look after people on whom others would be inclined to give up - in doing so, you demonstrate the highest standards of our profession.

Youth Mental Wellness

The third and final issue I want to discuss related to vulnerable populations is youth mental wellness. There are, of course, links to the previous two topics - particularly related to adverse childhood experiences and the impacts of unresolved trauma.

When I think of children and youth with mental illness, psychological stress or existential angst, dozens of children and young people come to mind…. patients, family members, children of my colleagues and friends. I suspect each of you could tell me stories of young people in distress who are part of your life or practice. I hear from university presidents and CEOs of corporations large and small about how mental illness among young people has an impact on their organization.

The number of children and youth on wait lists for mental health care is on the rise. A recent study in one Canadian province reported that children and youth with mental illness can wait up to 18 months for care.

When children and youth don't get the mental health care they need, the consequences are immense… untold anguish, further mental illness and healthcare costs, the inability to continue work or school programs, substance use disorders, violence and incarceration - plus the heartache of families who know something is very wrong, but feel desperate and powerless in the face of the suffering of loved ones.

This is not to mention the contribution these young people could make to society if they were able to function, or be better accepted and integrated in our communities in spite of mental health challenges.

Let's face it. Our health systems are not adequately meeting the needs of youth with mental illness, nor victims of abuse or trauma.

On this theme as well, there are creative Canadian doctors who imagine better ways to respond to young people in need, and spend endless hours building fantastic programs that provide hope for some of our most vulnerable citizens. I recently visited the Foundry in Vancouver-Granville where psychiatrists from St. Paul's Hospital have developed an outstanding space where youth feel at home and have their health and social needs addressed in a welcoming, holistic setting.

The issue of mental health care was also prioritized in negotiations with provinces and territories. The result is an unprecedented investment of $5 billion from the federal government for mental health care.

I mentioned earlier the multilateral agreement with federal, provincial and territorial governments. We plan to develop and report on a set national metrics so Canadians will know how we're doing in the areas of home care and mental wellness - and where we need to improve.

Conclusion

There are many vulnerable populations I could have discussed. I know for example that seniors and the needs of frail elderly Canadians are important for the CMA. I will have the opportunity to discuss this during today's Seniors Care Summit with Dr. Avery, Dr. Marcoux and my parliamentary secretary Joel Lightbound, MP for the local riding of Louis-Hébert.

So let's return to my opening questions.

Who is responsible for the health needs of vulnerable people?

What role do doctors have in promoting population health?

I believe that population health is a shared responsibility - shared by patients, communities, governments, health professionals and more.

In Canada, the role of doctors in promoting population health is less clear. But I do not believe that we can achieve a healthy population without the expertise and active engagement of Canada's doctors.

Many of you are familiar with the concept of the Triple Aim that was developed by the US-based Institute for Healthcare Improvement and has been championed by the Canadian Foundation for Healthcare Improvement. The triple aim includes the pursuit of better care for individuals, affordable costs and better population health. Many have wisely suggested that healthcare improvement should be a quadruple aim that includes improving the experience for care providers.

If we are serious about adopting those aims, surely doctors must be involved in all four aims - including population health.

This leads to the final question - how do we adapt health systems (and collaborate with other social systems) to achieve better care for our most vulnerable citizens - and ultimately better quality of life?

As health minister, I'm struck by how health systems are not designed to support or incentivize doctors who prioritize population health improvement including addressing the needs of vulnerable groups. In fact, the opposite is often true. Nor are doctors generally well trained in the realms of public health, population health or health promotion.

Of course doctors can't address the needs of vulnerable people without a broad range of other health professionals and social systems. But those systems will not succeed without the participation of physicians.

Think about the issues I discussed - the health outcomes of First Nations, Inuit and Metis peoples, the vulnerability of people who use drugs in an epidemic of overdose deaths and better mental health care, especially for children and youth.

Perhaps these are not issues that impact your day-to-day work. But I'm convinced it is in the best interest of all Canadians that our health and social systems prioritize these vulnerable groups. And I know that you have ideas and experience that could help.

Maybe we need a bold redesign of primary care - along the lines of Ontario's Price-Baker report that suggested primary care doctors should serve everyone in a geographic area. Maybe we need new fee structures or performance metrics that incentivize care for the most vulnerable.

Many wise people have noted that the true test of a civilized society is how it treats its most vulnerable citizens. Let's not allow Canada to fail that test. Doctors are essential to our success in passing the test.

In fact, Canada is positioned to do even better than a pass on such a test. I believe we could be world leaders in our commitment to health equity through our determination that no one should be left behind.

Because you are a doctor, society has granted you power and privilege, respect and responsibility. There is no better use of that power, than to advocate on behalf of those who do not have the same opportunities.

Because you are a doctor, you have acquired education, insight and practical wisdom. I know you can use your knowledge and creativity to create a better future for Canada's most vulnerable people.

Because you are a doctor, I know that you care. The instinct to care can get tangled up in anxiety, exhaustion, cynicism and doubt. Sometimes, the antidote to those feelings is to focus on the interests of others. What more do you want to do to promote mental wellness for young people; reduce harms for people who use drugs; support healthcare transformation for Indigenous Canadians? You have the ideas, the expertise and the drive that Canada needs to address these priorities.

For Canada to thrive, we need to improve the health of our most vulnerable populations. To do so successfully, we need Canada's doctors to be fully engaged. I hope we can pursue this important work together. Let's not be satisfied until Canada's abundant opportunities for health and wellness are fairly enjoyed by all.


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